the wennberg international collaborative, london, 2-4 ... · seite 3 wennberg international...

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Diagnosis and Treatment of Dementia Variation in ambulatory care for patients in Germany with special reference to non-institutionalized patients (work in progress; unpublished parts not to be cited) Dr. Dominik von Stillfried, Dr. Mandy Schulz et al

The Wennberg International Collaborative, London, 2-4 September 2015

/ www.zi.de 2 SEITE Wennberg International Collaborative , London, 2-4 September 2015

•  to explore present state of care for patients with dementia who live at home (fast growing patient group)

•  to identify the potential for systematic improvement of care by

•  analysing deviations from guideline recommendation (diagnosis, medication)

•  describing regional patterns – where to act?

•  analysing utilization and behavioral patterns, in particular using network analysis to compare patient care by type of main provider

Objective

rationale: with whom do we need to talk about what?

see published reports concerning diagnostic process / medication for dementia patients in Germany on www.versorgungsatlas.de


•  nationwide claims data bases containing

•  100% of all statutorily insured patients (~ 70 million)

•  100% of physician claims (~ 550 million cases p.a.), i.e. of GPs and office-based specialists (~ 100.000 practices) & ER claims by hospitals for patients not admitted to inpatient care

•  100% of filled prescriptions (~ 600 million prescriptions p.a.)

•  data selected for patients > 60 years, confirmed dementia dx (at least in two quarters of a year) as documented by GP and/or Neurologist/Psychiatrists (NP) only (analysis of diagnostic process) and by GP and/or all specialties resp. (analysis of medication), years 2009, 2010, 2011

•  join of selected dx with prescription data (anti-dementive, anti-psychotic, hypnotic/sedative, anti-depressant drugs)

•  not available:

•  hospital claims for inpatient care or ambulatory surgery

•  claims by logotherapist, ergotherapists etc.

Data


Selected Dementia-Diagnoses, Prevalenc/Incidence

1.  Alzheimer‘s dementia (AD) F00.x, G30.x 2.  Vascular dementia (VD) F01.x

3.  Other dementia with specific etiology F02.0, F02.3, G31.0, G31.82 4.  Other dementia with non-specific etiology F03, G31.1, G31.9 5.  Combinations of 1-4

Definitions according to Kaduskiewicz H et al 2013 Prevalent patients: n=955.811 (662.305 F, 293.506 M) in 2009 Incident patients: n=191.442 (126.214 F, 65.228 M) without dx in 2008

(for analysis of diagnostic process) N.B. for analysis of medication a slightly different dataset was used which did not allow to focus on diagnoses documented by GP and NP or to differentiate non-institutionalized patients (prevalent patients: 2009: n = 965.367 (Hamburg excluded due to missing data), 2010: n = 981.187; 2011: n = 1.014.710)


Prevalence/Incidence (Rates) including institutionalized patients


Prevalence/Incidence (Regional Distribution) including institutionalized patients


Who sees whom? incident non-institutionalized patients

variation in coding between GP/specialists confounds potential variation in utilization patterns

Incident patients GP only specialist only GP+specialist group practiceAlzheimer 7.7% 27.7% 9.2% 12.3%Vascular 14.1% 21.9% 2.8% 9.3%other specific 1.0% 5.6% 0.3% 2.1%other non-‐specific 66.9% 29.9% 16.6% 33.8%combinations 10.3% 14.9% 71.1% 42.5%total 100% 100% 100% 100%n=133,644 patients, year 2009


Diagnostic Process incident non-institutionalized patients

Diagnostic intensity varies with utilization pattern: -  patients seen by GP only may receive insufficient diagnostic testing -  patients seen by both GP and specialist are most intensely diagnosed -  there is room for increased neuropsychiatric testing

Irrespective of utilization there is a consistent gender pattern (f < m)

Incident patientsm f m f m f m f m f

lab tests 82.1 77.5 79.5 75.2 85.5 80.6 85.8 82.1 84.9 80.6neuropsychiatric tests 35.4 33.2 25.0 24.5 41.9 40.3 58.6 57.6 45.4 44.0imaging 21.0 16.6 8.2 6.1 33.9 33.1 40.1 36.4 35.3 31.4n=133,644 patients, year 2009

all GP only specialist only GP+specialist group practice


Diagnostic Process – moderate regional variation suggesting partially substitutive effects Percent of incident patients diagnosed with

lab tests neuropsychiatric

tests

imaging


Medication: underuse of antidementives/overuse of antipsychotics? N.B. m/f ratio reversed, distinctive regional pattern

antidementive antipsychotic hypnotic/sedative antidepressant m 27.5 33.0 8.6 23.0f 23.3 36.2 9.9 31.8

Alzheimer 42.4 35.2 8.9 30.6vascular 10.2 25.6 8.6 26.7other specific 19.2 29.7 8.9 31.2other non-‐specific 11.9 28.6 8.9 26.3combination 41.7 48.0 10.8 32.9

GP only 24.5 50.0 15.2 40.9specialist only 48.6 45.8 7.7 38.8GP+specialist 48.4 65.2 19.7 54.5other 3.5 4.9 1.2 3.6

large city 23.9 33.0 9.7 29.1metropolitan 25.2 37.1 10.6 29.7rural near city 24.0 34.5 7.6 27.1rural 25.0 34.9 8.0 29.0unknown 25.7 38.3 10.1 25.0total 24.6 35.2 9.5 29.0

N=1,014,710 prevalent patients in 2011

medicationpercent of patients

type of dementia

region

utilization


•  network nucleus: patients have been attributed to primary care physician who delivered most services to this patient – irrespective of diagnoses

•  all other GPs or specialists contacted by the patient form a virtual provider network with this primary care physician

•  networks with very few patients (N <10) were exluded

•  dementia patients: all prevalent patients in 2011 attributed to a network (N = 838,125)

•  „dementia networks“: problems of small numbers and uneven distribution of dementia patients

Network analysis


0 5

8 12

15 19

24 29

37

50

103

0

20

40

60

80

100

120

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 99%

prevalent dementia patients in virtual provider networks N=838,125 (2011)

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Frequency (percentiles)

Number of prevalent dementia patients

50% of virtual provider networks Up to 19



MIN 1

MAX 581

* Networks with 10 patients or less were excluded


Number of incident* dementia patients in virtual provider networks N=233,354 (2011)

frequency (percentiles)

Number of incident dementia patients




MIN 1

MAX 217

*without dementia dx in 2009 and in 2010

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networks without incident dementia patients have significantly fewer prevalent dementia patients


Regional Variation in the distribution of network populations size

marked differences

between regions but no discernable pattern according

to area type or provider structure


Diagnostic approach according to type of network

role of GP and importance of neuropsychiatric testing increase with no. of dementia patients

incident dementia patients without patients in long term care facilities, N=123.584 (2011)

<10 incident dementia patients

50% percentile of networks

18,10% 6,60% 5,10% 9,60% 39,40% 9,60% 8,10%

10-20 incident dementia patients

90% percentile of networks 22,30% 4,80% 4,30% 7,90% 39,40% 9,80% 7,10%

>20 incident dementia patients

99% percentile of networks 48,30% 2,00% 2,20% 5,00% 57,50% 9,30% 6,30%

percent of patients receiving …

total MRTCTtype of network

GP Neurologist

neuropsychiatric testing

Psychiatrist

Group practice


Prescription rates vary according to population size of virtual network (rates fall as population size increases) size of functional population prevalent patients large

(>100 prevalent dementia patients)

medium (50-100 prevalent dementia patients)

small (<50 prevalent dementia patients)

total

Anti-dementive drugs 16.9% 21.4% 26.5% 24.7%

Antipsychotics 34.0% 36.4% 35.6% 35.7%

Hypnotics/sedatives 9.1% 9.3% 9.3% 9.3%

Antidepressants 28.5% 29.7% 29.5% 29.5%

n=838,125, including institutionalized patients (2011)

size of functional population incident patients large

(>30 incident dementia patients)

medium (14-30 incident dementia patients)

small (<14 incident dementia patients)

total

Anti-dementia drugs 13.6% 21.8% 26.4% 24.4%

Antipsychotics 27.5% 33.1% 32.2% 32.5%

Hypnotics/sedatives 9.4% 9.8% 9.6% 9.7%

Antidepressants 28.3% 31.0% 30.5% 30.5%

n=233,354, including institutionalized patients (2011)


Taking a look at the networks - how important are dementia patients within the network population? networks size of functional population share of dementia patients (in all patients of the network)

large (>100 prevalent dementia patients)



total

high (share >10%) 117 92 57 266

medium (share 4-10%) 223 1,903 3,599 5,725

low (share <4%) 30 1,045 26,979 28,054

total 370 3,040 30,635 34,045

no of virtual networks: n=34,045 (2011)

< 1 percent of provider networks (266) had a high share of dementia patients, almost half of them had > 100 dementia patients per year the vast majority (79%) of networks had a low share and a low number of dementia patients


And how important are networks with a focus on dementia?

networks size of functional population share of dementia patients (relative to all patients of the network)




total

high (share >10%) 19,275 7,057 1,659 27,991

medium (share 4-10%) 28,443 126,949 114,527 269,919

low (share <4%) 3,407 65,055 471,753 540,215

total 51,125 199,061 587,939 838,125

virtual provider networks with a focus (high share and a high number of dementia patients) treat only 2.3% of all dementia patients, whereas > 50% of dementia patients were treated by networks with low share and low size.

no. of prevalent dementia patients, n=838,125 (2011)


size of functional population share of dementia patients (relative to all patients of the network)




total

high (share >10%) 14.9% 17.1% 18.0% 15.7%

medium (share 4-10%) 17.6% 20.5% 22.9% 21.2%

low (share <4%) 22.0% 23.7% 27.4% 26.9%

total 16.9% 21.4% 26.9% 24.4%

Networks with a focus on dementia show the lowest prescription rate of anti-dementia drugs (≠ guideline recommendation) Are these opinion leaders? Do they favor other treatment options? Do they collect specific patients (e.g. rare/serious cases, patients in long term care facilities?) What constitutes the dependence on patient population size?

And how important are networks with a focus on dementia? Prescription rates of anti-dementia drugs

no. of prevalent dementia patients, n=838,125 (2011)


size of functional population share of dementia patients (relative to all patients of the network)




total

high (share >10%) 31.5% 34.2% 34.5% 32.3%

medium (share 4-10%) 35.3% 35.6% 35.0% 35.3%

low (share <4%) 37.2% 38.3% 35.7% 36.0%

total 34.0% 36.4% 35.6% 35.7%

Networks with a focus on dementia show the lowest prescription rate of anti-psychotic drugs, there is an effect of size and focus, but the difference is small (similar for hypnotics/sedatives and anti-depressants) What prevents a greater reduction in prescribing rates? What could other networks learn from them?

And how important are networks with a focus on dementia? Prescription rates of anti-psychotic drugs

no of prevalent dementia patients, n=838,125 (2011)


Conclusions •  There is room for improvement in the diagnostic process of dementia

patients - in general, more cooperation between GP and specialists would be welcomed

•  Prescription of anti-psychotics seems high given potentially dangerous effects. Prescription of anti-dementia drugs is low compared to guideline recommendations. This pattern is observed both in prevalent and in incident dementia patients.

•  Prescription rates of anti-dementia drugs are affected by characteristics of virtual provider networks (size of functional population and share of dementia patients) but a focus on dementia patients leads to greater deviation from recommendations

•  There is no clear evidence of substition with other drugs or other kinds of treatment, however, prescription of antipsychotics increases with decreasing share of dementia patients

•  Before designing intervention: reasons for observed pattern need to be explored by communication with various network representatives


Vielen Dank für Ihre Aufmerksamkeit

www.zi.de Zentralinstitut für die kassenärztliche Versorgung in der Bundesrepublik Deutschland Herbert-Lewin-Platz 3 10623 Berlin Tel. +49 30 4005 2450 Fax +49 30 4005 2490 [email protected]

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