The Wennberg International Collaborative, London, 2-4 September 2015 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in ambulatory care for patients in Germany with special reference to non-institutionalized patients (work in progress; unpublished parts not to be cited) Dr.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 Zentralinstitut für die Kassenärztliche Versorgung in Deutschland
Objective 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 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 SEITE 2
Data 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. SEITE 3
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) SEITE 4
Prevalence/Incidence (Rates) including institutionalized patients SEITE 5
Prevalence/Incidence (Regional Distribution) including institutionalized patients SEITE 6
Who sees whom? incident non-institutionalized patients Incident patients GP only specialist only GP+specialist group practice Alzheimer 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 variation in coding between GP/specialists confounds potential variation in utilization patterns SEITE 7
Diagnostic Process incident non-institutionalized patients Incident patients all GP only specialist only GP+specialist group practice m 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 80.6 neuropsychiatric tests 35.4 33.2 25.0 24.5 41.9 40.3 58.6 57.6 45.4 44.0 imaging 21.0 16.6 8.2 6.1 33.9 33.1 40.1 36.4 35.3 31.4 n=133,644 patients, year 2009 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) SEITE 8
Diagnostic Process moderate regional variation suggesting partially substitutive effects Percent of incident patients diagnosed with lab tests neuropsychiatric tests imaging SEITE 9
Medication: underuse of antidementives/overuse of antipsychotics? N.B. m/f ratio reversed, distinctive regional pattern percent of medication patients antidementive antipsychotic hypnotic/sedative antidepressant m 27.5 33.0 8.6 23.0 f 23.3 36.2 9.9 31.8 type of dementia Alzheimer 42.4 35.2 8.9 30.6 vascular 10.2 25.6 8.6 26.7 other specific 19.2 29.7 8.9 31.2 other non- specific 11.9 28.6 8.9 26.3 combination 41.7 48.0 10.8 32.9 utilization GP only 24.5 50.0 15.2 40.9 specialist only 48.6 45.8 7.7 38.8 GP+specialist 48.4 65.2 19.7 54.5 other 3.5 4.9 1.2 3.6 region large city 23.9 33.0 9.7 29.1 metropolitan 25.2 37.1 10.6 29.7 rural near city 24.0 34.5 7.6 27.1 rural 25.0 34.9 8.0 29.0 unknown 25.7 38.3 10.1 25.0 total 24.6 35.2 9.5 29.0 N=1,014,710 prevalent patients in 2011 SEITE 10
Network analysis 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 SEITE 11
prevalent dementia patients in virtual provider networks N=838,125 (2011) 120 Number of dementia patients per virtual provider network 100 80 60 40 50% of virtual provider networks 90% of virtual provider networks 99% of virtual provider networks Number of prevalent dementia patients Up to 19 Up to 50 Up to 103 MIN 1 MAX 581 37 50 103 20 0 29 24 19 12 15 5 8 0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 99% Frequency (percentiles) * Networks with 10 patients or less were SEITE 12 Wennberg International Collaborative excluded, London, 2-4 September 2015
Number of incident* dementia patients in virtual provider networks N=233,354 (2011) *without dementia dx in 2009 and in 2010 Number of incident dementia patients Number of dementia patients per virtual provider network 50% of virtual provider networks 90% of virtual provider networks 99% of virtual provider networks Up to 6 Up to 14 Up to 30 MIN 1 MAX 217 networks without incident dementia patients have significantly fewer prevalent dementia patients frequency (percentiles) SEITE 13
Regional Variation in the distribution of network populations size marked differences between regions but no discernable pattern according to area type or provider structure SEITE 14
Diagnostic approach according to type of network percent of patients receiving neuropsychiatric testing type of network GP Neurolog ist Psychiatr ist Group practice total CT MRT <10 incident dementia patients 10-20 incident dementia patients 50% percentile of networks 90% percentile of networks 18,10% 6,60% 5,10% 9,60% 39,40% 9,60% 8,10% 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% incident dementia patients without patients in long term care facilities, N=123.584 (2011) role of GP and importance of neuropsychiatric testing increase with no. of dementia patients SEITE 15
Prescription rates vary according to population size of virtual network (rates fall as population size increases) prevalent patients large (>100 prevalent size of functional population medium (50-100 prevalent small (<50 prevalent 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 medium (14-30 incident small (<14 incident 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) SEITE 16
Taking a look at the networks - how important are dementia patients within the network population? networks share of dementia patients (in all patients of the network) large (>100 prevalent size of functional population medium (50-100 prevalent small (<50 prevalent 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 SEITE 17
And how important are networks with a focus on dementia? networks share of dementia patients (relative to all patients of the network) large (>100 prevalent size of functional population medium (50-100 prevalent small (<50 prevalent 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 no. of prevalent dementia patients, n=838,125 (2011) 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. SEITE 18
And how important are networks with a focus on dementia? Prescription rates of anti-dementia drugs share of dementia patients (relative to all patients of the network) large (>100 prevalent size of functional population medium (50-100 prevalent small (<50 prevalent 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% no. of prevalent dementia patients, n=838,125 (2011) Networks with a focus on dementia show the lowest prescription rate of antidementia 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? SEITE 19
And how important are networks with a focus on dementia? Prescription rates of anti-psychotic drugs share of dementia patients (relative to all patients of the network) large (>100 prevalent size of functional population medium (50-100 prevalent small (<50 prevalent 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% no of prevalent dementia patients, n=838,125 (2011) Networks with a focus on dementia show the lowest prescription rate of antipsychotic 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? SEITE 20
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 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 SEITE 21
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 zi@zi.de SEITE 22