Download PowerPoint-Präsentation - DETECT

Frequency and Routine Care Treatment of Diabetes
mellitus in Germany: Findings from the DETECT Study
Steffen Böhler1, David Pittrow1, Heide Glaesmer2, Jens Klotsche2, Isabell Hach1, Wolfgang Böcking1,
Wilhelm Kirch1, Hubert Scharnagl3, Winfried Maerz3, Günther Ruf4, Hans-Ulrich Wittchen2, Günter
Stalla5, Hendrik Lehnert6.
1Institute
of Clinical Pharmacology, Technical University Dresden, Germany; ²Institute of Clinical Psychology and Psychotherapy, Technical
University Dresden; Germany; ³Institute of Chemical and Medical Laboratory Diagnostics, Medical University Graz, Austria; 4Pfizer GmbH,
Germany; 5 Department of Endocrinology, Max-Planck Institute of Psychiatry, Munich, Germany; 6 Clinic for Endocrinology and Metabolic
Disorders, University of Magdeburg, Germany
Figure 1: Frequency of clinician and lab-defined (ADA) diabetes mellitus by age and gender in %
Background
Cardiovascular diseases account for more than two thirds of the deaths in
patients with type 2 diabetes mellitus (DM). Three fourths of these deaths
result from ischemic heart disease. Type 2 DM increases coronary heart
disease risk two to three times in men and three to seven times in women.
Yet, only a fraction of patients needing therapy seems to be recognized and
receives adequate antidiabetic and lipid-lowering treatment1-6.
Aims
DETECT7
The epidemiological study
(Diabetes-Cardiovascular Risk
Evaluation: Targets and Essential Data for Commitment of Treatment) was
launched to identify the reasons, the extent and the short-term consequences
of unmet needs in patients at high cardiovascular risk (especially DM
patients), using a representative sample of primary care offices in Germany.
This evaluation of our dataset focused on the frequency of DM, detection
rates of clinicians, as well as the extent and quality of treatment and
prescribed medications in primary care.
Methods
Design:
DETECT is a large multistage cross-sectional study of 55.518 unselected
con-secutive patients in 3.188 primary care offices in Germany. In a
prospective 12-month component, 7.519 patients of a random subset
underwent an additional standardized laboratory program with focus on
cardiovascular risk assessments. Patients‘ self-assessments and physicians’
assessments of each patient were obtained. The data reported are based
exclusively on the laboratory subset of patients and are not yet adjusted for
non-response and sampling design effects. Further details are available
under http://www.detect-studie.de. A more detailed description of the study
design can be found on poster no. 28 titled: ‘Combined Hypertension and
Dyslipidemia in Germany’.
Diabetes:
Blood samples for the measurement of fasting plasma glucose were taken
and the diagnosis DM was given according to the guidelines of the American
Diabetes Association (ADA; fasting plasma glucose ≥ 126 mg/dl, no caloric
intake for at least 8 h) or clinical history (physician’s diagnosis or being on
antidiabetic medication).
Lipids and lipoproteins:
Cholesterol and triglycerides were measured using enzymatic methods and
reagents from Roche Diagnostics (Mannheim, Germany). The lipid
measurements were calibrated using secondary standards for automated
analysers (Roche Diagnostics). LDL-cholesterol was determined by
quantitative agarose gel electrophoresis (Helena, Germany).
Results
In 7.376 out of 7.519 patients analysis of HbA1c, fasting plasma glucose and
lipoproteins were performed (see Table 1).
Table 1: Demographic characteristics
N=7.519
17,6% of the patients in the lab subsample
were identified as diabetics (4,8% Type 1;
95,2% Type 2) by the treating physicians.
The occurrence of DM increased with
advancing age of the patients (36,7% at
the age of 70 to 79 years; see figure 1).
According to the guidelines of the ADA
(fasting plasma glucose ≥ 126 mg/dl, no
caloric intake for at least 8 h) or clinical
history (physician’s diagnosis or being on
antidiabetic medication), 21,7% of the
patients were identified as diabetics. DM
was more frequent in men (27,4%) than in
women (17,7%).
Sex: male
female
3.081 (41%)
4.438 (59%)
Mean Age
57,7 years
Mean Body Mass Index
[kg/m2]
27,2 kg/m²
Overweight (BMI 25-29,99) /
Obesity (BMI 30)
[%]
39,2% /
25,5%
Mean HbA1c1 [%]
5,6%
Current Smoker [%]
21%
Mean Systolic blood pressure
[mmHg]
132,7 mmHg
Mean Diastolic blood pressure
[mmHg]
80,2 mmHg
Mean Total-cholesterin [mg/dl]
223,3 mg/dl
Mean HDL-cholesterin [mg/dl]
54,4 mg/dl
Mean LDL-cholesterin [mg/dl]
127,5 mg/dl
Mean Triglycerides [mg/dl]
154,4 mg/dl
Freq. in %
Freq. in %
45
45
40
40
physicians diagnosis
physicians diagnosis
ADA criteria
ADA criteria
35
35
30
30
25
25
20
20
15
15
10
10
5
5
0
0
18-29
30-39
40-49
50-59
60-69
70-79
80+
18-29
30-39
Age-groups women
40-49
50-59
60-69
70-79
80+
Age-groups men
Only 81% of the diabetic patients were previously recognized by their physicians,
19% were newly identified by our screening program. Only about three quarters
(72,7%) of the known patients with DM received antidiabetic medication (41,4%
metformin, 26,3% insulin, 29,5% sulfonylurea, 6,5% glucosidase-inhibitors, 4,2%
glitazones, and 3,4% glinides). About one third of the diabetic patients (32,8%) was
treated with lipid-lowering medication, mainly with statins (30,4%; see figure 2).
Figure 2: Prescription rates for antidiabetic and lipidlowering drugs
Statins
30,4
32,8
Lipid-lowering treatment
Glinides
3,4
Glitazones
4,2
6,5
Glucosidase-inhibitors
Sulfonylurea
29,5
Insulin
26,3
Metformin
41,4
0
10
20
30
40
50
Freq. in %
The majority of the diabetics did not meet the ADA treatment goals for fasting
glucose (53,9%), HbA1c (35,1%), LDL-cholesterol (75,9%), triglycerides (54,9%)
and blood pressure (87,3%).
Summary
According to the criteria of the ADA 21,7% of the sample was identified to be
diabetic. DM was more frequent in men (27,4%) than in women (17,7%). The
occurrence of DM increased with advancing age of the patients (36,7% in the
age group of 70 to 79 years). Surprisingly, only 81% of the diabetic patients
were previously recognized by the physicians, approximately 20% were newly
identified by our screening program.
About two thirds of these patients received antidiabetic medication,
approximately a third received lipid-lowering therapy mainly with statins. The
majority of the diabetic patients did not meet the ADA treatment goals for
plasma glucose (>50%), lipids (LDL-C>75%) and blood pressure (>85%).
Epidemiological data from national health registries in Germany estimate the
prevalence of DM in the general population to be 5-8%8-11. As expected the
prevalence in a primary care sample is higher. In another cross-sectional
German study the prevalence of diabetes was 15,6% based on physician’s
diagnoses12. The combination of measuring fasting plasma glucose and using
the 2-hour oral glucose tolerance test, as recommended by the WHO and the
IDF, would most likely result in even higher rates for DM13.
The presented results indicate that a significant proportion of diabetic patients
were not recognized by the physicians and the treatment of DM was often
insufficient. Patients with DM are at high risk for CHD. Lipid-lowering therapy
however, was inadequate in these patients.
Contact: Dr. med. Steffen Böhler, Institute of Clinical Pharmacology, Medical Faculty Carl Gustav Carus, Technical University Dresden, Fiedlerstrasse 27, 01307 Dresden,
Tel: +49351-4582815, Fax: +49351-4341, E-Mail: [email protected].
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614–620. 5. Pekkanen J, et al. N Engl J Med 1990; 322: 1700–1707. 6. Rosengren A, et al. Eur Heart J 1997; 18: 754–761. 7. Böhler S, et al. Exp Clin Endocrinol Diabetes 2004; 112: 157-170. 8. Michaelis D et al. Z Klin Med
1991; 46: 59-64. 9. Hauner H. Dtsch Med Wochenschr 1998; 123: 777-782. 10. Thefeld W. Gesundheitswesen 1999; 61: 85-89. 11. Palitzsch K, et al. Diabetes und Stoffwechsel 1999; 8: 189-200. 12. Lehnert H, et al. Dtsch
Med Wochenschr (in press). 13. Janka H, et al. Evidenzbasierte Diabetes-Leitlinien DDG. 1. Auflage. Düsseldorf: Deutsche Diabetes-Gesellschaft; 2000. 1-38: 1-40.