gms | German Medical Science

Background: The telephone-based coaching program for chronic ill patients with diabetes mellitus “Intensivberatung Diabetes mellitus” is an addition to the national structured care program (“DMP”) for diabetes patients. It is designed to decrease the progression of diabetes mellitus and to avoid cost-intensive sequelae and concomitant diseases. Patients eligible are selected by an algorithm which relies on age, previous hospitalisations and amount of practitioners prescribing antidiabetics or antidiabetics and medication for hypertension. Currently more than 3000 patients participate in the coaching program. Incident patients are contacted and undergo a problem-oriented case management by experienced health care coaches aimed to advice patients regarding lifestyle management, physicians surveillance, medication use and risk management. This study should give insight in the treatment and comorbidities of diabetes patients and whether pharmacotherapy of the treating doctors addresses these facts.

Materials and methods: In a subset of diabetic patients, who inscribed in the programme in the 4. quarter in 2009, data on medication use up to 4 quarters before (period 1) and 4 quarters after (period 2) inclusion of the programme was selected. This cohort consisted of 262 patients (172 male/90 female; age 17–76 years). Using Risk Classification Groups (RCG^®), a condensation of ICDs in groups of chronic conditions, we analysed comorbidities, summarized the prescriptions of the 4 quarters in each period and derived the arithmetic mean.

Results: The mean value of RCG´s per patient is 10.2 (min. 2, max. 23). Most of the patients have also hypertension (83.5%), other moderate endocrine and metabolic disorders or nutritional disturbances (82.5%), pain disorders/diseases of musculoskeletal system (74.8%) and mental disorders (69. 4%). We found a gradual increase in the use of insuline preparations (fast acting insuline and analoga 43.6% in period 1 vs. 49.6% in period 2, intermediate acting insuline and analoga 14.2% vs. 19.1%, long acting insuline and analoga 14.4% vs. 17.5%, intermediate acting insuline mixed with fast acting insuline and analoga 3.4% vs. 4.2%), suggesting intensified insuline therapy after entering the programme. An increase was also noted for the use of statins (26.7% vs. 30.1%) and the rate of ACE-inhibitors or angiotensin-receptor-blockers (66.8% to vs. 70.2%). The rate for platelet inhibitors remained widely unchanged (10.7% to 10.8%), indicating no apparent deterioration of the patients condition. A decline was noted in the use of oral antidiabetics: metformine (66.1% vs. 62.0%), sulfonylureas (16.9% vs. 13.3%) and glitazones (5.8% vs. 3.8%).

Conclusion: The increase of the prescription of insuline (analoga, fast acting insuline and premixed-insulin) might be a result of the intensification of the therapy with insuline caused by unsatisfying blood-glucose-rates, higher consumption of insuline due to increase of weight or adaption of the therapy in consequence of a malfunction of oral antidiabetics on type 2 diabetes patients. Probably the last fact could be explained with the decrease of the prescribtions of oral antidiabetics. Follow-up analyses, including metabolic-parameters, weight and type of diabetes (in particular analyses for type-2) should be done. The high rate of the concomitant disease hypertension or sequelae like nephropathy might be a reason for the increasing prescription-rate of ACE-inhibitors or angiotensin-receptor-blockers. This should be verified in further analyses. Also it might be interesting to examine to what extend participants of this program get a pharmacotherapy more conform to medical guidelines than other patients.