Thomas Grimmsmann

ZUSAMMENFASSUNG: Fragestellung Die Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) ist eine der häufigsten psychischen Störungen bei Kindern, mit zunehmender Bedeutung auch bei Erwachsenen. Es sollte untersucht werden, welche Bedeutung Neurologen und Psychiater bzw. Hausärzte sowie Kinder- und Jugendärzte bei der Verordnung von ADHS-Medikamenten in Deutschland spielen und ob sich ihre Bedeutung im 10-Jahres-Zeitraum von 2008 und 2018 verändert hat. Methode In dieser Sekundäranalyse von anonymisierten Verordnungsdaten berechneten wir die absoluten und relativen Häufigkeiten der ADHS-Verordnungen von Neurologen und Psychiatern – zusammengefasst als Spezialisten – und Hausärzte sowie Kinder- und Jugendärzte – zusammengefasst als Generalisten – zwischen 2008 und 2018. Ergebnisse Insgesamt 620 Praxen lieferten Daten für 77 504 Patienten mit der Diagnose ADHS, 38% (29 396/77 504) von ihnen hatten im Studienzeitraum mindestens einmal ein Rezept für ein ADHS-Medikament erhalten. Im Laufe der Zeit beobachteten wir eine Verlagerung von Generalisten zu Spezialisten. Erhielten im Jahr 2008 noch 59% der Patientinnen und Patienten ihre Verordnung von einem Generalisten und 41% von einem Spezialisten, so drehte sich das Verhältnis im Jahr 2018 ins Gegenteil: nur noch 37% erhielten ihr Medikament von einem Generalisten und die überwiegende Mehrheit (63%) von einem Spezialisten. Besonders deutlich war diese Entwicklung bei Erwachsenen: 58% von ihnen erhielten ihr ADHS-Medikament im Jahr 2008 von einem Spezialisten, im Jahr 2018 waren es bereits 80%. Der Anteil bei Kindern- und Jugendlichen mit Verordnung vom Spezialisten stieg im gleichen Zeitraum von 38% auf 51%. Schlussfolgerung Es gibt eine Verschiebung in der Arzneimittelversorgung weg von Generalisten hin zu Spezialisten, ohne dass bisher über Vor- oder Nachteile diskutiert wurde. Dies wäre jedoch wünschenswert, nicht zuletzt, weil Spezialisten allein möglicherweise nicht über genügend Ressourcen verfügen, um alle ADHS-Patienten zu versorgen.

Zusammenfassung: Hintergrund und Ziel Benzodiazepine und Z-Substanzen werden in erheblichem Umfang auf Privatrezept auch für gesetzlich Krankenversicherte verordnet, mit ehemals großen Unterschieden zwischen Ost- und Westdeutschland. Ziel der vorliegenden Studie ist es zu untersuchen, ob diese Unterschiede auch heute noch bestehen. Methode Die Sekundärdatenanalyse nutzte anonymisierte Verordnungsdaten von niedergelassenen Hausärzten, Neurologen und Psychiatern. Eingeschlossen wurden gesetzlich Krankenversicherte mit mindestens einer Verordnung eines Benzodiazepins oder einer Z-Substanz zwischen 2014 und 2020. Unterschiede zwischen Ost- und Westdeutschland im Anteil der Privatverordnungen waren zentrales Outcome. In multiplen Regressionsanalysen wurde geprüft, ob die Faktoren Region (Ost- vs. Westdeutschland) und Facharztgruppe (Hausärzte vs. Neurologen/Psychiatern) statistisch signifikante Prädiktoren für den Anteil an Privatverordnungen sind – unter Berücksichtigung der Alters- und Geschlechtszusammensetzung der Patienten einer Praxis. Ergebnisse Aus 867 Praxen wurden 2.200.446 Verordnungen von Z-Substanzen, Benzodiazepin-Anxiolytika und Benzodiazepin-Hypnotika/Sedativa ausgewertet. Über 38% dieser Verordnungen wurden in Form von Privatrezepten ausgestellt; in Ostdeutschland lag der Anteil bei 53,6%, in Westdeutschland bei 34,8%. Für Z-Substanzen war der Anteil an Privatverordnungen besonders hoch (70,7% in Ost- und 43,0% in Westdeutschland). Hausärzte griffen weit häufiger als Neurologen und Psychiater zu Privatverordnungen. Der Anteil von Privatverordnungen stieg im Untersuchungszeitraum an, vergleichsweise stark in den westlichen Bundesländern (von 33% auf 39%), geringfügig in den östlichen Bundesländern (von 53% auf 54%). Im multivariaten Modell waren die Region (Ost/West) und die Facharztgruppe ähnlich starke Prädiktoren für das Ausmaß an Privatverordnungen, besonders bei Z-Substanzen. Schlussfolgerung Entgegen einer allgemeinen Angleichung von Lebenserwartung, Morbiditätsrisiken und Gesundheitsverhalten in Ost- und Westdeutschland gibt es, trotz Annäherung, weiterhin einen deutlichen Unterschied zwischen beiden Regionen im Anteil an Privatverordnungen bei Benzodiazepinen, speziell bei Z-Substanzen. Die Arztgruppen, die maßgeblich diese Substanzen verordnen, nämlich Neurologen und Psychiater auf der einen, Hausärzte auf der anderen Seite unterscheiden sich ebenfalls erheblich in der Quote ihrer Privatrezepte für diese Substanzen.

Purpose: To analyse (1) how often patients insured under the statutory health insurance (SHI) scheme received repeated prescriptions for benzodiazepines or Z‐drugs as private prescriptions and (2) how often doctors switched from SHI prescriptions to private prescriptions and vice versa when issuing repeat prescriptions.Methods: On basis of anonymized prescriptions from 874 ambulatory practices in Germany, we analysed the percentage of private prescriptions for Z‐drugs, benzodiazepines/anxiolytics, and benzodiazepines/hypnotics and sedatives over 6 years (2014 to 2020).Results: Of 2 200 446 prescriptions for a benzodiazepine or Z‐drug, 38% were private prescriptions. In case of Z‐drugs, the rate of private prescriptions was 44.1% for single prescriptions and 48.9% for refills. The difference was smaller for anxiolytics (23.3% vs. 26.0%) and, for benzodiazepine/hypnotics and sedatives, the proportion of private prescriptions for refills was even lower than for single prescriptions. In case of Z‐drugs, the proportion of private prescriptions was, on average, 42.7% for the first prescription of a series of repeat prescriptions and 49.6% for the tenth prescription. The increase was smaller for anxiolytics and negligible for benzodiazepine/hypnotics and sedatives. Doctors stayed with their initial decision in more than three quarters of repeat prescriptions, be it a SHI or private prescription.Conclusion: While we observed a large number of private prescriptions for benzodiazepines and Z‐drugs, the proportion was only slightly higher for refills than for single prescriptions. Doctors do not seem to issue private prescriptions as a strategy to mask especially long‐term use of these substances.

Purpose: The aim of this study was to analyse whether the global trend in drug prescriptions for attention-deficit hyperactivity disorders (ADHD), as observed during the last years and often criticized as medicalization, have remained stable or shifted. Methods: This observational study was based on a secondary analysis of data from a large German database including patients with an ADHD diagnosis between 2008 and 2018. Prescription data comprised all important ADHD drugs. Results: A total of 620 practices delivered data from a total of 77,504 patients (31% of them females) with a diagnosis of AHDH. Nearly 38% (29,396/77,504) of all patients received, at least, one prescription for an ADHS medicine between 2008 and 2018. The number of patients receiving a drug steadily increased annually until 2012 and then slowly fell, but unevenly distributed across the age groups. While the number of younger patients ( ≤ 16 years) receiving a prescription fell by 24% and the defined daily doses (DDDs) remained stable, the number of patients between 17 and 24 years receiving a prescription increased by 113% and the DDDs by 150%. Respectively, the number of older adults (≥ 25 years) with a prescription increased by 355% and the DDDs by 515%. Nearly one-third of older adults received an ADHD medicine only once. Conclusion: The ever-increasing prescription of ADHD medicines stopped some years ago for children. ADHS and its pharmacological management are increasingly observed among older adolescents and adults, with a different pattern of drug persistence compared with children.

To study drug persistence for antihypertensive treatment considering typical patient behaviour including extended drug holidays or irregular repeat prescriptions.

Purpose Defined daily doses (DDD) are used for the measurement of drug utilisation. The aim of the study was to analyse whether differences between DDD and prescribed daily doses (PDD) exist for relevant drug classes such as antihypertensive drugs and, if so, whether they primarily depend on drug classes or patient-related factors. Methods Using the data of a large German statutory health insurance scheme, we analysed continuous prescriptions for the following antihypertensive drug classes: thiazide diuretics, beta-blockers, dihydropyridine calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-II receptor blockers (ARBs). We summed the doses of all dispensed drugs per person during a defined time frame. We calculated the PDD (= total dose divided by the number of days) and expressed them as the PDD:DDD ratio (= amount of DDD per day and person). Results During the study period, 149,704 patients continuously received an antihypertensive medication. The average PDD:DDD ratio ranged from 0.84 (beta-blockers) to 1.88 (ARBs) and 2.17 (ACEIs). The average prescribed dosage of each drug class remained unchanged, even if the patients had previously received another antihypertensive drug with another PDD:DDD ratio. For example, if patients were switched from a beta-blocker to an ACEI, the PDD:DDD ratio increased, on average, from 0.79 to 2.17. Vice versa, the ratio decreased for patients with a drug change from an ACEI to a beta-blocker from 2.06 to 0.75. Conclusions Even large differences between DDD and PDD seem to be a matter of drug classes and not primarily of patient characteristics.

Defined daily doses (DDD) are used to analyse drug utilisation. For frequently prescribed drug groups, we studied to what extent the DDD correspond to the average prescribed daily doses (PDD). We analysed all drugs prescribed for more than three months to insured of a large health insurance fund in Mecklenburg-Vorpommern, one federal state in Germany. PDD for plain ACE inhibitors, selective beta-antagonists and some antidiabetics (sulfonylurea compounds) were calculated and compared with their DDD. During the study period, about 38 500 patients received continuous prescriptions of each ACE inhibitors or selective beta-antagonists, and about 9 000 of sulfonylurea compounds. PDD differed from DDD in varying degrees. For ACE inhibitors, PDD ranged between 1.5 DDD (for captopril) and 3.5 (for ramipril). The PDD for beta antagonists were on average 0.9 DDD, similar for bisoprolol (0.8 DDD) and metoprolol (0.9 DDD). As for oral antidiabetics, doctors prescribed 1.0 DDD glibenclamid per day and patient and 2.0 DDD glimepirid. Depending on differences between DDD and PDD, real daily costs for drug therapy differed from the theoretical costs per DDD, for example in the case of ramipril they were 0.24 euros compared to 0.07 euros. The PDD were much higher than the DDD for several frequently prescribed drugs. Consequently, the daily drug costs exceeded the drug costs based on DDD. Evaluations of drug costs on the basis for DDD require careful interpretation. Moreover, the number of DDD alone is not a valid measurement for the appropriateness of drug therapy and can only give a rough estimate of the number of patients treated, at least for the drug groups in this study.

Objective To explore the influence of hospitalisation on the prescription of drugs in the primary care sector using prescription data of a major statutory health insurance (SHI) organisation, with a special focus on the so-called “Me-Too” drugs – in particular, 3-hydroxy-3-methyl-glutaryl (HMG) CoA reductase inhibitors (statins) and proton pump inhibitors (PPIs). Methods A comprehensive outpatient drug prescription analysis was conducted on members of a SHI who had been hospitalised during the first 3 months of 2004. The number and costs of all prescriptions of 2426 patients during a 3-month period before admission and after discharge, respectively, were compared using Wilcoxon’s signed rank test. Data are shown in absolute and relative numbers as well as relative risks (RR) and their 95% confidence intervals (CIs). Results The total number of prescriptions before hospitalisation and after discharge remained nearly the same, while the number of different active substances prescribed per patient decreased by 4%. However, overall costs increased after discharge by 15% due to the higher cost per prescription. Changes in medication affected nearly every patient (98.1%), and 60% had at least five changes. Of the substances prescribed to an individual before admission, 57% were cancelled after discharge, and 55% of all substances prescribed after discharge were novel prescriptions. Significantly more patients received a PPI or statin after hospitalisation (RR for a PPI: 1.27; 95% CI: 1.12 –1.45; RR for a statin: 1.16; 95% CI: 1.02–1.32). The increase in PPI medication was due to a 58% increase in the number of patients receiving pantoprazole, a “Me-Too” drug. Conclusion Hospitalisation exerts a marked influence on drug therapy in ambulatory care, with a significant increase in the prescription of novel, on-patent drugs instead of less expensive alternatives.