Selective enrollment in Disease Management Programs for coronary heart disease in Germany – An analysis based on cross-sectional survey and administrative claims data

Abstract

BackgroundIn 2002, Disease Management Programs (DMPs) were introduced within the German healthcare system with the aim to increase the quality of chronic disease care. Due to the enrollment procedures, it can be assumed a) that only certain patients actively decide to enroll in a DMP and/or b) that only certain patients get the recommendation for DMP enrollment from their physician. How strong this assumed effect of self- and/or professional selection is, is still unclear.MethodsWe used data from a cross-sectional postal-survey linked on individual level with administrative claims data from a German sickness fund. The sample consisted of individuals suffering from coronary heart disease (CHD) who i) were either enrolled in the respective DMP or ii) fulfilled the disease related criteria for enrollment but were not enrolled. We applied multivariate logistic regression analyses to assess factors on patient level associated with DMP enrollment.ResultsWe included 7070 individuals in our analyses. Male sex, higher age and receiving old age pension, a higher Charlson Score and a diagnosis of type 2 diabetes increased the odds for DMP-CHD enrollment significantly. Individuals with a diagnosed myocardial infarction (MI) were also more likely to be enrolled in the DMP-CHD. We found a significant interaction effect for MI and sex, indicating that the association between MI and DMP enrollment is stronger for women than for men.ConclusionDMP-enrollees and non-enrollees differ in various factors. Studies analyzing the effectiveness of DMP-CHD should carefully take into account these group differences. Furthermore, the results suggest that the DMP-CHD assessed reaches men better than women.

Participation in Disease Management Programs and Major Adverse Cardiac Events in Patients After Acute Myocardial Infarction.

“…Similar results (enrollment rate of 72%) were found throughout Germany in 2013 by Röttger et al [23] in patients with coronary heart disease. Possible explanations could be regional socio-economic differences and health characteristics of the respective cohorts as well as the time span between the studies [21,23]. In conclusion, it is apparent that the DMPs cannot reach their required target group in Saxony-Anhalt.…”

“…It is also remarkable, that the proportion of enrollment in DMP of about one quarter is substantially lower than the 77%, which was found eight years ago in a comparable study in the region of Augsburg by Laxy et al [16]. Similar results (enrollment rate of 72%) were found throughout Germany in 2013 by Röttger et al [23] in patients with coronary heart disease. Possible explanations could be regional socio-economic differences and health characteristics of the respective cohorts as well as the time span between the studies [21,23].…”

“…However, eighteen years after the introduction of the first DMP for coronary heart disease, there is still insufficient evidence regarding DMP effectiveness. Besides the mandatory evaluations of the insurance companies, only few studies were published, and they mostly focused on DMPs related to diabetes mellitus [16][17][18][19][20][21][22][23][24][25]. Since DMPs were introduced all over Germany as a mandatory service, only observational studies can contribute further evidence on their performance [26].…”

What should governments be doing to prevent diabetes throughout the life course?

“…As regards coordinated care programmes, the German disease-management programmes were implemented as policy initiatives 15 years ago and showed promising results in several evaluations [62,64]. However, an analysis recently revealed that characteristics such as male sex, increased age and receiving a pension were associated with higher odds for enrolment in these programmes [101]. For policy makers, this is important on two counts: on the one hand, these results show that the effectiveness of structured care programmes may differ between certain subpopulations, on the other hand, they highlight a need to ensure equal odds for the enrolment of different groups.…”

Patients with coronary artery disease after acute myocardial infarction: effects of continuous enrollment in a structured Disease Management Program on adherence to guideline-recommended medication, health care expenditures, and survival

“…Contrary to other countries, in which DMPs were implemented with a focus on scientific evidence, in Germany, DMP rollout was accompanied by an elaborate legal framework that involved quality-of-care requirements, a strict accreditation process, and strong financial incentives for statutory health insurance funds to set up programs [14]. Five studies [15][16][17][18][19] evaluated CAD DMPs in Germany all using survey data. These studies assessed influence of patient characteristics [15], educational attainment and area deprivation [16], or the horizontal inequity indices and socio-economic status [17] on DMP enrollment.…”