title: Selection effects may account for better outcomes of the German Disease Management Program for type 2 diabetes.
abstract: BACKGROUND
  The nationwide German disease management program (DMP) for type 2 diabetes was introduced in 2003. Meanwhile, results from evaluation studies were published, but possible baseline differences between DMP and usual-care patients have not been examined. The objective of our study was therefore to find out if patient characteristics as socio-demographic variables, cardiovascular risk profile or motivation for life style changes influence the chance of being enrolled in the German DMP for type 2 diabetes and may therefore account for outcome differences between DMP and usual-care patients.
  
  
  METHODS
  Case control study comparing DMP patients with usual-care patients at baseline and follow up; mean follow-up period of 36 ± 14 months. We used chart review data from 51 GP surgeries. Participants were 586 DMP and 250 usual-care patients with type 2 diabetes randomly selected by chart registry. Data were analysed by multivariate logistic and linear regression analyses. Significance levels were p ≤ 0.05.
  
  
  RESULTS
  There was a better chance for enrolment if patients a) had a lower risk status for diabetes complications, i.e. non-smoking (odds ratio of 1.97, 95% confidence interval of 1.11 to 3.48) and lower systolic blood pressure (1.79 for 120 mmHg vs. 160 mmHg, 1.15 to 2.81); b) had higher activity rates, i.e. were practicing blood glucose self-monitoring (1.67, 1.03 to 2.76) and had been prescribed a diabetes patient education before enrolment (2.32, 1.29 to 4.19) c) were treated with oral medication (2.17, 1.35 to 3.49) and d) had a higher GP-rated motivation for diabetes education (4.55 for high motivation vs. low motivation, 2.21 to 9.36).
  
  
  CONCLUSIONS
  At baseline, future DMP patients had a lower risk for diabetes complications, were treated more intensively and were more active and motivated in managing their disease than usual-care patients. This finding a) points to the problem that the German DMP may not reach the higher risk patients and b) selection bias may impair the assessment of differences in outcome quality between enrolled and usual-care patients. Suggestions for dealing with this bias in evaluation studies are being made.
authors.affiliation: Department of Primary Medical Care, Center of Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr, 52, 20246 Hamburg, Germany.
authors.forename: Ingmar
authors.initials: I
authors.lastname: Schäfer
authors.forename: Claudia
authors.initials: C
authors.lastname: Küver
authors.forename: Benjamin
authors.initials: B
authors.lastname: Gedrose
authors.forename: Eike-Christin
authors.initials: EC
authors.lastname: von Leitner
authors.forename: András
authors.initials: A
authors.lastname: Treszl
authors.forename: Karl
authors.initials: K
authors.lastname: Wegscheider
authors.forename: Hendrik
authors.initials: H
authors.lastname: van den Bussche
authors.forename: Hanna
authors.initials: H
authors.lastname: Kaduszkiewicz
mesh_terms: D000368:Aged; D015190:Blood Glucose Self-Monitoring / Q000379:methods; D016022:Case-Control Studies; D003695:Delivery of Health Care / Q000592:standards; D003924:Diabetes Mellitus, Type 2 / Q000517:prevention & control / Q000628:therapy*; D019468:Disease Management; D005260:Female; D005500:Follow-Up Studies; D005858:Germany; D006442:Glycated Hemoglobin / Q000032:analysis; D019983:Guideline Adherence; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009313:National Health Programs; D017063:Outcome Assessment, Health Care / Q000592:standards*; D019984:Quality Indicators, Health Care; D012042:Registries; D012307:Risk Factors; D012959:Socioeconomic Factors
chemical_list: D006442:Glycated Hemoglobin