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Populationsweite Utilisationsuntersuchung in Den Chronischen Krankheitsbildern Hypertonie, Hyperlipid¨Amieund Typ 2 Diabetes Mellitus –

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Populationsweite Utilisationsuntersuchung in Den Chronischen Krankheitsbildern Hypertonie, Hyperlipid¨Amieund Typ 2 Diabetes Mellitus – Ruhr-Universit¨atBochum Prof. Dr. rer. nat. Hans J. Trampisch Dienstort: Abteilung f¨urMedizinische Informatik, Biometrie und Epidemiologie Populationsweite Utilisationsuntersuchung in den chronischen Krankheitsbildern Hypertonie, Hyperlipid¨amieund Typ 2 Diabetes Mellitus { Eine Studie des Projekts PUKO-BHD an der Medizinischen Universit¨atWien Inaugural-Dissertation zur Erlangung des Doktorgrades der Medizin einer Hohen Medizinischen Fakult¨at der Ruhr-Universit¨atBochum vorgelegt von: Lisanne M. Jandeck aus Herford 2014 Dekan: Prof. Dr. med. Albrecht Bufe Referent: Prof. Dr. rer. nat. Hans J. Trampisch Korreferent: Prof. Dr. med. J¨urgenWindeler Tag der M¨undlichen Pr¨ufung:09.02.2017 Abstract Jandeck Lisanne M. Populationsweite Utilisationsuntersuchung in den chronischen Krankheitsbildern Hypertonie, Hyperlipid¨amieund Typ 2 Diabetes Mellitus Problem: Hypertonie (HT), Hyperlipid¨amie(HL) und Typ 2 Diabetes Mellitus (DM) stellen die h¨aufigstenchronischen Erkrankungen in Osterreich¨ dar, besonders bei Uber-50j¨ahrigen.Die¨ Zielsetzung dieser Teilstudie Utilisation\ des Projekts mit " dem Titel PUKO-BHD { Pr¨avalenz, Utilisation, Kosten und Outcome bei Blut- " hochdruck, Hyperlipid¨amieund Typ 2 Diabetes Mellitus\ ist eine populationsweite epidemiologische Untersuchung zu der Utilisation von Arzneimitteln zur Behand- lung dieser Krankheiten, insbesondere in Bezug auf Mehrfachverschreibungen (dou- ble prescriptions, DP) und Verschreibungen von Kombinationen von Wirkstoffen, die (schwerwiegende) Wechselwirkungen erzeugen k¨onnen (drug-drug interactions, DDI). Der m¨ogliche Nutzen der Studie liegt im Aufzeigen und ev. k¨unftigen Ver- meiden von Doppelverschreibungen desselben Wirkstoffs an eine/n PatientIn (Pat.) durch verschiedene ArztInnen¨ und durch die Vermeidung von Verschreibungen von Kombinationen, die miteinander Wechselwirkungen erzeugen k¨onnen, um die Pa- tientensicherheit zu erh¨ohenund Kosten zu senken. Methode: F¨urdie empirischen Analysen wurde eine pseudonymisierte Datenbank aller Arzneimittelverschreibungen in Osterreich¨ von 2007 teilweise, dann 2008 bis 2012 verwendet (Quelle: Hauptverband der ¨osterr.Sozialversicherungstr¨ager,HVB). Im Mittel sind darin eingel¨osteRezepte von 86 Antihypertensiva, 16 Lipidsenkern und 28 Antidiabetika erfasst. F¨urjedes Rezept wurde dessen zeitliche Abdeckungspe- riode mit Hilfe der durchschnittlichen verschriebenen Tagesdosis (average prescribed daily dosis, APDD) gesch¨atzt.Zur Ermittlung der DP/DDI wurden zwei verschiede- ne Pr¨avalenzen herangezogen: nach Pat. und nach Pat.-Jahren (PJ). Risikofaktoren (RF) f¨urDP/DDI wurden durch logistische Regression ermittelt. Ergebnis: F¨urdas Erhebungsjahr 2011 konnten eine Studienpopulation von ca. acht Mio. Versicherten und davon ausgehend die Patientenpopulation (Personen mit mind. einer Verschreibung von HT-, HL- oder DM-Pharmaka) festgelegt werden. Ins- gesamt waren 191.943 HT- (11,5%), 74.532 HL- (9,6%) und 34.047 DM-Pat. (9,5%) von DP betroffen; f¨urdie PJ lag der Anteil bei 0,8, 1,0 bzw. 0,6%. Verschreibungen mit potentiell schweren DDI (S.DDI) waren 3.032 HT- (0,18%), 404 HL- (0,05%) und 2.565 DM-Pat. (0,71%) ausgesetzt bzw. 0,3, 0,7 und 2,4 % der PJ. Als wichtiger RF f¨urDP konnte die Rezeptgeb¨uhrenbefreiung (RB) identifiziert werden; f¨urS.DDI die Komedikationen. Weiterhin waren Verschreibungen von Spit¨alernoder Internis- tInnen in gr¨oßeremMaße DP-exponiert, als die von praktischen ArztInnen¨ sowie die, die in den Sommermonaten erfolgten im Vergleich zu einer anderen Jahreszeit. F¨urDDI waren keine eindeutigen saisonalen Muster erkennbar. Diskussion: Die Studie zeigt, dass DP/DDI h¨aufiganzutreffen sind. Ein Teil der DP/DDI ist sicherlich auf die ordnungsgem¨aßezielgerichtete Therapie von Multi- morbidit¨atenzur¨uckzuf¨uhren,die nicht selten in Kooperation von Fach¨arztInnen realisiert wird. Weiterhin ist erkennbar, dass insbesondere fehlende finanzielle An- reize (RB) f¨ureinen beachtlichen Teil der DP verantwortlich sind { sowie bestimmte Komedikationen f¨urS.DDI. Eine Reduktion der DP/DDI k¨onnte zuk¨unftigdurch die st¨arkere Fokussierung auf eHealth-Systeme erreicht werden. 1 Inhaltsverzeichnis 1 Einleitung 11 1.1 Motivation . 11 1.2 Das Projekt PUKO-BHD . 15 1.2.1 Teilstudie Utilisation . 15 1.2.2 Ethische Aspekte . 16 1.2.3 Nutzen f¨urdie Versorgungspraxis . 17 1.3 Die drei chronischen Krankheitsbilder . 19 1.3.1 Hypertonie . 19 1.3.1.1 Pr¨avalenz und Definition . 19 1.3.1.2 Atiologie¨ . 20 1.3.1.3 Klassifikation und Stadieneinteilung . 21 1.3.1.4 Diagnostik . 22 1.3.1.5 Risikofaktoren und kardiovaskul¨aresGesamtrisiko . 24 1.3.1.6 Therapiem¨oglichkeiten von HypertonikerInnen . 25 1.3.2 Hyperlipid¨amie . 28 1.3.2.1 Definition der Serumlipide . 28 1.3.2.2 Einteilung der Hyperlipid¨amien . 30 1.3.2.3 Pr¨avalenz und Atiologie¨ . 31 1.3.2.4 Komplikationen und Folgeerkrankungen . 32 1.3.2.5 Pr¨aventions- und Therapiem¨oglichkeiten . 32 1.3.3 Diabetes Mellitus . 34 1.3.3.1 Pr¨avalenz . 35 1.3.3.2 Klassifikation: Typ 1 vs. Typ 2 DM und deren Atiologie¨ 35 1.3.3.3 Klinische Symptome und Diagnostik . 37 1.3.3.4 Komplikationen und Folgeerkrankungen . 40 1.4 Pharmakotherapie der drei Krankheitsbilder . 45 1.4.1 Pharmakotherapie der Hypertonie . 45 1.4.1.1 Die wichtigsten Wirkstoffgruppen: Firstline-Therapie 45 1.4.1.2 Therapiestrategien der Hypertonie . 51 1.4.2 Pharmakotherapie der Hyperlipid¨amie . 54 1.4.2.1 Wirkstoffgruppen . 54 1.4.2.2 Stufenschema zur Therapie einer Hyperlipid¨amie . 58 1.4.3 Pharmakotherapie des Typ 2 Diabetes Mellitus . 59 1.4.3.1 Wirkstoffgruppen . 59 1.4.3.2 Leitlinie zur Therapie des Typ 2 DM . 63 2 Zielsetzung 67 3 Methoden 69 3.1 Datens¨atzedes Hauptverbands der ¨osterreichischen Sozialversiche- rungstr¨ager . 69 3.1.1 Stammdatensatz . 69 3.1.2 Verschreibungs- bzw. Rezeptdatensatz . 69 3.1.3 Krankenhausaufenthaltsdatensatz . 70 3.2 Methodisches Vorgehen . 70 3.2.1 Erstellung der ATC-Listen f¨urdie drei Krankheitsbilder . 71 3.2.2 Mehrfachverordnungen (DP) . 71 3.2.3 Potentielle Wechselwirkungen (DDI) . 73 2 3.2.4 Sch¨atzungder Pr¨avalenzen von DP bzw. DDI . 74 3.2.5 Charakterisierung der Pat. und ArztInnen¨ mit DP bzw. DDI . 75 3.2.5.1 Ermittlung von Risikofaktoren: logistische Regres- sionen . 75 3.2.5.2 Klassifikation der Fachgruppen in der Gesundheits- versorgung . 76 3.2.5.3 Komedikationen . 78 4 Ergebnisse 80 4.1 Univariate Datenanalyse . 80 4.1.1 Darstellung von Versicherten- und Patientenpopulation . 80 4.1.2 Anzahl und Verteilung der Krankenhausaufenthalte . 82 4.1.3 Pr¨avalenzen der drei betrachteten Krankheitsbilder . 84 4.1.4 ATC Codes bzw. Wirkstoffe mit den h¨aufigsten Verordnungen f¨ur2011 . 98 4.2 Mehrfachverordnungen (DP) . 100 4.2.1 DP nach Anzahl bzw. Anteil der ATC Codes . 100 4.2.2 DP nach Anzahl bzw. Anteil an Pat. und PJ . 101 4.2.3 DP nach Geschlecht . 104 4.2.4 ATC Codes mit den h¨aufigstenDP f¨ur2011 . 107 4.2.5 Charakterisierung der Pat. und ArztInnen¨ mit DP f¨ur2011: Analysen f¨urdie sechs ATC Codes mit den h¨auftigstenDP . 117 4.3 Potentielle Wechselwirkungen (DDI) . 133 4.3.1 DDI nach Anzahl bzw. Anteil der ATC Codes . 133 4.3.2 DDI nach Anzahl bzw. Anteil der Pat. und PJ . 133 4.3.3 DDI nach Geschlecht . 135 4.3.4 ATC Codes mit den h¨aufigstenS.DDI f¨ur2011 . 144 4.3.5 Charakterisierung der Pat. und ArztInnen¨ mit S.DDI f¨ur2011: Analysen f¨urdie sechs ATC Codes mit den h¨aufigstenS.DDI . 147 5 Diskussion 164 6 Zusammenfassung 171 7 Literaturverzeichnis 174 Anhang 184 A ATC-Listen 184 A.1 Hypertonie . 184 A.2 Hyperlipid¨amie . 187 A.3 Typ 2 Diabetes Mellitus . 188 Danksagung 189 Lebenslauf 190 3 Abk¨urzungsverzeichnis A Alter (pro Dekade) ACE Angiotensin Converting Enzyme adj. adjustiert AGES Agentur f¨urGesundheit und Ern¨ahrungssicherheit AkdA¨ Arzneimittelkommission der deutschen Arzteschaft¨ ANV akutes Nierenversagen Anz. Anzahl APDD average prescribed daily dosis Apo-Verlag Osterreichische¨ Apotheker-Verlagsgesellschaft m.b.H. AR attributionales Risiko ArztInnen¨ Arzte¨ und Arztinnen¨ AT Angiotensin ATC anatomisch-therapeutisch-chemisches Klassifikationssys- tem f¨urArzneimittel ATC2 Second ATC-Level BB Blutbild Bez. Bezeichnung BMI Body Mass Index BZ Blutzucker/Blutglucose CCB calcium channel blockers CeMSIIS Zentrum f¨urMedizinische Statistik, Informatik und Inte- lligente Systeme CK Creatinkinase CM Chylomikronen comb. combination CT Konventionelle Insulintherapie CYP450 Cytochrom P450 Cyt. Cytochrom DDD defined daily dosis DDG Deutsche Diabetes Gesellschaft DDI drug-drug interactions/Wechselwirkungen Def. Definition DEGAM Deutsche Gesellschaft f¨urAllgemeinmedizin und Familien- medizin der. derivatives DFS Diabetisches Fuß-Syndrom DGIM Deutsche Gesellschaft f¨urInnere Medizin DHL Deutsche Hochdruckliga e.V. DiabetikerInnen Diabetiker und Diabetikerinnen Diagn. Diagnose diast. diastolisch DP double prescriptions/Mehrfachverschreibungen DPP4 Dipeptidyl-Peptidase-4 DM Typ 2 Diabetes Mellitus DS doctor shopping durchschn. durchschnittlich ES Endorgansch¨aden 4 ESC European Society of Cardiology ESH European Society of Hypertension FA Facharzt f.a. fast-acting f.i. for injection FI.DDI Wechselwirkungen nach Fachinformationen FV freundschaftliche`-Verschreibungen ' gesl Geschlecht GI gastrointestinal GIP Gastric Inhibitory Polypeptide Glc Glucose GLP-1 Glucagon-like Peptide-1 Hb H¨amoglobin HbA1c Glykoh¨amoglobin HCT Hydrochlorothiazid HDL High Density Lipoproteins HVB Hauptverband der ¨osterreichischen Sozialversicherungstr¨a- ger HL Hyperlipid¨amie HMG-CoA RI HMG-CoA-Reduktase-Hemmer/Statine HNO Hals-Nasen-Ohrenheilkunde HT Hypertonie HypertonikerInnen Hypertoniker und Hypertonikerinnen
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