Diabetes accounts for a large share of excess morbidity and mortality globally.¹ Patients with type 2 diabetes mellitus (T2DM) are more susceptible to macro- or microangiopathic complications, such as myocardial infarction (MI), stroke, and peripheral arterial occlusive disease, than people without T2DM.² During the last decade, differences between men and women with T2DM have been intensively investigated, revealing a lower quality of life and mental well-being in women than in men, as well as a shorter survival in diabetic women than in diabetic men after acute MI.^3,4 Since glycemic control and diabetes-related complications are associated with healthcare utilization, the individual glycemic status has to be continuously checked in order to prevent an increase in comorbidity.⁵

Healthcare utilization seems to be higher among women than among men, especially at younger ages.^6,7 Although there are analyses of the association between healthcare utilization and T2DM, studies analyzing disparities between men and women are still rare.^8,9 Generally, it is assumed that T2DM-specifi c disease management programs (DMPDM) by sickness insurance funds improve outcome and process quality of medical care and limit gender-specifi c utilization differences due to their managing character.¹⁰ Although it was shown that DMP-DM improve process quality in Germany,¹⁰ gender differences in quality of life between DMP-DM patients remain.¹¹

The primary aim of this study was to investigate gender differences in healthcare utilization of patients with T2DM in Germany participating in large part in DMP-DM of sickness insurance funds with additional consideration of quality of glycemic control.

METHODS

Study Design and Study Population

This analysis was based on data from the baseline examination of the DIANA study (Type 2 Diabetes Mellitus: New Approaches to Optimize Medical Care in General Practice), an epidemiological prospective cohort study of patients with T2DM conducted in the Ludwigsburg- Heilbronn area located in southwest Germany. The study was initiated in 2008 to address (short- and longterm) diabetes-related outcomes and to evaluate potential for health services improvements in patients with T2DM. Participants 18 years and older with physician-diagnosed T2DM were recruited according to a standardized protocol by 38 general practitioners (GPs) during regular practice visits between October 2008 and March 2010. The study protocol was approved by the Ethics Committees of the medical faculty of the University of Heidelberg (reference S186/2008) and of the Chamber of Physicians of Baden-Württemberg (reference B-2008-168).

Inclusion criteria for patients were prevalent T2DM, a visit to one of the participating study practices between October 2008 and March 2010, and sufficient knowledge of the German language. We excluded nursing home residents as well as patients seen by the general practitioners for palliative or emergency care only. A total of 1146 unselected patients with physician-diagnosed T2DM gave written informed consent and completed a self-administered standardized questionnaire at baseline. Medical information was obtained from the GPs by a standardized questionnaire, and a blood sample was collected by the recruiting physicians for glycated hemoglobin (A1C) measurement. A1C was assessed by a central laboratory,using ion-exchange high-pressure liquid chromatography (HPLC) (G8, Tosoh Biosciences).

Definition of Key Variables

This analysis was based on data collected from patients’ and physicians’ questionnaires at baseline and the A1C levels reported by the cooperating central laboratory.

The covariates, such as age at time of recruitment, gender, level of school education, marital status, place of residence, living condition, occupational status, smoking history, and alcohol consumption, were obtained from the participant questionnaire. To estimate general health status, the fi rst question of the short-form-12 (SF-12) questionnaire (“In general, would you say your health is … ?”; response categories “poor,” “fair,” “good,” “very good,” and “excellent”) was used.¹²

Information on diabetes duration, participation in a DMP-DM, body mass index (BMI) (kg/m²), and total number of prescribed medications (diabetes medications and other medications combined) was taken from the physician questionnaire.

Information on prevalent comorbidities including hypertension, hypercholesterolemia, coronary heart disease, heart failure, MI, stroke, intermittent claudication, diabetic retinopathy, diabetic neuropathy, diabetic nephropathy, depression, and cancer was taken from the physician questionnaire. In the few cases (3.8%) where no medical information was available from the GPs, information was taken from the participant questionnaire. Prevalent coronary heart disease including history of myocardial infarction or stroke, heart failure, and intermittent claudication was summarized as cardiovascular disease.

According to the recommendations of the International Diabetes Federation (IDF), glycemic control was classifi ed by an A1C level >7.5% indicating poor glycemic control (PGC).¹³ This classifi cation is commonly used worldwide in order to anticipate the level of diabetes progression; ie, T2DM patients with an A1C level >7.5% have a poorer disease prognosis.

Our primary outcomes were the number of outpatient appointments with general practitioners or with medical specialists within the last 3 months as well as total numbers of prescribed medications, hospitalizations, and inpatient rehabilitations including length of stay (in days) within the last 12 months. The information was available from the patient questionnaire.

Statistical Analysis