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Kateryna Karimova, MSc; Lorenz Uhlmann, MSc; Marc Hammer, MPH; Corina Guethlin, PhD; Ferdinand M. Gerlach, MD, MPH; and Martin Beyer, MSc
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The Development of Diabetes Complications in GP-Centered Healthcare

Kateryna Karimova, MSc; Lorenz Uhlmann, MSc; Marc Hammer, MPH; Corina Guethlin, PhD; Ferdinand M. Gerlach, MD, MPH; and Martin Beyer, MSc
This study compared general practitioner–centered healthcare (Hausarztzentrierte Versorgung [HZV]) with non-HZV healthcare in Germany regarding the development of diabetes complications. HZV is associated with reduced risk of diabetes complications.

Objectives: To compare the development of diabetes complications, measured in terms of clinical end points, of patients enrolled in general practitioner (GP)-centered healthcare (Hausarztzentrierte Versorgung [HZV]) and patients in usual GP care (non-HZV) over 4 years. 

Study Design: Retrospective closed cohort study based on German claims data.

Methods: The main end points in our evaluation were dialysis, blindness, amputation, stroke, myocardial infarction, cardiovascular disease, hypoglycemia, and mortality. We used Cox proportional hazards regression models for multivariable analysis. 

Results: We included 217,964 patients in our study: 119,355 were enrolled in HZV and 98,609 were in non-HZV. Compared with non-HZV, the HZV group had a 15.6% lower risk of requiring dialysis during the 4 years of observation. Risks were also lower in the HZV group for all other end points except mortality. 

Conclusions: The results of the present study indicate that GP-centered healthcare is associated with a delay in the occurrence of serious diabetes complications and reduces the risk of diabetes complications. This may be because GP-centered care is associated with improved coordination of care. 

Am J Manag Care. 2018;24(7):322-327
Takeaway Points

This study compared the development of diabetes complications within general practitioner (GP)-centered healthcare in Germany (regional state of Baden-Württemberg).
  • GP-centered healthcare is associated with a delay in the occurrence of serious diabetes complications.
  • Differences in all-cause mortality rates could not be corroborated in the multivariable Cox regression.
  • Delaying diabetes complications cannot be directly attributed to either the disease management program (DMP) or GP-centered healthcare, as enrollment of patients into the DMP was a main feature of GP-centered healthcare.
Diabetes is among the most costly and prevalent chronic conditions in Germany, with 7% to 12% in the general population and 20% in the elderly population (>65 years) affected. Most patients (90%) have type 2 diabetes.1 The main aims of diabetes care are to reduce the risk of short- and long-term complications, increase longevity, and improve health-related quality of life.2,3 Diabetes is associated with macrovascular complications, including an increased risk of coronary heart disease or stroke, and microvascular complications, such as kidney failure, blindness, and amputation.4 In 2010, incremental medical costs attributed to diabetes were €2391 per patient. Of that amount, 26.5% was spent on the management of hyperglycemia (€633) and 73.5% on the treatment of complications (€1758).5

Interventions to improve quality of care for patients with diabetes should focus on the patients and their individual problems, as well as on restructuring care.6 Structured and well-coordinated healthcare that includes close monitoring can delay or prevent the onset of complications and thus improve the treatment of patients.7 General practitioners (GPs) in Germany play a central role in performing and coordinating the provision of care for their patients with diabetes.8 However, most German GPs work in small private practices (1 or 2 physicians) with no involvement in large managed healthcare plans. Two attempts to integrate chronic care structures into this system were the nationwide disease management program (DMP) and GP-centered healthcare contracts (in several federal states).

The GP-centered healthcare contract, Hausarztzentrierte Versorgung (HZV), aims to enhance healthcare for patients with chronic diseases and complex healthcare needs (eg, those requiring long-term care).9 The terms of HZV are based on §73b of Social Code Book V and were formulated in a contract that took effect in Baden-Württemberg, Germany, on July 1, 2008.10 Doctors who have registered to participate in GP-centered healthcare are required to perform the following tasks with respect to diabetes care: participation in structured quality circles on drug therapy (ie, small groups of physicians who receive feedback on their prescribing, evidence-based information, and plan improvements10), rigorous application of evidence-based guidelines developed for use in family healthcare, and participation in DMPs. Patients voluntarily enroll in HZV with a personal GP, who coordinates referrals (gate-keeping). To some extent, HZV is comparable with the Chronic Care Model (CCM)11 in the United States. Both models aim to foster self-management and structure healthcare for chronically ill patients. In a systematic review, Stellefson et al provide evidence that the CCM is effective in improving the health of people with diabetes.12

The DMP for diabetes mellitus (DM DMP) includes the implementation and audit of evidence-based clinical guidelines using quality indicators and quality assurance measures, regular recalls for patients (ie, a set number of visits per year), and individual goal setting and self-management by the patient with the physician’s active input, with consideration of the individual’s circumstances and risk profile.6

Only 18% of registered interventional diabetes studies include patient-oriented outcome measures as primary outcomes.13 Patient-oriented outcomes may be death and quality of life (compromised by major morbid events, such as stroke, myocardial infarction, amputation, loss of vision, and end-stage renal disease, or minor morbid events, such as hypoglycemic events). Most noninterventional evaluations of diabetes outcomes within integrated healthcare management programs have reported all-cause mortality6,7,14 or diabetes care costs2,15,16 as primary outcomes. All-cause mortality is an end point that must account for the possibility of competing risk factors, which are not always visible (nonmeasurable confounding) in claims data evaluations. Furthermore, lower costs do not always reflect better treatment. However, we regard clinically significant complications as the more relevant patient-oriented outcomes.

The aim of this retrospective closed-cohort study was to evaluate the development of diabetes outcomes in terms of clinically significant complications, comparing those of patients enrolled in GP-centered healthcare programs with those of patients in usual GP care.



The analysis was carried out as part of an evaluation of HZV in the German regional state of Baden-Württemberg and was fully approved by the ethics committee of Frankfurt University Hospital. All participants in the study were insured by the largest regional statutory healthcare fund, Allgemeine Ortskrankenkasse Baden-Württemberg (AOK-BaWü), which has 4 million members.


To be included in the study, participants had to have diabetes (International Classification of Diseases, Tenth Revision codes E10-E14), be ongoing AOK-BaWü members, live in Baden-Württemberg, be 18 years or older, not be participating in other healthcare programs, and satisfy further administrative inclusion criteria. Patients in the HZV group had to enroll in the program before January 1, 2011; patients in the usual care group had to have an identifiable GP. Patients who switched to other healthcare funds during the observation period (2011-2014) were excluded. We considered deceased patients to be censored observations until time of death. We had no missing values because of our inclusion criteria (available insurance data) and study design.

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