Comments on “Disease Management Programmes in Germany”

The reflection which follows offers a few comments on the article on the SHA website entitled Disease Management Programmes in Germany . Although the presentation which accompanies the article is on the web it is barely audible . Some of the points I raise may be answered when I’m able to watch the video.


The article begins by noting the high demand on healthcare by patients with chronic conditions. It is regrettable that the article includes a meaningless pair of charts regarding the relationship between time and health status and between time and cost. There is no labelling on these charts so they do not state how health status and cost are measured, and the period of time covered by the charts.

Disease management programmes

Since patients with a chronic condition are treated by a large number of clinicians in several settings it is vital, as the article notes, that all data on a patients’ conditions and treatment are collected to an agreed consistent standard. That set of data should then be available to every clinician who treats the patient. The means of sharing data is to hold records electronically and access these by means of a unique patient identifier.

The author notes that “Such systems are still underdeveloped even in upper income countries.”

There is a Europe-wide project known as SemanticHealthNet which has among its aims the establishment of an agreed common terminology across the healthcare systems of each country in Europe. There is no reference to this project in the article, which is surprising given that there are some areas of Europe where patient data is being shared effectively across healthcare providers and commissioners.

Evaluating Disease management programmes

The figures presented in the article suggest that although the number of German patients with a chronic condition recruited to a DMP is increasing there are still many with a chronic condition not enrolled on a DMP. In 2010 in North Rhine only 42% of patients with coronary artery disease were members of a DMP.

The list of quality regulations for DMPs is similar to many of the indicators in the NHS Quality Outcomes Framework (QOF). Like the QOF the DMPs are set targets for eg prescribing drugs and controlling blood pressure. Some of these targets are much less than 100%. As with QOF targets what is the incentive to improve for a clinician who has reached a target for eg the proportion of patients prescribed a statin?

Since I’ve not heard the presentation I do not wish to comment on the odds ratios listed. The table describing change in blood pressure over time should state the number of patients in each group, and this also may be discussed in Professor Lauterbach’s presentation.

The table comparing the costs on the DMP for diabetes with patients not on a DMP raises as many questions as it answers. Although the table does not say so these figures appear to be the cost per patient. The overall cost in 2007 for DMP patients was around $600 less than that for patients not on a DMP. The drug costs for each of these patients are stated as being virtually the same. This is curious since earlier the article has shown that DMP patients received more prescribed drugs than those not on the programme. The difference in the overall costs of the two groups is due to differences in hospital costs. This however is also a curiosity. The median number of hospital stays both for patients on a DMP and those not on a DMP is 0. In other words at least half the patients in each group were not admitted to hospital. There is not a big difference between the number of hospital stays in each group. There was an average of 0.55 hospital stays among the DMP group and 0.62 in the non-DMP group. The table does not state if this difference is statistically significant. The difference between the two groups is the length of hospital stay. The DMP group had an average stay of 4.97 days compared to 6.41 for the non-DMP. It would be of interest to have more information on the reasons for admission for each group.


Although there is no doubt that patients on a defined care pathway receive better care and tend to have better outcomes than those not on a pathway the article does not make the case for DMPs sufficiently convincingly. One benefit of linking patient data the article does not mention is the scope for using these datasets for the monitoring, planning and evaluation of healthcare. By using anonymised linked datasets managers of healthcare have the means to create more efficient and effective healthcare systems than are provided now