Background Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental health disorders among children, and it is rapidly surging among adults as well. The aim of this study was to investigate the role of community neurologists and psychiatrists as well as general practitioners and paediatricians in prescribing ADHD medications in Germany and whether their role has changed over the 10-year period from 2008 and 2018. Methods In this secondary analysis of anonymized prescribing data, we calculated the absolute and relative frequencies of ADHD prescriptions by neurologists and psychiatrists, summarized as specialists, and family physicians and paediatricians, summarized as generalists, and how it has changed during the years 2008 to 2018. Results A total of 620 practices delivered data on 77,504 patients diagnosed with ADHD, 38% (29,396/77,504) of them had received a prescription for ADHD medicine at least once in the study period. Over time, we observed a shift from generalists to specialists. While 59% of patients received their prescription from a generalist and 41% from a specialist in 2008, there was reverse in the ratio in 2018: only 37% received their medication from a generalist and the vast majority (63%) from a specialist. This trend was particularly evident among adults: 58% of them received their ADHD medication from a specialist in 2008, but 80% in 2018. The proportion of children and adolescents who received their prescriptions from a specialist rose from 38% to 51% over the same period. Conclusion There is a shift in drug prescription away from generalists to specialists, without any discussion of advantages or disadvantages so far. However, this would be desirable, not least because specialists alone may not have sufficient resources to care for all ADHD patients.

ZUSAMMENFASSUNG Fragestellung Die Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) ist eine der häufigsten psychischen Störungen bei Kindern, mit zunehmender Bedeutung auch bei Erwachsenen. Es sollte untersucht werden, welche Bedeutung Neurologen und Psychiater bzw. Hausärzte sowie Kinder- und Jugendärzte bei der Verordnung von ADHS-Medikamenten in Deutschland spielen und ob sich ihre Bedeutung im 10-Jahres-Zeitraum von 2008 und 2018 verändert hat. Methode In dieser Sekundäranalyse von anonymisierten Verordnungsdaten berechneten wir die absoluten und relativen Häufigkeiten der ADHS-Verordnungen von Neurologen und Psychiatern – zusammengefasst als Spezialisten – und Hausärzte sowie Kinder- und Jugendärzte – zusammengefasst als Generalisten – zwischen 2008 und 2018. Ergebnisse Insgesamt 620 Praxen lieferten Daten für 77 504 Patienten mit der Diagnose ADHS, 38% (29 396/77 504) von ihnen hatten im Studienzeitraum mindestens einmal ein Rezept für ein ADHS-Medikament erhalten. Im Laufe der Zeit beobachteten wir eine Verlagerung von Generalisten zu Spezialisten. Erhielten im Jahr 2008 noch 59% der Patientinnen und Patienten ihre Verordnung von einem Generalisten und 41% von einem Spezialisten, so drehte sich das Verhältnis im Jahr 2018 ins Gegenteil: nur noch 37% erhielten ihr Medikament von einem Generalisten und die überwiegende Mehrheit (63%) von einem Spezialisten. Besonders deutlich war diese Entwicklung bei Erwachsenen: 58% von ihnen erhielten ihr ADHS-Medikament im Jahr 2008 von einem Spezialisten, im Jahr 2018 waren es bereits 80%. Der Anteil bei Kindern- und Jugendlichen mit Verordnung vom Spezialisten stieg im gleichen Zeitraum von 38% auf 51%. Schlussfolgerung Es gibt eine Verschiebung in der Arzneimittelversorgung weg von Generalisten hin zu Spezialisten, ohne dass bisher über Vor- oder Nachteile diskutiert wurde. Dies wäre jedoch wünschenswert, nicht zuletzt, weil Spezialisten allein möglicherweise nicht über genügend Ressourcen verfügen, um alle ADHS-Patienten zu versorgen.

BACKGROUND AND OBJECTIVE:Benzodiazepines and Z-drugs are prescribed to a considerable extent as private prescription also for persons insured by a statutory health insurance (SHI), with formerly large differences between East and West Germany. The aim of the present study was to investigate whether these differences still exist today.METHOD:This secondary data analysis used anonymized prescription data from general practitioners (GPs), community neurologists, and psychiatrists. SHI-insured patients with at least one prescription for a benzodiazepine or Z-substance between 2014 and 2020 were included. Differences between East and West Germany in the proportion of private prescriptions were the central outcome. Multiple regression analyses were performed to test whether the factors region (eastern vs. western Germany) and specialist group (GPs vs. neurologists/psychiatrists) were statistically significant predictors of the proportion of private prescriptions - taking into account the age and gender composition of patients in a practice.RESULTS:From 867 practices, 2,200,446 prescriptions for Z-substances, benzodiazepine anxiolytics, and benzodiazepine hypnotics/sedatives were evaluated. More than 38% of these prescriptions were issued as private prescriptions: 53.6% in eastern Germany and 34.8% in western Germany. For Z-substances, the proportion of private prescriptions was particularly high (70.7% in eastern and 43.0% in western Germany). GPs issued private prescriptions far more frequently than neurologists and psychiatrists. The proportion of private prescriptions increased during the study period, comparatively strongly in the western states (from 33% to 39%) and slightly in the eastern states (from 53% to 54%). In the multivariate model, practice area (east/west) and specialist group were similarly strong predictors of the extent of private prescriptions, especially for Z-substances.CONCLUSION:Contrary to a general alignment in life expectancy, morbidity risks, and health behaviour in East and West Germany, there is, despite convergence, still a significant difference in the proportion of private prescriptions for benzodiazepines and especially for Z-substances between the two regions. The groups of physicians who mainly prescribe these substances, namely neurologists and psychiatrists, on the one hand, and GPs, on the other, also differ considerably in the proportion of their private prescriptions for these substances.

Zusammenfassung Hintergrund und Ziel Benzodiazepine und Z-Substanzen werden in erheblichem Umfang auf Privatrezept auch für gesetzlich Krankenversicherte verordnet, mit ehemals großen Unterschieden zwischen Ost- und Westdeutschland. Ziel der vorliegenden Studie ist es zu untersuchen, ob diese Unterschiede auch heute noch bestehen. Methode Die Sekundärdatenanalyse nutzte anonymisierte Verordnungsdaten von niedergelassenen Hausärzten, Neurologen und Psychiatern. Eingeschlossen wurden gesetzlich Krankenversicherte mit mindestens einer Verordnung eines Benzodiazepins oder einer Z-Substanz zwischen 2014 und 2020. Unterschiede zwischen Ost- und Westdeutschland im Anteil der Privatverordnungen waren zentrales Outcome. In multiplen Regressionsanalysen wurde geprüft, ob die Faktoren Region (Ost- vs. Westdeutschland) und Facharztgruppe (Hausärzte vs. Neurologen/Psychiatern) statistisch signifikante Prädiktoren für den Anteil an Privatverordnungen sind – unter Berücksichtigung der Alters- und Geschlechtszusammensetzung der Patienten einer Praxis. Ergebnisse Aus 867 Praxen wurden 2.200.446 Verordnungen von Z-Substanzen, Benzodiazepin-Anxiolytika und Benzodiazepin-Hypnotika/Sedativa ausgewertet. Über 38% dieser Verordnungen wurden in Form von Privatrezepten ausgestellt; in Ostdeutschland lag der Anteil bei 53,6%, in Westdeutschland bei 34,8%. Für Z-Substanzen war der Anteil an Privatverordnungen besonders hoch (70,7% in Ost- und 43,0% in Westdeutschland). Hausärzte griffen weit häufiger als Neurologen und Psychiater zu Privatverordnungen. Der Anteil von Privatverordnungen stieg im Untersuchungszeitraum an, vergleichsweise stark in den westlichen Bundesländern (von 33% auf 39%), geringfügig in den östlichen Bundesländern (von 53% auf 54%). Im multivariaten Modell waren die Region (Ost/West) und die Facharztgruppe ähnlich starke Prädiktoren für das Ausmaß an Privatverordnungen, besonders bei Z-Substanzen. Schlussfolgerung Entgegen einer allgemeinen Angleichung von Lebenserwartung, Morbiditätsrisiken und Gesundheitsverhalten in Ost- und Westdeutschland gibt es, trotz Annäherung, weiterhin einen deutlichen Unterschied zwischen beiden Regionen im Anteil an Privatverordnungen bei Benzodiazepinen, speziell bei Z-Substanzen. Die Arztgruppen, die maßgeblich diese Substanzen verordnen, nämlich Neurologen und Psychiater auf der einen, Hausärzte auf der anderen Seite unterscheiden sich ebenfalls erheblich in der Quote ihrer Privatrezepte für diese Substanzen.

A Secondary Analysis of Office-Based Prescription DataThe use of benzodiazepines and so-called Z-drugs remains high in many countries, despite warnings and restrictions on prescription (1).They are often indicated for the treatment of insomnia, but the benefits are marginal and there are risks of tolerance, dependence, and an increased danger of falling (2).For those with statutory health insurance (SHI), the SHI providers cover the cost of these medications, but physicians can also issue private prescriptions to persons with SHI at the latter's own expense.One motive for this could be the masking of longterm prescription of benzodiazepines in order to comply with the requirement for only short-term use.On the other hand-especially in the case of prescription on demand-physicians may issue private prescriptions, with the associated costs, to make patients aware of their own responsibility.Private prescriptions are not recorded by the SHI providers.Therefore, reports of a decline in benzodiazepine and Z-drug prescriptions that are based on SHI statistics (3) could be misleading and underestimate the dangers of these drugs, e.g., dependency.This study set out to analyze how many private prescriptions for benzodiazepines and Z-drugs had been issued to persons with SHI over the previous 6 years.

To analyse (1) how often patients insured under the statutory health insurance (SHI) scheme received repeated prescriptions for benzodiazepines or Z‐drugs as private prescriptions and (2) how often doctors switched from SHI prescriptions to private prescriptions and vice versa when issuing repeat prescriptions.

Purpose This study aims to assess the implementation of published research, contraindications, and warnings on the prescription of dual renin-angiotensin-hormone system (RAS) blockade in ambulatory care in Germany. Methods Cohort study based on health claims data of 6.7 million subjects from 2008 to 2015. Yearly prevalence and incidence for dual RAS blockade with (a) angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers (ACEI + ARB) and (b) aliskiren and ACEI or ARB (aliskiren + ACEI/ARB) were calculated. We assessed prescriber specialty and associations between discontinuing dual RAS blockade with specialist (internal medicine, cardiology, nephrology) visits and hospital discharge in the previous year. Results A total of 2 984 517 patients were included (age 51.4 +/- SD 18.4 y, 48.5% male). Prescription rates for ACEI + ARB decreased from 0.6% (n = 17 907) to 0.4% (n = 12 237) and for aliskiren + ACEI/ARB from 0.23% (n = 6634) to 0.03% (n = 818). Incident prescriptions decreased from 0.23% (n = 6705) to 0.19% (n = 5055) (ACE + ARB) and from 0.1% (n = 2796) to 0.005% (n = 142) (aliskiren + ACE/ARB); 59% of ACEI + ARB and 48% of aliskiren + ACE/ARB combinations were prescribed only by one physician. Of those, 73% (ACEI + ARB) and 58% (aliskiren + ACE/ARB) were primary care providers (PCPs). Discontinuing dual RAS blockade was associated with specialist care and hospital discharge in the previous year (specialist care: RR 1.4, 95% CI, 1.3-1.6; hospital visit: RR 1.5, 95% CI, 1.3-1.6). Conclusions Our results suggest a delayed uptake of treatment recommendation for ACEI + ARB and a higher impact of Dear Doctor letters addressing PCPs directly compared with published research, contraindications, and warnings. Targeted continuous medical education, practice software alerts, and stronger involvement of pharmacists might improve the implementation of medication safety recommendations in ambulatory care.

Purpose The aim of this study was to analyse whether the global trend in drug prescriptions for attention-deficit hyperactivity disorders (ADHD), as observed during the last years and often criticized as medicalization, have remained stable or shifted. Methods This observational study was based on a secondary analysis of data from a large German database including patients with an ADHD diagnosis between 2008 and 2018. Prescription data comprised all important ADHD drugs. Results A total of 620 practices delivered data from a total of 77,504 patients (31% of them females) with a diagnosis of AHDH. Nearly 38% (29,396/77,504) of all patients received, at least, one prescription for an ADHS medicine between 2008 and 2018. The number of patients receiving a drug steadily increased annually until 2012 and then slowly fell, but unevenly distributed across the age groups. While the number of younger patients ( ≤ 16 years) receiving a prescription fell by 24% and the defined daily doses (DDDs) remained stable, the number of patients between 17 and 24 years receiving a prescription increased by 113% and the DDDs by 150%. Respectively, the number of older adults (≥ 25 years) with a prescription increased by 355% and the DDDs by 515%. Nearly one-third of older adults received an ADHD medicine only once. Conclusion The ever-increasing prescription of ADHD medicines stopped some years ago for children. ADHS and its pharmacological management are increasingly observed among older adolescents and adults, with a different pattern of drug persistence compared with children.

BACKGROUND AND OBJECTIVES Hospitalisation influences drug therapy in ambulatory care and this influence is generally negatively perceived. The few studies that have explored changes in benzodiazepine or sleep medication use as a function of hospitalisation failed to precisely determine the hospital's role in initiating, continuing and discontinuing these drugs on a valid basis. The aim of the study was to ascertain the overall influence of hospitalisation on the prescription of benzodiazepines and Z-drugs in outpatient care with a special focus on the role of different hospital departments and drug classes. METHODS In a secondary data analysis, we used prescription data for 181 037 patients who visited 127 hospitals and compared the numbers of patients with prescriptions of benzodiazepines and Z-drugs 50 days before and 50 or 100 days after hospitalisation. RESULTS The proportion of patients who received benzodiazepines or Z-drugs increased from 3.1% before admission to 3.6% at 50 days after discharge and fell to the former level after an additional 50 days. A multivariable logistic regression showed that gender and department had an additional impact on these results. Of those patients without a prescription for a benzodiazepine or Z-drug before admission, 0.6% received a prescription in both time-windows after discharge. Of those patients who were prescribed a benzodiazepine, 38.0% received short-acting substances and 40.3% received long-acting substances before hospitalisation. After hospitalisation, these rates changed to favour short-acting substances (44.4% and 34.4%, respectively). CONCLUSIONS The hospital effect on initiating and increasing hypnotic or sedative drug use seems to be only moderate and temporary. A change in favour of short-acting substances is even welcome. In less than 1% of patients, the hospital initiated the continuous use of benzodiazepines and Z-drugs, which may put pressure on primary care physicians. However, the widespread use of these drugs in hospitals does not seem to be continued on a large scale in primary care.

IntroductionHypnotics and sedatives, especially benzodiazepines and Z-drugs, are frequently prescribed for longer periods than recommended—in spite of potential risks for patients. Any intervention to improve this situation has to take into account the interplay between different actors, interests and needs. The ultimate goal of this study is to develop—together with the professionals involved—ideas for reducing the use of hypnotics and sedatives and then to implement and evaluate adequate interventions in the hospital and at the primary and secondary care interface.Methods and analysisThe study will take place in a regional hospital in northern Germany and in some general practices in this region. We will collect data from doctors, nurses, patients and a major social health insurer to define the problem from multiple perspectives. These data will be explored and discussed with relevant stakeholders to develop interventions. The interventions will be implemented and, in a final step, evaluated. Both quantitative and qualitative data, including surveys, interviews, chart reviews and secondary analysis of social health insurance data, will be collected to obtain a full understanding of the frequency and the reasons for using hypnotics and sedatives.Ethics and disseminationApproval has been granted from the ethics review committee of the University Medical Center Göttingen, Germany. Results will be disseminated to researchers, clinicians and policy makers in peer-reviewed journal articles and conference publications. One or more dissemination events will be held locally during continuous professional development events for local professionals, including (but not confined to) the study participants.

Objectives: The aim of the study was to compare therapy persistence among patients who started with one of three drug regimens: a monotherapy, or combination therapy either as a fixed combination (ie, 'single pill') or as a free combination (ie, two separate antihypertensive agents).Design: In a secondary data analysis, we used descriptive statistics and multivariate logistic regression to measure the effect of the three therapy regimens on therapy persistence over 4 years.Setting: Prescription data from a large German statutory health insurance provider.Participants: All patients who started with a new antihypertensive therapy in 2007 or 2008 (n=8032) were included and followed for 4 years.Primary outcome measure: Therapy persistence, defined as receiving a refill prescription no later than within 180 days.Results: The persistence rates after 4 years were nearly identical among patients who started with a monotherapy (40.3%) or a fixed combination of two drugs (39.8%). However, significantly more patients who started with free-drug combinations remained therapy persistent (56.4%), resulting in an OR of 2.00 (95% CI 1.6 to 2.5; p<0.0001) for free combinations versus fixed combinations. This trend was observed in all age groups and for men and women. At the end of the study period, the number of different antihypertensive agents was still similar between patients who started with a fixed combination (2.41) and patients who started with a free combination (2.28).Conclusions: While single-pill combinations make it easier to take different drugs at once, the risk is high that these several substances are stopped at once. Therapy persistence was significantly better for patients who started with a free-drug combination without taking much fewer different antihypertensive drugs as those with a fixed combination.

Pentaerythrityl tetranitrate (PETN) was the most commonly prescribed long‐acting nitrate in Germany. We aimed to assess whether the discontinuation of PETN reimbursability in 2011 resulted in alternative prescriptions of anti‐anginal medications or in a discontinuation of anti‐anginal therapy.

To study drug persistence for antihypertensive treatment considering typical patient behaviour including extended drug holidays or irregular repeat prescriptions.

Purpose Defined daily doses (DDD) are used for the measurement of drug utilisation. The aim of the study was to analyse whether differences between DDD and prescribed daily doses (PDD) exist for relevant drug classes such as antihypertensive drugs and, if so, whether they primarily depend on drug classes or patient-related factors. Methods Using the data of a large German statutory health insurance scheme, we analysed continuous prescriptions for the following antihypertensive drug classes: thiazide diuretics, beta-blockers, dihydropyridine calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-II receptor blockers (ARBs). We summed the doses of all dispensed drugs per person during a defined time frame. We calculated the PDD (= total dose divided by the number of days) and expressed them as the PDD:DDD ratio (= amount of DDD per day and person). Results During the study period, 149,704 patients continuously received an antihypertensive medication. The average PDD:DDD ratio ranged from 0.84 (beta-blockers) to 1.88 (ARBs) and 2.17 (ACEIs). The average prescribed dosage of each drug class remained unchanged, even if the patients had previously received another antihypertensive drug with another PDD:DDD ratio. For example, if patients were switched from a beta-blocker to an ACEI, the PDD:DDD ratio increased, on average, from 0.79 to 2.17. Vice versa, the ratio decreased for patients with a drug change from an ACEI to a beta-blocker from 2.06 to 0.75. Conclusions Even large differences between DDD and PDD seem to be a matter of drug classes and not primarily of patient characteristics.

AIM:Defined daily doses (DDD) are used to analyse drug utilisation. For frequently prescribed drug groups, we studied to what extent the DDD correspond to the average prescribed daily doses (PDD).METHODS:We analysed all drugs prescribed for more than three months to insured of a large health insurance fund in Mecklenburg-Vorpommern, one federal state in Germany. PDD for plain ACE inhibitors, selective beta-antagonists and some antidiabetics (sulfonylurea compounds) were calculated and compared with their DDD.RESULTS:During the study period, about 38 500 patients received continuous prescriptions of each ACE inhibitors or selective beta-antagonists, and about 9 000 of sulfonylurea compounds. PDD differed from DDD in varying degrees. For ACE inhibitors, PDD ranged between 1.5 DDD (for captopril) and 3.5 (for ramipril). The PDD for beta antagonists were on average 0.9 DDD, similar for bisoprolol (0.8 DDD) and metoprolol (0.9 DDD). As for oral antidiabetics, doctors prescribed 1.0 DDD glibenclamid per day and patient and 2.0 DDD glimepirid. Depending on differences between DDD and PDD, real daily costs for drug therapy differed from the theoretical costs per DDD, for example in the case of ramipril they were 0.24 euros compared to 0.07 euros.CONCLUSION:The PDD were much higher than the DDD for several frequently prescribed drugs. Consequently, the daily drug costs exceeded the drug costs based on DDD. Evaluations of drug costs on the basis for DDD require careful interpretation. Moreover, the number of DDD alone is not a valid measurement for the appropriateness of drug therapy and can only give a rough estimate of the number of patients treated, at least for the drug groups in this study.

Purpose The reasons for the dramatic increase in proton pump inhibitors (PPI) prescriptions remain unclear and cannot be explained solely by increased morbidity, new indications or a decrease in alternative medication. Inappropriate use and discharge recommendations in hospitals are considered to be possible explanations. As the quality of PPI recommendations in hospital discharge letters in Germany has not been investigated to date, we have studied the appropriateness of these referrals. Methods Hospital discharge letters with recommendations for PPI medication from 35 primary care practices in the county of Mecklenburg-Western Pomerania (MV; North-east Germany) were collected and analysed, and the appropriateness of the PPI indication was rated. Results No information justifying the recommendation for continuous PPI medication could be identified in 54.5% of the discharge letters; in 12.7%, the indication was uncertain, and in 32.7%, we found an evidence-based indication for PPI medication. The most common indication for adequate PPI use was nonsteroidal anti-inflammatory drug-prophylaxis in high-risk patients. Conclusions Inadequate recommendations for PPIs in discharge letters are frequent. This may lead to a continuation of this therapy in primary care, thereby unnecessarily increasing polypharmacy and the risk of adverse events as well as burdening the public health budget. Hospitals should therefore critically review recommendations for PPI medication and the dosage thereof in their discharge letters and clearly document the reason for PPI use and the need for continuous prescription in primary care.

To ascertain the rate and range of continuous polypharmacy in German general practices and compare practice characteristics and prescribing profiles in practices with a high rate of polypharmacy patients (HPP) and a low rate of polypharmacy patients (LPP), respectively.

Ziel der Studie: Definierte Tagesdosen (defined daily doses; DDD) dienen der Analyse des Arzneimittelverbrauchs. Für verordnungsstarke Arzneimittelgruppen sollte untersucht werden, inwieweit DDD und tatsächlich verordnete Tagesdosen (prescibed daily dose; PDD) übereinstimmen.

OBJECTIVE:To explore the influence of hospitalisation on the prescription of drugs in the primary care sector using prescription data of a major statutory health insurance (SHI) organisation, with a special focus on the so-called "Me-Too" drugs - in particular, 3-hydroxy-3-methyl-glutaryl (HMG) CoA reductase inhibitors (statins) and proton pump inhibitors (PPIs).METHODS:A comprehensive outpatient drug prescription analysis was conducted on members of a SHI who had been hospitalised during the first 3 months of 2004. The number and costs of all prescriptions of 2426 patients during a 3-month period before admission and after discharge, respectively, were compared using Wilcoxon's signed rank test. Data are shown in absolute and relative numbers as well as relative risks (RR) and their 95% confidence intervals (CIs).RESULTS:The total number of prescriptions before hospitalisation and after discharge remained nearly the same, while the number of different active substances prescribed per patient decreased by 4%. However, overall costs increased after discharge by 15% due to the higher cost per prescription. Changes in medication affected nearly every patient (98.1%), and 60% had at least five changes. Of the substances prescribed to an individual before admission, 57% were cancelled after discharge, and 55% of all substances prescribed after discharge were novel prescriptions. Significantly more patients received a PPI or statin after hospitalisation (RR for a PPI: 1.27; 95% CI: 1.12 -1.45; RR for a statin: 1.16; 95% CI: 1.02-1.32). The increase in PPI medication was due to a 58% increase in the number of patients receiving pantoprazole, a "Me-Too" drug.CONCLUSION:Hospitalisation exerts a marked influence on drug therapy in ambulatory care, with a significant increase in the prescription of novel, on-patent drugs instead of less expensive alternatives.