In the U.S. Congress, the authorization-appropriation process is the formal model that establishes the separation between legislative and funding bills. Additionally, it determines the jurisdiction of the congressional committees that oversee those bills. However, a number of scholars have concluded that the authorization-appropriations dichotomy is substantially different in practice than the model suggests. Research in this area has shown that broad changes over the years have altered the roles of the authorization and appropriations committees. At different times, members of the appropriations committees have been regarded as guardians of the federal treasury, advocates of federal funds for their congressional district, or partisans in support of a political agenda (Adler, 2000). In addition to these roles, appropriators evidently have become more active in policymaking -- a role that traditionally has been the domain of the authorizing committees. To further explore the policymaking role of appropriators, this dissertation used a case study approach that traced appropriators' interactions with the executive branch, focusing on a federal agency and its links with the appropriations subcommittees that have oversight and funding jurisdiction over the agency's programs. Specifically, the study analyzed the relationship between the House and Senate Subcommittees on Labor, Health and Human Services, Education, and Related Agencies (L/ HHS) and the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) during the period from 1989-2009. Through an examination of critical incidents and contextual elements, this dissertation examined whether the Subcommittees on L/HHS increasingly have become significant players in shaping AHRQ's policies and direction. In addition, the dissertation examined the impacts on AHRQ and possible reciprocal [Agency] influences on the Subcommittees. This research has the potential to build on existing works related to the dynamics of the authorization-appropriations process. Moreover, this research could provide a conceptual framework for analyzing the roles that the other congressional appropriations subcommittees play in relation to the executive branch agencies under their jurisdictions. / Ph. D.

Class of 2013 Abstract / Specific Aims: To evaluate and describe the Agency for Healthcare Research and Quality (AHRQ) affiliated practice-based research network (PBRN) websites to determine the best qualities regarding format, content, and accessibility using a developed PBRN website information extraction form. Methods: A PBRN information extraction form was developed to assess the format, content, and accessibility of each AHRQ-affiliated PBRN website. Each student investigator completed an electronic copy of the extraction form for each PBRN website to confirm consistency of findings. A phone interview was then conducted with the webmasters of the PBRNs with the highest scores to determine the influences and challenges those webmasters faced during the development of their PBRN websites. Main Results: The information extraction form was completed for each of the 104 active PBRN websites in the U.S. The most common elements seen on the PBRN websites were site map, email address, mission statement, phone number, and search toolbar. The inter-rater agreement between the two student investigators for the data collected was 84 percent. Regarding the webmaster interviews, the majority of the webmasters believed that the single most important factor in creating a successful PBRN website was identifying the audience of the PBRN and making the material appropriate for that audience. Conclusion: The developed information extraction form was used to successfully evaluate and describe the AHRQ-affiliated PBRN websites. Audience identification is important in order to provide appropriate content, as well as in the development of an effective PBRN website.

While government contracting out its work continues to proliferate and studies about this phenomenon have increased during the past two decades, still little is known about how effective government sponsored networks are at managing broad and complex networks of primarily non-governmental entities. This dissertation reports the results of one such investigation, which examined a U.S. federal agency's contracting experiences in evidence-based health care. The Agency for Healthcare Research and Quality (AHRQ) is a unit of the U.S. Department of Health and Human Services (HHS). Among other tasks, AHRQ supports the development and dissemination of evidence about current best practices in health services delivery through its Evidence-based Practice Center (EPC) programs that contract out its work and operate in broad and complex network. The purpose of this study was to examine the extent to which AHRQ's EPC Program I was effective in supporting the translation of evidence reports and disseminating the products to the public by contracting with public and non-profit entities to do the work. This dissertation also sought to examine the extent to which the evidence reports and derivative products were publicly accessible by operationalizing the objectives articulated in AHRQ's authorizing legislation in a manner consistent with theories of representative democracy and exploring Program I's effectiveness using William T. Gormley's ideas (1989; Gormley & Balla 2003) of bureaucratic control. The results from this dissertation suggest that a decentralized network was related to overall higher translation and dissemination network effectiveness. Specifically, the findings from this study suggest that a decentralized network was related to overall higher translation and dissemination network effectiveness. Also, weak ties among the network actors when transferring complex knowledge was associated with higher translation and dissemination network effectiveness on the whole. The findings from this dissertation also contribute to network theory by extending Gormley's bureaucratic control typology (1989; Gormley & Balla 2003) to the network level, and also to the type of control that was available to the Agency over the network. Finally, the results contribute to better understanding of the dynamics that can be associated with the effectiveness of similar programs. / Ph. D.

Background and Objectives: To describe patterns of healthcare utilization among patients with generalized anxiety disorder (GAD) in general practitioner (GP) settings in Germany. Methods: Using a large computerized database with information from GP practices across Germany, we identified all patients, aged > 18 years, with diagnoses of, or prescriptions for, GAD (ICD-10 diagnosis code F41.1) between October 1, 2003 and September 30, 2004 ("GAD patients"). We also constituted an age- and sex-matched comparison group, consisting of randomly selected patients without any GP encounters or prescriptions for anxiety or depression (a common comorbidity in GAD) during the same period. GAD patients were then compared to those in the matched comparison group over the one-year study period. Results: The study sample consisted of 3340 GAD patients and an equal number of matched comparators. Mean age was 53.2 years; 66.3% were women. Over the 12-month study period, GAD patients were more likely than matched comparators to have encounters for various comorbidities, including sleep disorders (odds ratio [OR] = 6.75 [95% CI = 5.31, 8.57]), substance abuse disorders (3.91 [2.89, 5.28]), and digestive system disorders (2.62 [2.36, 2.91]) (all p < 0.01). GAD patients averaged 5.6 more GP encounters (10.5 [SD = 8.8] vs 4.9 [5.7] for comparison group) and 1.4 more specialist referrals (2.3 [2.9] vs 0.9 [1.7]) (both p < 0.01). Only 58.3% of GAD patients received some type of psychotropic medication (i.e., benzodiazepines, antidepressants, and/or sedatives/hypnotics). Conclusions: Patients with GAD in GP practices in Germany have more clinically recognized comorbidities and higher levels of healthcare utilization than patients without anxiety or depression.

Class of 2012 Abstract / Specific Aims: This study was aimed to evaluate inpatient clinical treatment characteristics associated with the use of intracranial implantation of chemotherapeutic wafers for malignant brain neoplasms within United States, and assess inpatient mortality and total charges regarding treatment with wafer versus without. Methods: A retrospective cohort investigation was conducted utilizing inpatient discharge records from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample from 2005 to 2009. From this nationally-representative sample, 9,455 adults aged 18 years or older were identified with malignant neoplasms of the brain treated with implantable chemotherapeutic wafers. Outcomes of inpatient mortality and charges were assessed via multivariate regression analysis, controlling for patient characteristics, hospital structure, comorbidities, and clinical complications. Main Results: The average age of patients with brain neoplasms was 56.6 (±16.5) years, and of those patients, 42.9% were female. The odds ratio for inpatient mortality of patients treated with implantable chemotherapeutic wafers was OR=0.380 (P<0.001), and patients that received wafer treatment had increased charges exp(b)=2.147 (P<0.001). Conclusions: Multiple factors were associated with inpatient mortality and charges among the 247,829 patients that were diagnosed with malignant brain neoplasms from 2005-2009. With regards to these patients, implantable chemotherapeutic wafers were associated with increased inpatient survival and increased charges.

Class of 2012 Abstract / Specific Aims: To evaluate disease- and patient-related characteristics, mortality, and charges associated with non-AIDS defining malignancies (NADM) among inpatient settings in the United States from 2005 to 2009. Methods: This retrospective cohort investigation utilized nationally-representative hospital discharge records from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (H-CUP) Nationwide Inpatient Sample. Inclusion criteria included adult inpatients ≥18 years with a diagnosis of HIV or AIDS and malignant neoplasms. Multivariate regression analyses were used to assess inpatient mortality and charges. Main Results: Overall, 104,488 were included. Average age associated with each case was 46.9 years (±10.66), with 21.9% cases being female (n=22,868). The mean length of stay was 8.6 days (±10.5) and inpatient mortality occurred in 7.7% of cases (n=8,035). The mean number of procedures performed was 2.3 (±2.5) and the mean number of diagnoses on record was 9.5 (±4.4). Charges for each episode of care averaged $59,483 (±85,748), summing to a national bill of $6.14 billion (2011 dollars) over the five-year course. A higher number of cases were associated with teaching hospitals (74.1%), the south (42%), large metropolitan areas (75.1%), median household income in the 0-25th percentile (41.2%), and Medicaid payers (34.3%). Increased mortality was associated with increased age, increased number of diagnoses and procedures, and the comorbidities of anemia, coagulopathy, lymphoma, and fluid and electrolyte disorders. Conclusions: This investigation of NADMs suggest a considerable clinical and economic burden of illness, summing to a 7.7% inpatient death rate and $1.3 billion in charges per year.

Class of 2011 Abstract / OBJECTIVES: To assess the role of patient, payer, clinical and disease-related factors in charges and mortality among adult inpatient cases of polycythemia vera in the United States from 2004 to 2008. METHODS: This retrospective cohort study utilized hospital discharge records from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) five consecutive years from 2004 to 2008. RESULTS: There were a total of 156,490 episodes of care involving polycythemia vera between 2004 and 2008. Average age upon admission was 65.94 years (±16.03), with 56% of cases being male (n=87,662). The mean length of stay was 5.14 days (±5.31) and inpatient mortality occurred in 3.1% of cases (n=4,927). The mean number of procedures performed was 1.43 (±2.08) and the mean number of diagnoses on record was 9.56 (±3.86). Charges for each episode of care averaged $32,620 (±42,801), summing to a national bill of $5.02 billion (2010 dollars) over the five-year time horizon. Higher charges were associated with longer length of stay, larger hospital bed size, urban hospital location, teaching status, increased number of diagnoses and procedures, private payer, Western U.S. region, and higher income bracket. Increased mortality was associated with increased age, increased number of diagnoses and procedures, self pay, payer other than Medicare, Medicaid, private or self, and the comorbidities of congestive heart failure, coagulopathy, and fluid/electrolyte disorders. CONCLUSION: Polycythemia vera is associated with considerable burden of illness.

Background: The prevalence of type 2 diabetes mellitus (T2D) and the number of patients with comorbidities like hypertension, dyslipidemia and cardiovascular diseases are increasing worldwide. Evidence-based medicine uses the best available evidence from systematic research to make decisions about the care of individual patients. The systematisation and appraisal of evidence are done in care guidelines, which in turn aim to guide the application of effective diabetes prevention and care interventions in different age groups and settings. Patients with T2D need continuous and individualised care. They are therefore seen as the ideal target group for the use of digital health interventions like telemedicine. However, heterogeneous patient populations, telemedicine phenotypes and settings hamper the evaluation of digital health interventions. Comparing study results to provide evidence-based recommendations is further complicated by the diversity of applied study designs. Therefore, there is a need for a systematic review of the current state of research while considering the described variability. In line with this aim five research studies were conducted. Objective: The overall objective of this thesis was, to identify current needs of patients with diabetes (publication 1), to systematically analyse the effectiveness of different diabetes prevention and care interventions (publications 2+3) and to evaluate digital diabetes prevention and care interventions (publications 4+5). Material und Method: To analyse current needs of patients with diabetes, three substudies were conducted in the beginning (publication 1). They consisted of a standardised survey of experts to analyse existing chronic care programs, an expert workshop to identify patients’ needs and an online survey to prioritise the categorised needs dimensions seen from the perspective of patients and health care providers. Two literature overviews were performed to analyse the best available evidence in diabetes prevention and care. An umbrella review analysed the available evidence to identify effective interventions of blood sugar regulation on cardiovascular risk (publication 2). Study quality was assessed using OQAQ (Overview Quality Assessment Questionnaire). Afterwards, a literature overview aimed to identify effective measures of population-based prevention and communication strategies to provide recommendations for policy makers on how to prevent diabetes in different age groups and settings (publication 3). In a next step, digital diabetes prevention and care interventions were summarised. To evaluate digital health interventions with more than one active function, a study protocol was developed. It describes the evaluation of a hypothetical gamification-based smartphone application for weight loss in overweight and obese adolescents (publication 4). As a last step, an umbrella review (publication 5) systematically analysed the effectiveness of telemedicine interventions in diabetes, dyslipidaemia and hypertension. Potentially relevant records had to analyse the effectiveness of telemedicine on clinical outcomes under real-life conditions in patients with one of the defined target diseases using either a systematic review or meta-analysis based on RCTs. Results of meta-analyses and their subgroup analyses were used to identify effective components or other characteristics (e.g. intensity or frequency of feedback). Overall certainty of outcomes was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. Results and Implications: The standardised survey on current care models indicated that a lack of national guidelines, cost-ineffective and non-individualised health care as well as long waiting periods were criticised. Education of patients, communication within the team and with the patient, prevention and health promotion as well as the accessibility of services were significantly more important to patients when compared to health care providers. The identified differences in priorities support the early assessment of these preferences. The umbrella review on the potential of blood sugar regulation for the reduction of cardiovascular risk identified 44 records which were of good quality (OQAQ-median = 17). The results suggest that pharmacological and non-pharmacological interventions have the potential to improve cardiovascular outcomes. When deciding for a certain intervention as well as its intensity, baseline blood pressure and cardiovascular risks of the patient should be considered. Guidelines on cardiovascular prevention should take into account pathophysiological mechanisms as well as individual lifestyle interventions. While effective measures for individual level prevention including physical activity and diet programs were found, available evidence for population-based intervention was scarce and insufficient. The literature overview conducted afterwards identified evidence-based interventions for population-based prevention, including taxation of unhealthy products and specific prevention strategies in certain settings (e.g. kindergartens, schools). These strategies may contribute to the development of policies and governmental regulations for the prevention of diabetes in different age groups and settings. To evaluate a digital mobile health intervention consisting of more than one component, a study protocol for a single-centre, two-arm, triple-blinded, randomised controlled trial following the CONSORT recommendations was developed. The intervention consists of a smartphone application that provides both tracking and gamification elements for lifestyle change. The control group uses an identically designed application, which solely features the tracking of health information. It appears favourable to use RCTs for proof of concept assessments, to evaluate the effectiveness of an app or specific components in controlled settings. The fifth publication of this thesis shows that telemedicine may lead to significant and clinically relevant reductions of HbA1c (≤ -0,5 %) in patients with T2D. The identified reduction rates are comparable to those of non-pharmacological and even some pharmacological interventions. Extracted subgroup analyses showed that certain population and intervention characteristics seem to be associated with improved clinical benefits. This applies to interventions with a rather short duration (< 6 months) and those with frequent or intensive feedback. Age (< 55 years), time since diagnosis (< 8,5 years) and baseline HbA1c (> 8,0 %) were identified as population characteristics favourable for clinically relevant improvements of HbA1c. In addition to the characteristics, future updates of guidelines should carefully consider the low levels of certainty as indicated by the low GRADE results. The present thesis provides a systematic overview of effective measures in diabetes prevention and care. Overall, there is a potential for the early and structured assessment of patients’ preferences. The systematisation and appraisal of the best available evidence on the effectiveness of telemedicine in patients with diabetes and associated comorbidities revealed areas for the update of present guidelines. There is a need for methodologically robust studies on the effectiveness of telemedicine in specific populations and in consideration of combined digital health components. The results and identified research needs have the potential to motivate future studies.:Inhaltsverzeichnis I Abkürzungsverzeichnis III Abbildungsverzeichnis VI Tabellenverzeichnis VII Liste der entstandenen Publikationen VIII 1 Einführung in die Thematik 1 1.1 Diabetes 1 1.1.1 Epidemiologie 1 1.1.2 Krankheitstypen, Krankheitsstadien und Begleiterkrankungen 2 1.1.3 Diabetesprävention 5 1.1.4 Diabetesversorgung 6 1.2 Evidenzbasierte Medizin 9 1.3 Digitalisierung 14 1.4 Stand der Forschung 15 1.4.1 Unterstützungs- und Versorgungsprobleme 15 1.4.2 Individuelle und populationsbasierte Maßnahmen zur Diabetesprävention 16 1.4.3 Herausforderungen digitaler Diabetesprävention und -versorgung 22 1.5 Zieldefinition und Fragestellung 25 2 Thematischer Zusammenhang und Methodenüberblick 26 3 Individualising Chronic Care Management by Analysing Patients’ Needs – A Mixed Method Approach 28 4 Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention 31 5 What should governments be doing to prevent diabetes throughout the life course? 34 6 Efficacy of gamification-based smartphone application for weight loss in overweight and obese adolescents: study protocol for a phase II randomized controlled trial 36 7 Mapping the Evidence on the Effectiveness of Telemedicine Interventions in Diabetes, Dyslipidemia, and Hypertension: An Umbrella Review of Systematic Reviews and Meta-Analyses 38 8 Diskussion und Ausblick 41 8.1 Einordnung der Ergebnisse 41 8.2 Limitationen und Methodenkritik 49 8.3 Wissenschaftliche Kontribution und Ausblick 50 9 Schlussfolgerung 51 10 Zusammenfassung 53 11 Summary 57 12 Literaturverzeichnis 60 13 Anhang 110 13.1 Wissenschaftliche Kontribution der Publikationen 110 13.2 Details zu Publikationen als Erstautor 112 13.3 Volltexte der entstandenen Veröffentlichungen 117 13.4 Curriculum Vitae 198 13.5 Danksagung 199 Anlage 1 200 Anlage 2 202 / Hintergrund: Die Häufigkeit des Typ-2-Diabetes mellitus (T2D) sowie die Zahl von Patienten mit Begleiterkrankungen wie Hypertonie, Lipidstoffwechselstörungen und kardiovaskulären Erkrankungen sind weltweit ansteigend. Die evidenzbasierte Medizin nutzt die beste verfügbare Evidenz aus systematischer Forschung um Entscheidungen für die individuelle Patientenversorgung zu treffen. Die Aufarbeitung und Bewertung der Evidenz erfolgt in Versorgungsleitlinien, welche wiederum zur Verwendung wirksamer Maßnahmen der Diabetesprävention und -versorgung in verschiedenen Altersgruppen und Settings anleiten können. Patienten mit T2D bedürfen der kontinuierlichen und individualisierten Versorgung. Sie gelten daher als ideale Patientengruppe, um digitale Versorgungsformen wie Telemedizin zu nutzen. Heterogene Patientenpopulationen, Telemedizinanwendungen und Settings erschweren jedoch die Evaluation digitaler Gesundheitsanwendungen. Zusätzlich wird durch die Diversität der angewandten Studiendesigns ein Vergleich der Studienergebnisse, mit dem Ziel evidenzbasierte Empfehlungen zu formulieren, verkompliziert. Es fehlt daher an einer systematischen Aufarbeitung des Forschungsstands unter Berücksichtigung der geschilderten Variabilität. Mit diesem Ziel wurden fünf Forschungsarbeiten angefertigt. Fragestellung: Übergeordnetes Ziel der vorliegenden Arbeit war es, bestehende Unterstützungs- und Versorgungsprobleme von Patienten mit Diabetes zu identifizieren (Publikation 1), die Wirksamkeit verschiedener Maßnahmen der Prävention und Versorgung des Diabetes systematisch aufzubereiten (Publikationen 2+3) und digitale Diabetespräventions- und –versorgungsstrategien zu bewerten (Publikationen 4+5). Material und Methode: Mit dem Ziel, bestehende Unterstützungs- und Versorgungsprobleme von Patienten mit Diabetes zu analysieren, wurden zu Beginn drei Teilstudien durchgeführt (Publikation 1). Diese beinhalteten eine standardisierte Expertenbefragung zu bestehenden Versorgungsmodellen, einen Workshop zur Identifikation von Versorgungs- und Unterstützungsproblemen und die Durchführung einer mehrsprachigen Online-Befragung zur Priorisierung der kategorisierten Problembereiche aus Sicht der Patienten und Leistungserbringer. Zur Analyse der besten verfügbaren Evidenz zur Diabetesprävention und –versorgung wurden zwei Übersichtsarbeiten durchgeführt. Ein Umbrella Review untersuchte die verfügbare Evidenz effektiver Maßnahmen der Blutzuckerregulation auf das kardiovaskuläre Risiko (Publikation 2). Die Studienqualität wurde durch OQAQ (Overview Quality Assessment Questionnaire) bewertet. Im Anschluss hatte eine Literaturübersicht das Ziel, wirksame Maßnahmen der Verhältnisprävention sowie Kommunikations-strategien zu identifizieren, um Handlungsempfehlungen abzuleiten, wie politische Entscheidungsträger in verschiedenen Altersgruppen und Settings Diabetes verhindern können (Publikation 3). In einem nächsten Schritt wurden Ansätze der digitalen Diabetesprävention und –versorgung aufgearbeitet. Zur Evaluation von digitalen Interventionen mit mehr als einer aktiven Funktion wurde ein Studienprotokoll entwickelt. Dieses beschreibt die Evaluation einer (hypothetischen) spielbasierten mobilen Applikation zur Gewichtsreduzierung bei übergewichtigen und adipösen Jugendlichen (Publikation 4). Im letzten Schritt wurde ein Umbrella Review (Publikation 5) durchgeführt, um die Wirksamkeit von Telemedizin bei Patienten mit Diabetes, Lipidstoffwechselstörungen und Hypertonie systematisch zu erheben. Potentiell relevante Forschungsarbeiten mussten die Wirksamkeit (effectiveness) von Telemedizin auf klinische Outcomeparameter unter realweltlichen Bedingungen bei mindestens einer der definierten Erkrankungen in Form von systematischen Übersichtsarbeiten und Meta-Analysen auf Basis von RCTs untersucht haben. Ergebnisse von Meta-Analysen und deren Subgruppenanalysen wurden herangezogen, um effektive Funktionen oder andere Charakteristika (z.B. Intensität oder Häufigkeit von Feedback) zu identifizieren. Um das Vertrauen in den Effektschätzer der Subgruppenanalysen zu bewerten, wurde das GRADE-Schema (Grading of Recommendations Assessment, Development and Evaluation) angewandt. Ergebnisse und Schlussfolgerungen: Die standardisierte Befragung zu verfügbaren Versorgungsmodellen von Patienten mit Diabetes ergab, dass das Fehlen nationaler Versorgungsleitlinien, nicht kosteneffektive und nicht-individualisierte Versorgung sowie lange Wartezeiten häufig bemängelt wurden. Für die befragten Patienten waren im Vergleich zu den befragten Leistungserbringern die Patientenschulung, Kommunikation im Behandlungsteam und mit dem Patienten, die Prävention und Gesundheitsförderung, sowie die Verfügbarkeit der Versorgungsdienstleistungen signifikant wichtiger. Die identifizierten unterschiedlichen Prioritäten zwischen den an der Versorgung beteiligten Akteuren legen nahe, diese Präferenzen frühzeitig zu erfassen. Der Umbrella Review zum Potential der Blutzuckerregulation für Verbesserungen kardiovaskulärer Risiken identifizierte 44 Übersichtsarbeiten mit mehrheitlich guter Qualität (OQAQ-Median = 17). Unter Berücksichtigung unterschiedlicher Endpunkte legen die Erkenntnisse nahe, dass sowohl pharmakologische als auch nicht-pharmakologische Interventionen kardiovaskuläre Endpunkte verbessern können. Die Entscheidung für eine Intervention und ihre Intensität sollte neben dem Blutdruck auch das bestehende kardiovaskuläre Risiko zu Beginn der Behandlung berücksichtigen. Leitlinien im Bereich der kardiovaskulären Prävention sollten sowohl pathophysiologische Mechanismen als auch individuelle verhaltensorientierte Präventionsmaßnahmen einbeziehen. Während im Bereich der Verhaltensprävention wirksame Strategien, wie die Steigerung der körperlichen Aktivität und die Anpassung der Ernährungsgewohnheiten, identifiziert wurden, war die verfügbare Evidenz von populationsbasierten Maßnahmen der Verhältnisprävention im durchgeführten Umbrella Review begrenzt und nicht belastbar. Die im Anschluss durchgeführte Literaturübersicht konnte jedoch belastbare Evidenz zur Verhältnisprävention, wie die Besteuerung ungesunder Nahrungsmittel und spezifische Präventionsmaßnahmen in Settings (z.B. Kindergarten, Schule etc.), identifizieren. Diese Ansätze können dazu beitragen, regulatorische Maßnahmen zur Diabetesprävention in verschiedenen Altersgruppen und Settings zu entwickeln. Zur Evaluation einer mobilen digitalen Gesundheitsanwendung mit mehreren Funktionen wurde ein CONSORT-konformes Studienprotokoll für eine monozentrische, zweiarmige, dreifach verblindete, randomisierte, kontrollierte Studie entwickelt. Die Intervention bestand aus einer Smartphone-Applikation, die „Tracking“ und spielerische Anregungen zur Lebensstiländerung verbindet. Die Kontrollgruppe erhielt eine Smartphone-Applikation mit identischem Design, die jedoch ausschließlich Tracking von Gesundheitsinformationen anbietet. Im Rahmen des frühen Wirksamkeitsnachweises scheinen RCTs hilfreich, um die Wirksamkeit einer App bzw. ausgewählter Funktionen klinisch kontrolliert zu testen. Die fünfte Publikation der vorliegenden Dissertation zeigt, dass Telemedizin den HbA1c bei Patienten mit T2D klinisch relevant (≤ -0,5 %) reduzieren kann. Die identifizierten Reduktionsraten sind mit jenen von etablierten lebensstilmodifizierenden und selbst einigen pharmakologischen Interventionen vergleichbar. Extrahierte Subgruppenanalysen legen nahe, dass bestimmte Populations- und Interventionscharakteristika mit einer gesteigerten Wirksamkeit assoziiert sind. Hierzu gehören Interventionen mit relativ kurzer Dauer (< 6 Monate) und jene mit häufigem oder intensivem Feedback. Das Alter (< 55 Jahre), die Zeit seit Diagnosestellung (< 8,5 Jahre) und der Baseline HbA1c (> 8,0 %) wurden als Patientencharakteristika identifiziert, bei denen Telemedizin zu klinisch relevanten und signifikanten Verbesserungen des HbA1c führte. Neben diesen Charakteristika sollten zukünftige Leitlinienupdates das geringe Vertrauen in die Effektschätzer, in Form der schlechten GRADE Bewertungen, berücksichtigen. Die vorliegende kumulative Dissertation liefert einen Beitrag zur systematischen Übersicht über wirksame Ansätze der Diabetesprävention und –versorgung. In der Gesamtschau zeigt sich ein Potential für die frühzeitige und strukturierte Berücksichtigung von Patientenpräferenzen. Durch die Aufbereitung und methodische Bewertung der verfügbaren Evidenz zur Wirksamkeit von Telemedizin bei Diabetes und assoziierten Begleiterkrankungen wurden Ansätze für die gezielte Aktualisierung bestehender Leitlinien identifiziert. Es besteht ein Bedarf für methodisch robuste Studien zur Wirksamkeit von Telemedizin in spezifischen Populationen und unter Berücksichtigung der Kombination digitaler Interventionsfunktionen. Die Ergebnisse und identifizierten Forschungsbedarfe haben das Potential, zukünftige Studien zu motivieren.:Inhaltsverzeichnis I Abkürzungsverzeichnis III Abbildungsverzeichnis VI Tabellenverzeichnis VII Liste der entstandenen Publikationen VIII 1 Einführung in die Thematik 1 1.1 Diabetes 1 1.1.1 Epidemiologie 1 1.1.2 Krankheitstypen, Krankheitsstadien und Begleiterkrankungen 2 1.1.3 Diabetesprävention 5 1.1.4 Diabetesversorgung 6 1.2 Evidenzbasierte Medizin 9 1.3 Digitalisierung 14 1.4 Stand der Forschung 15 1.4.1 Unterstützungs- und Versorgungsprobleme 15 1.4.2 Individuelle und populationsbasierte Maßnahmen zur Diabetesprävention 16 1.4.3 Herausforderungen digitaler Diabetesprävention und -versorgung 22 1.5 Zieldefinition und Fragestellung 25 2 Thematischer Zusammenhang und Methodenüberblick 26 3 Individualising Chronic Care Management by Analysing Patients’ Needs – A Mixed Method Approach 28 4 Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention 31 5 What should governments be doing to prevent diabetes throughout the life course? 34 6 Efficacy of gamification-based smartphone application for weight loss in overweight and obese adolescents: study protocol for a phase II randomized controlled trial 36 7 Mapping the Evidence on the Effectiveness of Telemedicine Interventions in Diabetes, Dyslipidemia, and Hypertension: An Umbrella Review of Systematic Reviews and Meta-Analyses 38 8 Diskussion und Ausblick 41 8.1 Einordnung der Ergebnisse 41 8.2 Limitationen und Methodenkritik 49 8.3 Wissenschaftliche Kontribution und Ausblick 50 9 Schlussfolgerung 51 10 Zusammenfassung 53 11 Summary 57 12 Literaturverzeichnis 60 13 Anhang 110 13.1 Wissenschaftliche Kontribution der Publikationen 110 13.2 Details zu Publikationen als Erstautor 112 13.3 Volltexte der entstandenen Veröffentlichungen 117 13.4 Curriculum Vitae 198 13.5 Danksagung 199 Anlage 1 200 Anlage 2 202

Background and Objectives: To describe patterns of healthcare utilization among patients with generalized anxiety disorder (GAD) in general practitioner (GP) settings in Germany. Methods: Using a large computerized database with information from GP practices across Germany, we identified all patients, aged > 18 years, with diagnoses of, or prescriptions for, GAD (ICD-10 diagnosis code F41.1) between October 1, 2003 and September 30, 2004 ("GAD patients"). We also constituted an age- and sex-matched comparison group, consisting of randomly selected patients without any GP encounters or prescriptions for anxiety or depression (a common comorbidity in GAD) during the same period. GAD patients were then compared to those in the matched comparison group over the one-year study period. Results: The study sample consisted of 3340 GAD patients and an equal number of matched comparators. Mean age was 53.2 years; 66.3% were women. Over the 12-month study period, GAD patients were more likely than matched comparators to have encounters for various comorbidities, including sleep disorders (odds ratio [OR] = 6.75 [95% CI = 5.31, 8.57]), substance abuse disorders (3.91 [2.89, 5.28]), and digestive system disorders (2.62 [2.36, 2.91]) (all p < 0.01). GAD patients averaged 5.6 more GP encounters (10.5 [SD = 8.8] vs 4.9 [5.7] for comparison group) and 1.4 more specialist referrals (2.3 [2.9] vs 0.9 [1.7]) (both p < 0.01). Only 58.3% of GAD patients received some type of psychotropic medication (i.e., benzodiazepines, antidepressants, and/or sedatives/hypnotics). Conclusions: Patients with GAD in GP practices in Germany have more clinically recognized comorbidities and higher levels of healthcare utilization than patients without anxiety or depression.

No description available.