The Utilization of Lipid-Lowering Drugs and Participation in the German Disease Management Program for Coronary Artery Disease in Patients With Atherosclerotic Disease

An Analysis of Claims Data

Patients with atherosclerotic cardiovascular disease (ASCVD) have increased morbidity and mortality. Lipid-modifying therapy (LMT) is indicated in all patients with ASCVD to lower LDL cholesterol concentration and thus, cardiovascular risk; nevertheless, the majority of these patients do not achieve the recommended LDL cholesterol treatment targets [1]. The German disease management program for coronary artery disease (DMP-CAD) was introduced in 2002. Patient participation is voluntary, but physicians receive higher remuneration for enrolment and documentation. The treatment of participants must follow clinical practice guidelines and be documented. While registry studies from 2009 and 2016 suggest that participation in the DMP for CAD and diabetes may improve risk factor control [2, 3], recent data clearly demonstrating potential benefits of these resource-intensive structured treatment programs are lacking.

Table

Methods

We analyzed the association between DMP-CAD participation and utilization of LMT in the German Analysis Database for Evaluation and Health Services Research (Deutsche Analysendatenbank, DADB; www.gesundheitsforen.net). The DADB contains health claims data from 16 statutory health insurance funds; data on privately insured individuals are not available. Additional regional information on socioeconomic status was obtained from the INKAR database (Indikatoren und Karten zur Raum- und Stadtentwicklung; Indicators and Maps for Spatial and Urban Development).

Patients with a diagnosis of ASCVD in 2023 (at least one quarter of the year with ICD-10 code or billed OPS code [OPS: Operationen- und Prozedurenschlüssel, the German official classification for the encoding of operations, procedures and general medical measures] for CAD, cerebrovascular disease, or peripheral artery disease) and full insurance coverage in 2022/2023 were included in the study. The primary outcome was prescription of at least one LMT in 2023 (statin, ezetimib, bempedoic acid, evolocumab, alirocumab, inclisiran). The following covariates were included for multivariable logistic regression after assessment for skewness and standardization: new or existing participation in the DMP-CAD, age, gender, German nationality, incident ASCVD (coded diagnosis in 2023 without the same diagnosis in 2022), unemployment benefits, voluntary insurance status, pensioner status, receipt of citizens’ benefits, job loss, house move, diabetes mellitus, chronic kidney disease, hypertension, smoking or chronic obstructive pulmonary disease (COPD). The following regional factors were extracted from the INKAR database: resident of a city with ≥ 100 000 and ≥ 20 000/< 100 000 inhabitants, ≥ 1 hospital with acute cardiac care facilities in the municipality, income tax per capita, distance to nearest pharmacy, number of hospital beds per 1000 inhabitants, and number of general practitioners per 10 000 inhabitants.

Figure

Results

Among 2.8 million persons in the database in 2022/2023, n = 261 675 met the inclusion criteria. One third of the patients (33.7%) did not receive any LMT, and 53.1%, 12.6%, and 0.5% received oral monotherapy, oral combination LMT, and a PCSK9 inhibitor, respectively. Patients with LMT were slightly older, more often male, and exhibited more cardiovascular risk factors (Table). In DMP-CAD participants, incident ASCVD was associated with more frequent prescription of LMT, while the opposite was the case for non-participants (Figure). In the multivariable analysis, the explanatory variables with the largest effect sizes for LMT were existing or new participation in the DMP-CAD (adjusted odds ratio [aOR] 4.06; (95% confidence interval [3.94; 4.19]) and aOR 5.74 [5.29; 6.23], respectively). The next largest effect size was found for hypertension with an aOR of 1.90 (1.86–1.94). The factors with the largest negative effect size for the use of LMT were female gender (aOR 0.66 [0.65; 0.67]) and incident atherosclerosis (0.81 [0.80; 0.83]). The remaining factors reflecting cardiovascular risk or socioeconomic status had smaller or non-significant effect sizes (0.83 ≤ aOR ≤ 1.44).

Discussion

One-third of patients in this large contemporary cohort of 261 675 patients with ASCVD did not receive any LMT. DMP-CAD participation was associated with more frequently prescribed LMT in patients with incident atherosclerosis. The use of LMT was much lower in women with ASCVD, consistent with the literature [4]. Among a multitude of potential explanatory variables—including factors reflecting socioeconomic status—participation in the DMP-CAD was the strongest predictor for LMT. A previous analysis demonstrated no clear benefit of DMP introduction on cardiovascular or all-cause mortality compared to mortality trends in other European countries [5]. The present results support the hypothesis that DMP-CAD participation improves the management of dyslipidemia in patients with ASCVD. Furthermore, they highlight the need for increased attention to the treatment of women. Approximately half (45.9%) of the men and women with ASCVD had no diagnosed CAD and were therefore not eligible for inclusion in the DMP-CAD. The prescription rates of LMT were lower in these patients than in those with diagnosed CAD.

The treatment indication for LMT was based on the presence of diagnosed ASCVD, consistent with current guidelines recommendations, while the actual lipid concentrations were not available. The data were collected for claims purposes. Miscoding of diagnoses and unknown actual intake of the medications are further potential limitations.

In summary, one in three patients with ASCVD did not receive LMT. Participation in the DMP-CAD was strongly associated with use of LMT, supporting early and consistent patient enrolment in the DMP-CAD as well as expansion of the scope of the DMP-CAD to atherosclerosis of other vascular territories than the coronary arteries.

Alexander Kogel*, Lisa-Marie Müller*, Jonas Krampe, Ulrich Laufs, Julius L. Katzmann

Funding

AK‘s participation in this work was supported by the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG), project number 493646873, MD-LEICS.

Conflict of interest statement
AK is a member of the German–Austrian–Swiss Society for Prevention of Cardiovascular disease (DACH-Gesellschaft Prävention von Herz-Kreislauf-Erkrankungen e. V., DACH), the German Cardiac Society (Deutsche Gesellschaft für Kardiologie, DGK), and the European Society of Cardiology (ESC).

LMM is a member of the DGK.

UL and/or the University of Leipzig have received honoraria for lectures and/or consultancy and/or reimbursement of travel costs and/or support for congress attendance or research from Amgen, AstraZeneca, Bayer, Boehringer, Daiichi Sankyo, Lilly, MSD, Novartis, NovoNordisk, Pfizer, and Sanofi. UL is a committee member of DACH and the European Atherosclerosis Society (EAS) and an active member of the DGK and the ESC.

JLK has received honoraria for consultancy and/or lectures and/or reimbursement of travel costs from Boehringer Ingelheim, Daiichi Sankyo, Lilly, Novartis, and Synlab. He is a committee member of DACH and a member of the DGK and the EAS.

JK declares that no conflict of interest exists.

Manuscript received on 11 November 11 2025, revised version accepted on 9 February 2026.

Cite this as: Kogel A, Müller LM, Krampe J, Laufs U, Katzmann JL: The utilization of lipid-lowering drugs and participation in the German disease management program for coronary artery disease in patients with atherosclerotic disease: an analysis of claims data.
Dtsch Arztebl Int 2026; 123: 233–4. DOI: 10.3238/arztebl.m2026.0022

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