Ambulatory heart failure management in private practice in France.

UNLABELLED: Management of ambulatory heart failure was assessed in a group of 600 patients, mean age 73, 64% males, NYHA I: 9%; II: 52%; III: 33%; IV: 6%; followed up by a representative sample of private cardiologists. Fifty-two percent of patients had been previously hospitalised for worsening heart failure with a mean duration of stay of 13.1 days, for those hospitalised in the year preceding the survey (26%). First diagnosis of heart failure had been performed by a cardiologist (57%), a general practitioner (37%) or another category of physician (6%). Seventy percent of patients received three or more different classes of heart failure medications. Diuretics were prescribed to 71%, angiotensin converting enzyme inhibitors to 54% and digitalis to 35% of the population. Beta-blockers were given to only 14% of the patients. In patients aged over 80 years, only 45% received angiotensin converting enzyme inhibitors. CONCLUSION: This survey of ambulatory heart failure patients confirms that the disease is predominantly observed in elderly patients, and associated with prolonged and recurrent hospitalisations. The underuse of recommended therapeutic classes including angiotensin converting enzyme inhibitors and beta-blockers deserves further investigation.

[Representative observations of therapies in arterial hypertension]. / Observatoire représentatif des usages dans l'hypertension artérielle.

An enquiry was conducted by 125 general practitioners in 1998 concerning 1,204 hypertensive patients (55.5% women, 71% aged 60 or over, 54% with normalised blood pressures). At the first visit (inclusion) the most frequently described therapeutic classes were: diuretics (19%), betablockers (19%), ACE inhibitors (14%), angiotensin II inhibitors (7%). The use of fixed associations was uncommon except for that of ACE inhibitors with diuretics (10.5%). The incidence of normalisation of blood pressure was the same in all therapeutic classes, about 55%, comparable to reported data; however, 42% of non-normalised patients were on monotherapy. Only 7.4% of patients had their treatment changed at inclusion: 3.8% of normalised and 11.2% of non-normalised hypertensives. This low incidence of change of treatment is partially explained by the patients' own opinion about the treatment of their hypertension. In fact, the majority of therapeutic changes is observed when the patient and the doctor both concur. This data on the treatment of hypertension confirms the respective usage of the main therapeutic classes but the limited number of treatment changes at inclusion does not allow yet assessment of these new choices. One year follow-up of this cohort to the second phase of results should provide important information with respect to this point.

[Observations on the management of cardiac failure in ambulatory patients. Results of a survey of cardiologists]. / Observatoire de la prise en charge de l'insuffisance cardiaque en ambulatoire. Enquête auprès des cardiologues.

An enquiry was undertaken amongst 71 cardiologists in 1999 evaluating 600 ambulatory patients with cardiac failure (64% men; mean age 73 years; NYHA Class I: 9%, Class II: 52%, Class III: 33%, Class IV: 6%). Cardiac failure is commoner in men (81%) before the age of 70. After the age of 80, the tendency is inversed (53% of women). Fifty-two per cent of patients had a history of hospital admission for cardiac failure: 26% in the year before the enquiry (on average 13.1 days' hospital stay). On inclusion, the diagnosis was made 4.2 +/- 4.6 years previously and the patients had been followed up for an average of 3.04 +/- 3.3 years. The diagnosis of cardiac failure was made by the cardiologist (57%), the general practitioner (37%), or another category of physician (6%). Eight per cent of patients were treated with a single drug before inclusion, 22% had a bi-therapy and 70% a polytherapy. The most frequently prescribed drugs were: diuretics (71%), angiotensin converting enzyme (ACE) inhibitors (54%) and digitalis (35%). The prescription of betablockers was only reported in 14% of the population. In the over-80's, only 45% of patients were prescribed ACE inhibitors. These results confirm that ambulatory patients with cardiac failure are mainly in NYHA Classes II and III, that the pathology concerns elderly patients and that it is the cause of recurrent hospital admission. The prescription of diuretics is the main therapy in all NYHA Classes. ACE inhibitors were only prescribed in 2/3 of patients and in less than half of patients over 80 years of age. The prescription of betablockers remains marginal. The reason for the underprescription of recommended drugs (International Recommendations) would justify further investigation.

[Changes in prescription patterns for peripheral and cerebral vasoactive drugs before and after establishing prescription standards in France]. / Evolution de la prescription des vaso-actifs périphériques et cérébraux avant et après les références médicales opposables.

OBJECTIVES: Assess changes in the number of prescriptions for peripheral and cerebral vasoactive drugs for the treatment of lower limb arteritis and cerebrovascular disease since the promulgation in 1995 of prescription standards for the treatment of lower limb arteritis. Assess compliance to prescription standards with a detailed analysis of patient features, prescriptions written for lower limb arteritis, cerebrovascular disease and concomitant diseases and evaluate changes in treatment costs for lower limb arteritis and cerebrovascular disease as well as cost of the full prescription, including treatments for associated diseases. METHODS: This study was based on data recorded during the Permanent Study of Medical Prescriptions conducted from March 1994 to February 1995 and from March 1995 to February 1996 by the IMS. Prescription costs were established from the National Description Files of the IMS. Treatment costs were expressed as public price (FF) tax included. Prescriptions meeting the following criteria were selected for each period: prescriptions written by general practitioners for drugs with peripheral and cerebral vasoactivity (excepting calcium antagonists with a cerebral target) belonging to the Anatomic Therapeutic Classes C4A1 of the European Pharmaceutical Marketing Research Association, Bromly 1996; prescriptions for diagnoses 447.6 (arteritis) and 437.9 (cerebrovascular disease) according to the 9th WHO classification. A random sample of 500 prescriptions was selected to calculate costs. RESULTS: Since the advent of the prescription standards in 1995, prescriptions have dropped off by 6.3% for lower limb arteritis and by 14.8% for cerebrovascular disease. There was a 3.7 point decline in the percentage of multiple prescriptions of vasoactive drugs for lower limb arteritis (21.7% prior to March 1995 versus 18% after promulgation of the prescription standards, p > 0.1) and a 1.8 increase in the percentage of multiple prescriptions for cerebrovascular disease (14% prior to March 1995 and 15.8% after promulgation of the prescription standards, p > 0.1). For the treatment of lower limb arteritis, prescription costs fell by a mean 9% per prescription and for the treatment of cerebrovascular disease they rose by a mean 7% per prescription. The price rise, due to multiple prescriptions of vasoactive drugs was 190 FF per prescription for lower limb arteritis and 104 FF per prescription for cerebrovascular disease. CONCLUSION: Despite the retrospective nature of this study where confounding factors could not be controlled, our findings are in agreement with those reported earlier suggesting that cost containment policy implemented by the prescription standards has had little efficacy. In patients with arterial disease of the lower limbs, the percentage of prescriptions not complying with the recommended standards decreased by one-third to one-half over a 2-year period since the prescription standards were first announced in 1994.

[Prescription of beta-lactams for community-acquired broncho-pulmonary infections in adults. Observations in the hospital environment]. / Prescription des bêta-lactamines pour infections broncho-pulmonaires communautaires de l'adulte. Observatoire en milieu hospitalier.

OBJECTIVE: Analyze beta-lactam prescription patterns used in hospitals for the treatment of community-acquired lower respiratory tract infections in adults. PATIENTS AND METHODS: A prospective study was carried out over 4 months (October 1997 to January 1998) in 54 medical units caring for lung disease, internal medicine/infectious disease, geriatric and general medicine patients in 27 hospitals representative of the public facilities in France. Data were collected on the medical unit, the patients, and the antibiotic prescriptions, including discharge prescriptions. The cost analysis of antibiotic therapy took into account all antibiotics given to the patients during their hospital stay. RESULTS: One thousand eighteen patients were included in the study: 266 were treated for acute bronchitis, 405 for bronchitis infection with underlying chronic respiratory disease, and 347 for pneumonia. Noteworthy findings included: low percentage of protocols within the medical units (25.3%), an unexpected frequency of hospitalization for acute bronchitis generally among elderly women, and prolonged intravenous antibiotic therapy and hospitalization (5 to 6 days and 9 to 12.5 days respectively). CONCLUSION: This study confirms the need to reinforce measures aimed at optimizing antibiotic prescriptions in hospitals.