Hospitalisations with infections related to antimicrobial-resistant bacteria from the French nationwide hospital discharge database, 2016.

Massive use of antibiotics has led to increased bacterial resistance to these drugs, making infections more difficult to treat. Few studies have assessed the overall antimicrobial resistance (AMR) burden, and there is a paucity of comprehensive data to inform health policies. This study aims to assess the overall annual incident number of hospitalised patients with AMR infection in France, using the National Hospital Discharge database. All incident hospitalisations with acute infections in 2016 were extracted. Infections which could be linked with an infecting microorganism were first analysed. Then, an extrapolation of bacterial species and resistance status was performed, according to age class, gender and infection site to estimate the total number of AMR cases. Resistant bacteria caused 139 105 (95% CI 127 920-150 289) infections, resulting in a 12.3% (95% CI 11.3-13.2) resistance rate. ESBL-producing Enterobacteriaceae and methicillin-resistant Staphylococcus aureus were the most common resistant bacteria (>50%), causing respectively 49 692 (95% CI 47 223-52 142) and 19 493 (95% CI 15 237-23 747) infections. Although assumptions are needed to provide national estimates, information from PMSI is comprehensive, covering all acute bacterial infections and a wide variety of microorganisms.

Health care utilization by men with prostate cancer during the year before their death: A 2015 population-based study.

INTRODUCTION: To study the characteristics and health care utilization of men with prostate cancer (PCa) during their last year and last month of life, as these data have been rarely reported to date. SUBJECTS AND METHOD: Men covered by the national health Insurance general scheme (77% of the French population) treated for PCa (2014-2015), who died in 2015 were identified in the national health data system, including reimbursed hospital and outpatient care, and their causes of death. RESULTS: A total of 11,193 men (mean age: 81 years, SD: 9.6) were included. Almost 58% of these men died in a short-stay hospital (SSH), 4% died in hospital-at-home, 9% died in Rehab, 9% died in skilled nursing homes and 21% died at home. During the last year of life, almost all men were hospitalised at least once in SSH and 47% received hospital palliative care (HPC), immediately prior to death in 8% of cases. During the last month of life, 76% of men were hospitalised at least once in SSH, 43% attended an emergency department and 14% were admitted to intensive care, 7% received a chemotherapy session, and 24% received an antineoplastic agent dispensed by a retail pharmacy. Cancer was the main cause of death for 63% of men, corresponding to PCa in 40% of cases, and cardiovascular disease was the main cause of death for 13% of men with marked variations according to age, place of death, and use of HPC. The mean cost reimbursed per man during the last year of life was €38,750 (€48,601 including HPC). CONCLUSIONS: In France, end-of-life management of men with PCa, regardless of the cause of death, is centered on SSH and HPC, essentially at the time of death. Certain indicators of end-of-life management were particular high. LEVEL OF EVIDENCE: 4.

Deaths in France: Characteristics, place of death, hospitalisations and use of palliative care during the year before death.

AIM: Only limited data are available concerning the diseases managed and the hospital pathway before death. The aim of this study was to describe diseases, hospitalisations, and use of palliative care one year before death as well as place of death in France. METHODS: French health insurance general scheme beneficiaries who died in 2013 were identified in the National Health Insurance Information System (SNIIRAM) with a selection of information concerning their various hospital stays, including hospital palliative care (HPC) and nursing home care. Diseases were identified by algorithms from reimbursement data recorded in the SNIIRAM database. RESULTS: A total of 347 253 people were included (61% of all deaths in France). The mean age of death was 77 years (SD 15.1). Diseases managed before death were cardiovascular/neurovascular diseases (56%), cancers (42%), neurological and degenerative diseases (25%), diabetes (21%) and chronic respiratory diseases (20%). Deaths occurred in hospital in 60% of cases: 51% in acute wards, 6% in rehabilitation units, 3% in hospital at home (HaH), and 13% in nursing homes. During the year preceding death, 84% of people were hospitalised at least once and 29% received HPC. People receiving HPC more often died in hospital than people not receiving HPC (69% vs. 44%). CONCLUSION: Health administrative data from the SNIIRAM database can refine our knowledge of the care pathway prior to death and of the use of hospital palliative care and can be useful to evaluate the new governmental palliative care plan recently deployed in France.

Impact of nursing home admission on health care use and disease status elderly dependent people one year before and one year after skilled nursing home admission based on 2012-2013 SNIIRAM data.

BACKGROUND: The aim of this study was to compare disease status and health care use 1 year before and 1 year after skilled nursing home (SNH) admission. METHODS: People over the age of 65 years admitted to SNH during the first quarter of 2013, covered by the national health insurance general scheme (69% of the population of this age), and still alive 1 year after admission were identified (n = 14,487, mean age: 86 years, women: 76%). Their reimbursed health care was extracted from the Système National d'Information Interrégimes de l'Assurance Maladie (SNIIRAM) [National Health Insurance Information System]. RESULTS: One year after nursing home admission, the most prevalent diseases were cardiovascular/neurovascular diseases and neurodegenerative diseases (affecting 45% and 40% of people before admission vs 51% and 53% after admission, respectively). Physical therapy use increased (43% vs 64% of people had at least one physical therapy session during the year, with an average of 47 vs 84 sessions/person during the year), while specialist consultations decreased (29% of people consulted an ophthalmologist at least once during the year before admission vs 25% after admission; 27% vs 21% consulted a cardiologist). Hospitalization rates were lower during the year following institutionalization (75% vs 40% of people were hospitalized at least once during the year), together with a lower emergency admission rate and a higher day admission rate. CONCLUSIONS: Analysis of the new French reimbursement database specific to SNH shows that nursing home admission is associated with a reduction of some forms of outpatient care and hospitalizations.

[Characteristics, diseases and mortality of people admitted to nursing homes for dependent seniors during the first quarter of 2013 in France]. / Caractéristiques, pathologies et mortalité des résidents en établissements d'hébergement pour personnes âgées dépendantes (Ehpad) admis au cours du premier trimestre 2013 en France.

BACKGROUND: To describe the state of health, through healthcare consumption and mortality, of people admitted to nursing homes (Ehpad) in France. METHODS: People over the age of 65 years admitted to an Ehpad institution during the first quarter of 2013, beneficiaries of the national health insurance general scheme (69% of the population of this age), were identified from the Resid-Ehpad database and their reimbursed health care was extracted from the SNIIRAM database, identifying 56 disease groups by means of algorithms (long-term disease diagnoses and hospitalisations, medicinal products, specific procedures). Disease prevalences were compared to those of other beneficiaries by age- and sex-standardized morbidity/mortality ratios (SMR). RESULTS: A total of 25,534 people were admitted (mean age: 86 years, 71% women). Before admission, these people presented a marker for cardiovascular or neurovascular disease (48% of cases), dementia (34%), cancer (18%), and psychiatric disorders (14%). Compared to non-residents, new residents more frequently presented dementia (SMR=3-40 according to age and sex), psychiatric disorders (SMR=2.5-12, including psychotic disorders SMR=18-21 in the 65-74 year age-group), neurological disorders (SMR=2-12, including epilepsy SMR=14 in the 65-74 year age-group), and cardiovascular and neurovascular disease (SMR=1.2-3). Overall mortality in 2013 was 22%, with a maximum excess between the ages of 65-74 years (males, SMR=8.8, females, SMR=15.9). CONCLUSION: Medical and administrative data derived from linking the Resid-Ehpad/Sniiram databases reveal a severely impaired state of health, considering healthcare use of institutionalized dependent elderly people, and a high prevalence of diseases responsible for severe dependence and excess mortality, especially among the younger residents.

Value of a national administrative database to guide public decisions: From the système national d'information interrégimes de l'Assurance Maladie (SNIIRAM) to the système national des données de santé (SNDS) in France.

In 1999, French legislators asked health insurance funds to develop a système national d'information interrégimes de l'Assurance Maladie (SNIIRAM) [national health insurance information system] in order to more precisely determine and evaluate health care utilization and health care expenditure of beneficiaries. These data, based on almost 66 million inhabitants in 2015, have already been the subject of numerous international publications on various topics: prevalence and incidence of diseases, patient care pathways, health status and health care utilization of specific populations, real-life use of drugs, assessment of adverse effects of drugs or other health care procedures, monitoring of national health insurance expenditure, etc. SNIIRAM comprises individual information on the sociodemographic and medical characteristics of beneficiaries and all hospital care and office medicine reimbursements, coded according to various systems. Access to data is controlled by permissions dependent on the type of data requested or used, their temporality and the researcher's status. In general, data can be analyzed by accredited agencies over a period covering the last three years plus the current year, and specific requests can be submitted to extract data over longer periods. A 1/97th random sample of SNIIRAM, the échantillon généraliste des bénéficiaires (EGB), representative of the national population of health insurance beneficiaries, was composed in 2005 to allow 20-year follow-up with facilitated access for medical research. The EGB is an open cohort, which includes new beneficiaries and newborn infants. SNIIRAM has continued to grow and extend to become, in 2016, the cornerstone of the future système national des données de santé (SNDS) [national health data system], which will gradually integrate new information (causes of death, social and medical data and complementary health insurance). In parallel, the modalities of data access and protection systems have also evolved. This article describes the SNIIRAM data warehouse and its transformation into SNDS, the data collected, the tools developed in order to facilitate data analysis, the limitations encountered, and changing access permissions.

[Health status of populations living in French overseas territories in 2012, compared with metropolitan France: An analysis of the national health insurance database]. / L'état de santé des populations des départements d'outre-mer en 2012, comparativement à la métropole : une analyse de la base nationale de l'Assurance maladie.

BACKGROUND: This study uses healthcare consumption to compare the health status of beneficiaries of the French national health insurance general scheme between individuals living in French overseas territories (FOT) and those living in metropolitan France. METHODS: Data were extracted from the French national health insurance database (Sniiram) for 2012, using algorithms, 56 groups of diseases and 27 groups of hospital activity were isolated. Standardized morbidity ratio for age and sex (SMR) were used to compare FOT to mainland France. RESULTS: Compared with mainland France, people living in the four FOT had high SMR for diabetes care (Guadeloupe 1.9; Martinique 1.7; Guyane 1.9; La Réunion 2.3), dialysis (2.7; 2.4; 3.8; 4.4), stroke (1.2; 1.1; 2.0; 1.5), and hospitalization for infectious diseases (1.9; 2.5; 2.4; 1.4) and obstetrics (1.4; 1.2; 1.9; 1.2). Care for inflammatory bowel disease or cancer were less frequent except for prostate in Martinique and Guadeloupe (2.3). People living in Martinique, Guadeloupe and la Reunion had more frequently care for psychotic disorders (2.0; 1.7; 1.2), dementia (1.1; 1.3; 11), epileptic seizures (1.4; 1.4; 16) and hospitalizations for burns (2.6; 1.7; 2.9). In la Reunion, people had more frequently coronary syndrome (1.3), cardiac heart failure (1.6), chronic respiratory diseases except cystic fibrosis (1.5), drug addiction (1.4) and hospitalizations for cardiovascular catheterization (1.4) and toxicology, poisoning, alcohol (1.7). Other differences were observed by gender: HIV infection, peripheral arterial disease, some chronic inflammatory disease (lupus) were more frequent in women living in Martinique or Guadeloupe, compared to women from mainland France and psychotic disorders for men. From la Reunion, men had more frequently liver and pancreatic diseases and hospitalisation for toxicology, poisoning, alcohol than men from mainland France. CONCLUSION: This study highlights the utility of administrative database to compare and follow population health status considering healthcare use. Specific Public Health policies are justified for FOT, taking into account the specific context of each FOT, the necessity of prevention initiatives and screening to reduce the frequency of the chronic diseases.

Estimation of breast, prostate, and colorectal cancer incidence using a French administrative database (general sample of health insurance beneficiaries).

AIM: The aim of this study was to compare incidence of breast, prostate, and colorectal cancer incidence estimated from a French administrative database with the incidences estimated from the cancer registry data. MATERIALS AND METHODS: A cohort of 426,410 people included in the general sample of health insurance beneficiaries (EGB) database as of January 1, 2007, was constituted. Several algorithms were developed to estimate cancer incidence between 2008 and 2012 using principal diagnosis (PD) of hospital discharge data (medical information systems program [PMSI]) and/or long-term disease (LTD) and together with a procedure necessary for histological diagnosis and indicating initial disease management. The incidence rates obtained were compared with those from the registry data using the standardized incidence ratio (SIR). RESULTS: The algorithm taking into account LTD and PD in the PMSI and the mandatory presence of a marker procedure provided estimates close to those from the registry data for breast cancer (SIR: 1.12 [1.07-1.18]) and colorectal cancer (SIR: 0.94 [0.88-1.02] in men and SIR: 0.93 [0.86-1.01] in women). For prostate cancer, taking into account specific procedures and drugs in addition to LTD and PD in the PMSI enhanced the estimation of incidence (SIR: 1.03 [0.98-1.08]). CONCLUSION: The PMSI together with reimbursement data (LTD, procedures, drugs) provided estimates of breast, prostate, and colorectal cancer incidence, at a national level, comparable to those from the cancer registry data.

[Health care use by free complementary health insurance coverage beneficiaries in France in 2012]. / Consommations de soins des bénéficiaires de la couverture maladie universelle complémentaire (CMUC) ou de l'aide pour une complémentaire santé (ACS) en 2012.

BACKGROUND: The objective was to investigate healthcare use among people covered by one of the two complementary healthcare insurance schemes available for people with low annual income: CMUC (universal complementary healthcare insurance) and, for people whose income exceeds the CMUC ceiling, ACS (aid for complementary healthcare insurance). Comparisons were made between CMUC and ACS beneficiaries versus CMUC and ACS non-beneficiaries and between CMUC beneficiaries and ACS beneficiaries. METHODS: Using the national health insurance information system (SNIIRAM), people less than 60 years old covered by the general national health insurance (86% of the 66 million inhabitants) and with ACS or CMUC coverage in 2012 were selected. Diseases were identified using hospital diagnosis, drugs refunds and long-term chronic disease status. Hospital related diagnoses were categorized in major hospital activity groups. Sex- and age-standardized relative risk (RR) were calculated. RESULTS: There were 4.4 million (9.6%) CMUC beneficiaries and 732,000 (1.6%) ACS beneficiaries (56% and 54% women; mean age: 24 years and 29 years respectively versus 52% and 30 years for CMUC or ACS non-beneficiaries). CMUC or ACS beneficiaries had more often cardiovascular diseases (RR=1.4;2.1) and diabetes (RR=2.2;2.4). Their sex- and age-standardized hospitalisation rates for all diagnosis were higher (18%; 17%, RR=1.3;1.4) than CMUC or ACS non-beneficiaries (13%). This was especially the case for the following major groups: toxicology, intoxications, alcohol major group (RR=3.8;4.0); psychiatry (RR=2.8;4.1); respiratory disease (RR=1.9;2.3); infectious disease (RR=1.9;2.7). Compared with CMUC beneficiaries, ACS beneficiaries had more often cancer (RR=1.5), cardiovascular disease (RR=1.5), neurological disease (RR=2.7), psychiatric illness (RR=2.6), end-stage renal disease (RR=2.8), hemophilia (RR=1.4) or cystic fibrosis (RR=1.6) and they received also more often disability allowance (20%, 4%). CONCLUSION: The disease and hospitalisation rates of ACS beneficiaries are similar or higher than those of CMUC beneficiaries, especially for disabling diseases. Both CMUC and ACS beneficiaries received healthcare for chronic diseases that can be targeted by prevention and screening programs for more optimal healthcare.

Care pathways and healthcare use of stroke survivors six months after admission to an acute-care hospital in France in 2012.

INTRODUCTION: Care pathways and healthcare management are not well described for patients hospitalized for stroke. METHODS: Among the 51 million beneficiaries of the French national health insurance general scheme (77% of the French population), patients hospitalized for a first stroke in 2012 and still alive six months after discharge were included using data from the national health insurance information system (Sniiram). Patient characteristics were described by discharge destination-home or rehabilitation center (for < 3 months)-and were followed during their first three months back home. RESULTS: A total of 61,055 patients had a first admission to a public or private hospital for stroke (mean age; 72 years, 52% female), 13% died during their stay and 37% were admitted to a stroke management unit. Overall, 40,981 patients were still alive at six months: 33% of them were admitted to a rehabilitation center (mean age: 73 years) and 54% were discharged directly to their home (mean age 67 years). For each group, 45 and 62% had been previously admitted to a stroke unit. Patients discharged to rehabilitation centers had more often comorbidities, 39% were highly physically dependent and 44% were managed in specialized neurology centers. For patients with a cerebral infarction who were directly discharged to their home 76% received at least one antihypertensive drug, 96% an antithrombotic drug and 76% a lipid-lowering drug during the following month. For those with a cerebral hemorrhage, these frequencies were respectively 46, 33 and 28%. For those admitted to a rehabilitation center, more than half had at least one visit with a physiotherapist or a nurse, 15% a speech therapist, 10% a neurologist or a cardiologist and 15% a psychiatrist during the following three months back home (average numbers of visits for those with at least one visit: 23 for physiotherapists and 100 for nurses). Patients who returned directly back home had fewer physiotherapist (30%) or nurse (47%) visits but more medical consultations. The 3-month re-hospitalization rate for patients who were discharged directly to their home was 23% for those who had been admitted to a stroke unit and 25% for the others. In rehabilitation centers, this rate was 10% for patients who stayed < 3 months. CONCLUSIONS: These results illustrate the value of administrative databases to study stroke management, care pathways and ambulatory care. These data should be used to improve care pathways, organization, discharge planning and treatments.

First hospitalization for transient ischemic attack in France: Characteristics, treatments and 3-year outcomes.

INTRODUCTION: Characteristics of patients hospitalized for transient ischemic attack (TIA) management before and during this hospitalization and follow-up are not well documented on very large populations. METHODS: Among the 51 million beneficiaries of the French national health insurance general scheme (77% of French population), those subjects hospitalized for a first TIA in 2010 were included using the national health insurance information system (SNIIRAM). The frequencies of comorbidities during the previous five years and drug treatments received during the previous year and the first month after discharge were estimated from the SNIIRAM and then compared to data derived from the permanent randomized sample of all health insurance beneficiaries based on standardized morbidity ratios (SMR). The three-year outcome and factors associated with at least one readmission for TIA or ischemic stroke during the three months following the first hospitalization were investigated. RESULTS: A total of 18,181 patients were included (mean age: 69 years, 55% of women). The crude incidence of hospitalized TIA was 0.36 per 1000. Before hospitalization, patients presented a significantly higher rate of carotid and cerebral atherosclerosis (2.4% SMR=1.4), atrial fibrillation (9.1%, SMR=1.3), ischemic heart disease (13.7%, SMR=1.3), valvular heart disease (9.7%, SMR=1.5), and treatment with platelet aggregation inhibitors (29%, SMR=1.4), antihypertensives (60%, SMR=1.2) and antidiabetics (16%, SMR=1.5). These SMR decreased with age. One month after discharge from hospital, 82% of patients still alive filled at least one prescription for antithrombotic therapy (platelet aggregation inhibitor: 74%, vitamin K antagonist: 12%), one class of antihypertensive in 57% of patients, an antiarrhythmic in 9% of patients, an antidiabetic treatment in 14% of patients and a lipid-lowering agent in 53%. During the month following discharge from hospital, 3.2% of patients were readmitted at least once for TIA, 1.9% were readmitted for ischemic stroke and 1.5% of patients died. These figures were 3.9%, 2.4% and 2.9% at three months, and 7.2%, 5% and 16.3% at three years, respectively. On multivariate analysis, factors associated with readmission for TIA or ischemic stroke were age ≥ 65 years and antidiabetic treatment before hospitalization. In contrast, male gender, admission to a stroke unit and length of stay were associated with a lower readmission rate. CONCLUSIONS: These results illustrate the value of administrative databases to study TIA. Hospitalizations for TIA were relatively frequent and the recurrence rate was similar to that reported in similar recent studies. Level of primary and secondary prevention must be improved.

[PSA testing, biopsy and cancer and benign prostate hyperplasia in France]. / Dosage du PSA, biopsie, cancer et hypertrophie bénigne de la prostate en France.

INTRODUCTION: Prostate-specific antigen (PSA) testing is high in France. The aim of this study was to estimate their frequency and those of biopsy and newly diagnosed cancer (PCa) according to the presence or absence of treated benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: This study concerned men 40 years and older covered by the main French national health insurance scheme (73 % of all men of this age). Data were collected from the national health insurance information system (SNIIRAM). This database comprehensively records all of the outpatient prescriptions and healthcare services reimbursed. This information are linked to data collected during hospitalisations. RESULTS: The frequency of men without diagnosed PCa (10.9 millions) with at least one PSA test was very high in 2011 (men aged 40 years and older: 30 %, 70-74 years: 56 %, 85 years and older: 33 % and without HBP: 25 %, 41 % and 19 %). Men with treated BPH totalized 9 % of the study population, but 18 % of the men with at least one PSA test, 44 % of those with at least one prostate biopsy and 40 % of those with newly managed PCa. Over a 3-year period, excluding men with PCa, 88 % of men with BPH had at least one PSA test and 52 % had three or more PSA tests versus 52 % and 15 % for men without BPH. One year after PSA testing, men of 55-69 years with BPH more frequently underwent prostate biopsy than those without BPH (5.4 % vs 1.8 %) and presented PCa (1.9 % vs 0.9 %). CONCLUSIONS: PSA testing frequencies in France are very high even after exclusion of men with BPH, who can be a group with more frequent managed PCa. LEVEL OF EVIDENCE: 4.

[Characteristics and prevention among patients with stroke: a study of 36,844 patients hospitalized in France]. / Caractéristiques et traitements des assurés du régime général hospitalisés pour accident vasculaire cérébral au cours du premier semestre 2008.

INTRODUCTION: This study evaluates comorbidities, primary and secondary drug prevention and two years survival among patients hospitalized for stroke during the first half of 2008. METHODS: First hospitalization with stroke diagnosis was identified by using the national hospital discharge database and linked to the reimbursement database of the beneficiaries covered by the general health insurance scheme (74% of the 64 million population). A medication was considered to be used when there were more than two reimbursements over the 6 months following or preceding hospitalization. RESULTS: Among the 36,844 patients with stroke, 31.6% had a main diagnosis of transient ischemic attack (TIA), 53.6% a cerebral infarct (CI) and 14.8% a cerebral hemorrhage (CH). For the 8429 patients aged less than 60 years, high frequency of low-income and full health insurance coverage (11% of the covered population) was found for CI (17.6%) and CH (24.6%). Specific refund for invalidating stroke before hospitalization was found for 16% of patients with CI and 10.5% of those with CH. During the two previous years, around 7% of all patients were hospitalized for stroke, 30% for arterial hypertension, 13% for cardiac electric disorders, 10% for coronary disease and 12% for diabetes. Death rates one month after hospitalization were 11.3% for CI and 33.8% for CH, and two years after 22.5% for CI, 43% for CH and 7.7% for TIA. At least one antihypertensive drug treatment was found for 55.2% of patients with a TIA before hospitalization and 62.9% after and respectively 59.4% and 65.8% for CI and 51.1% and 57.7% for CH. Before hospitalization, beta-blocker was the most frequent antihypertensive class (21 to 25.6% according to stroke type). After hospitalization, frequency increased for angiotensin-converting enzyme inhibitors among CI patients (31% vs. 18.7%) and calcium-channel blockers among CH patients (27.1% vs. 13.7%). Antiplatelet drugs were used by 58% of the patients with CI after hospitalization (27.8% before). An anticoagulant drug was present for 74.8% of patients with CI, 69.5% for TIA and 19.2% for CH. Among patients with ischemic stroke, half of them had a lipid-lowering drug after hospitalization. A combination of antihypertensive, anticoagulant and lipid lowering drugs was found for 32.9% of patients with a TIA, 39.9% for CI and 7.6% for CH after hospitalization. CONCLUSION: These patients presented frequently a history of stroke and comorbidities and their level of secondary prevention must be improved.

Long-term chronic diseases and 1-year use of healthcare services by children under 18 years of age during 2018-2019: A French nationwide observational study.

OBJECTIVE: Among children younger than 18 years, the prevalence of long-term chronic diseases (LTDs) is not well known in France, nor the frequency of the use of healthcare services. This nationwide observational study focused on both topics over a 1-year period following the birth or birthday of French children in 2018 and compared the LTD status and use of healthcare. MATERIALS AND METHODS: We selected children living in mainland France from the national health data system (SNDS). It includes data concerning the LTD status, which guarantees 100% reimbursement for related healthcare expenditures. We calculated the median and interquartile range (IQR) for the prevalence of LTDs and the rate of children using healthcare services at least once during the year. RESULTS: We included 13.211 million children (51.2% boys), of whom 4% had at least one LTD (boys: 4.6%, girls: 3.3%). Mental and behavioral disorders were the most frequent cause (1.6%). At least one visit to a general practitioner (GP) or pediatrician was found for 88% of children (median: 3, IQR: 2-6): 98% for children under 1 year of age and 81% for children aged 14-17 years. A pediatrician was visited by 17% of children, another specialist by 39%, a dentist by 37%, with peaks of about 60% at the ages of 6, 9, and 12 years; 8% visited a nurse and 7% visited a physiotherapist. At least one emergency department visit was recorded for 24% of children (42% <1 year) and one short-stay hospitalization (SSH) for 9%. Regional variations were observed. Children with LTDs more frequently used all services, such as specialist visits (50% vs. 40%), ED visits (32% vs. 23%), SSHs (26% vs. 8% and 15% vs. 4.0% for one night or more), and psychiatric hospital admissions (5% vs. 0.1%). CONCLUSION: Most children saw a GP or pediatrician during the year and children with an LTD showed more frequent use. Nevertheless, outpatient visits appeared to be underutilized with respect to recommendations or free-of-charge prevention visits, such as for dentists. More detailed studies are required to identify factors associated with the use of healthcare services in France, for example, studies including the deprivation index and regional variations.

[Alzheimer disease and other dementia in France: Identification, management and neuroleptic use (2007-2009)]. / Maladie d'Alzheimer et autres démences : identification, prise en charge et consommation de neuroleptiques chez les bénéficiaires du régime général (2007-2009).

Numbers of patients with Alzheimer's disease or other dementia (ADD) are necessary for care organisation and indicators development as rates of neuroleptics prescription will have a negative risk-benefit balance. Among people of 60 years old and more covered by the general regime (11 millions, 80% of French people), patients with ADD were identified by at least one of the following criteria: long-term affection status for ADD (67.1% of the identified), refunds for Alzheimer medication (67.5%) or hospitalization for ADD (13.6%). In 2009, 353,482 patients were identified using the presence of one criterion in 2009 and 409,021 were identified the same year when criteria were selected over a period of 3 years (2007 to 2009) (prevalence 3.58%, 2.35 to 5.31% between French regions). By extrapolation, their number for whole France was 551,000. Among patients with ADD, 16% had at least three refunds for neuroleptic in 2009 (9.3 to 22.8% according to regions). Increased use of neuroleptic was associated with hospitalisation in a community hospital, the number of general practitioner consultation and an age between 60 and 75 years. At least one liberal psychiatrist consultation decreased the use. This study gives information among ADD patients management and supports prevention program for neuroleptics use.

[Hospitalization rates for immigrant-related illness among individuals with low income and full health insurance coverage in France, 2009]. / Taux d'hospitalisation des bénéficiaires de la couverture maladie universelle complémentaire (CMUC) pour des pathologies associées aux immigrants en France en 2009.

Complementary Universal Health Insurance (CMUC) which provides free access to health care has been available in France since 2000 for people with an annual income less than 60% of the poverty threshold. Hospitalization rates in 2009 for common diseases among immigrants were compared between beneficiaries of the general scheme under the age of 60 years with (4.5 millions) or without CMUC (34.1 millions) in 2008 and still alive at the end of the year. Data were derived from the French national health insurance reimbursements and short-stay hospital discharge databases. Age - and sex-adjusted hospitalization rates and relative risk significantly greater overall hospitalization rates (17.5% vs 13.2%) (males RR= 2.0, female RR 2.3) and each parasitic diseases (RR = 2.1), which include viral diseases and fevers of unknown origin (1.1/1000, RR =1.6), septicaemia (0.4/1000, RR = 2.2), HIV infection (0.7/1000, RR = 3.5), other infectious and parasitic diseases (0.7/1000, RR= 2.5) and, more precisely, measles (2.7/1000, RR = 5.0). Hospitalization for sickle cell disease (3%, RR = 4.5) were also more frequent as also for lead poisoning (0.12/1000, RR = 5.2). In this low-income population with free access to health care, hospitalizations were higher for many diseases that are targets for prevention and screening actions. This is tha case for immigrant with CMUC coverage arriving in France and when they travel to their country of origin.

Five-year cause-specific survival after meningioma surgery. A nationwide population-based study.

BACKGROUND: Survival after meningioma surgery is often reported with inadequate allowance for competing causes of death. METHODS: We processed the French administrative medical database (Système National des Données de Santé: SNDS), to retrieve appropriate cases of surgically treated meningioma. Cause-specific survival in meningioma-related death was analyzed with the Fine & Gray (F&G) and cause-specific (CS) Cox models to identify associated factors. RESULTS: Five-year cumulative incidence was 2.85% for meningioma-related death and 6.3% for unrelated death (P<0.001). In the adjusted F&G and cause-specific Cox regression models for meningioma-related death, gender, age at surgery, co-morbidities, neurofibromatosis type 2, tumor insertion, tumor grade, cerebrospinal fluid (CSF) shunt insertion, preoperative embolization and need for redo surgery for recurrence emerged as independent prognostic factors of cause-specific survival (CSS) in meningioma-related death. CONCLUSION: At 5 years, the risk of meningioma-unrelated death was 2.21-fold greater than the risk of dying from the meningioma disease. Five-year CSS after meningioma surgery was greater in younger adults with benign spinal meningioma with low comorbidity. Those with malignant cranial tumor requiring preoperative embolization or CSF shunting for associated hydrocephalus and with severely degraded overall health status showed a significantly increased risk of meningioma-related death. Redo surgery for recurrence failed to improve the risk of meningioma-related death. We recommend the use of net survival methods such as CSS in meningioma studies where unrelated mortality is predominant, as this approach results in more accurate estimates of disease risk and associated predictors.

[Carpal tunnel syndrome surgery in France in 2008: patients' characteristics and management]. / Syndrome du canal carpien opéré en France en 2008 : caractéristiques des malades et de leur prise en charge.

INTRODUCTION: Carpal tunnel syndrome (CTS) is the most common upper limb neuropathy. There has been a dramatic increase in CTS surgery since the 1990s. This study focuses on changing incidence of CTS surgery in France and associated factors. PATIENTS AND METHOD: Cases of CTS surgery were identified using the national hospital discharge database for persons living in metropolitan France. Patient characteristics, comorbidities and care management were studied using the reimbursement database of the beneficiaries covered by the general health insurance scheme (76% of the 64-million French population) comparing those with or without CTS surgery in 2008. RESULTS: In 2008, hospital admissions for CTS surgery were identified in 127,269 patients aged 20 years and older, giving an overall incidence of 2.7/1000 (females 3.6/1000, males 1.7/1000) in metropolitan France. Between 1999 and 2008, the number of patients with CTS surgery increased 25%. Half of this increase was directly related to increasing demographics. For people in the 20 to 59-year age range, incidences were respectively 2.5/1000, 3.6/1000 and 1.3/1000 with high regional variations (1.1/1000-5.5/1000). Individuals aged 60 years and older accounted for 36% of the patients. Using a negative binomial regression, regional incidence variation was significantly and positively associated with the regional density of surgeons practising CTS surgery, proportion of manual workers in the population and proportion of employment in the industrial sector and negatively associated with densities of primary care physicians, rheumatologists and physiotherapists. Certain comorbidities were found to be significantly associated with CTS surgery: diabetes mellitus (Relative Risk [RR]=1.6), hypothyroidism (RR=1.3), end-stage renal disease treated with dialysis (RR=3.3), depression (RR=1.5), hereditary metabolic disease (RR=1.3), ankylosing spondylosis (RR=1.5). Interestingly, a significant negative association was found for full healthcare coverage linked with very low income (RR=0.7) and certain chronic diseases: Alzheimer's disease (RR=0.3), Parkinson's disease (RR=0.7), neuroleptic medications (RR=0.4), multiple sclerosis (RR=0.7). This could be associated with lower frequency of occupational risk factors and a lack of complaint or investigation. After surgery, 55.0% of the patients in the 18 to 59 years age range had a period of sick leave and 36.8% returned to work later than the upper limit of the recommended recovery period of 56 days. The annual cost of sick leaves was estimated at 81 million euros for the general health insurance scheme. CONCLUSION: The number of CTS surgical procedures is increasing in France. Prevention of CTS in the workplace must be sustained and encouraged. Recommendations for sick leave periods should be followed.

French national health insurance information system and the permanent beneficiaries sample.

In France, in the early 2000s, legislators ordered that the National Health Insurance regime develop an inter-regime information system (SNIIR-AM) aimed at better understanding and evaluating beneficiaries' health care consumption and associated expenditures. In 2009, it contained data from the general health insurance regime that covers 86% of the French population; approximately 53 million people. Data are only available for a period of two years plus the current year. In addition, a permanent sample of health insurance beneficiaries (EGB) was created from the SNIIR-AM database. This is a permanent, representative cross-sectional sample of the population covered by National Health Insurance which, since 2004, monitors beneficiaries' health care consumption over a period of 20 years. It contains anonymous sociodemographic and medical characteristics and records of health care reimbursements. It was created using a systematic sampling method (1/97) on the two-digit control key of beneficiaries' national identification number and includes both current year reimbursement recipients and non-recipients. In 2009, it grouped together almost 500,000 beneficiaries covered by the National Health Insurance Fund for Salaried Workers; 77% of the population residing in France excluding public service employees and students. The EGB is used to conduct longitudinal studies as it permits tracing back patients' care paths and use of care in both hospital and office-based care environments and to calculate individual expenditures. It also permits the study of certain relatively frequent diseases characterised by a 100% reimbursement rate for certain chronic diseases and the reimbursement of tracer drugs. Eventually, the SNIIR-AM will include beneficiaries covered by all the different Health Insurance regimes in France.

Factors associated with regional disparities for registration on the French national liver transplantation waiting list.

AIM: This study compared the gap between supply and need for liver transplantation among the geographic regions of France. METHODS: Supply was estimated by registration rates on the national waiting list and need by cirrhosis-related death rates. Hierarchical ascendant classification and principal component analysis were applied to identify regional patterns in the gap between supply and need. Associations between socio-ecodemographics and regional healthcare factors were investigated. RESULTS: We have found regional disparities between supply and need, mainly in regions with high rates of cirrhosis-related death. Among the 22 regions studied, six regional patterns were identified. The biggest gap between supply and need was found in regions characterized by the lack of a regional transplantation center or a low density of general and specialized practitioners. These regions were mainly rural or without a city with more than 200,000 inhabitants, and had high proportions of young people and lower social classes. The smallest gap between supply and need was found in regions presenting the opposite patterns. CONCLUSION: These results might be considered by health authorities when planning resource allocation for liver transplantation. Transplantation teams and their networks should strive for better geographical access before registration on the waiting list.