Knowledge and opinions of French dental students related to caries risk assessment and dental sealants (preventive and therapeutic).

OBJECTIVES: A national questionnaire study was performed to document knowledge and opinions of French dental students (FDSs) about minimal intervention (MI) in dentistry especially caries risk assessment (CRA) and dental sealants (DSs). MATERIALS AND METHODS: A questionnaire was administered to the fifth-year dental FDSs (n = 1370) from the 16 French dental schools. Descriptive and statistical analyses were performed. RESULTS: The response rate was 84.5%. A large majority of respondents (87.8%) linked MI with minimally invasive dentistry and 77.4% considered MI as a concept based on prevention. About 80% stated they use CRA in clinical practice, mostly without any specific form. If 80.4% of the respondents would base their treatment plans on CRA, only 55.1% would regularly plan preventive regimens according to individual risk level. However, while 96.6% declared they perform preventive DSs, only 44.3% considered therapeutic sealants as a routine treatment. Although 75.1% of FDSs stated that they had sufficient learning and training related to CRA, 55.9% thought that they need further education about preventive and therapeutic DSs. CONCLUSION: Although FDSs seem to be aware of the importance of CRA and preventive strategies, this study shows the need to harmonize the teaching in cariology according to the latest European recommendations. CLINICAL RELEVANCE: A national questionnaire study showed variability towards knowledge and opinions of FDSs related to MI in cariology. This may impact care provisions in their future professional life showing the urgent need to harmonize the teaching of MI in cariology in France.

Impact of vitamin D supplementation on health-care use in a 25-hydroxyvitamin D-tested population in France: a population-based descriptive cohort study.

OBJECTIVE: Chronic vitamin D deficiency has been associated in some patients with diffuse musculoskeletal pain. These unspecific symptoms may partly explain why vitamin D deficiency is often diagnosed late. Our aim was to analyse health-care claims after vitamin D supplementation in patients likely to have vitamin D deficiency. DESIGN: Ambulatory health-care claims were compared before and after a vitamin D supplementation prescribed following a 25-hydroxyvitamin D assay. SETTING: Health Insurance Fund (FHIF) database of the Rhône-Alpes area, France. SUBJECTS: Among patients reimbursed for a 25-hydroxyvitamin D assay between 1 December 2008 and 31 January 2009, those supplemented with vitamin D after the assay were matched on the date of assay to patients who did not receive vitamin D. RESULTS: Among the 3023 patients who had a 25-hydroxyvitamin D assay, 935 were consequently supplemented and matched to 935 patients not supplemented. Their median age was 50·0 and 49·5 years, respectively. Patients supplemented decreased their muscle relaxant consumption whereas no change was observed in the reference group, the difference between the two groups was significant (P=0·03). Second and third Pain Relief Ladder prescriptions decreased in both groups but not significantly differently between groups (P=0·58). There was a decrease in prescriptions of biological examination in both groups with no significant difference. CONCLUSIONS: Besides a decrease in muscle relaxant prescriptions in the supplemented group, it was difficult to assess the impact of vitamin D supplementation in patients likely to have vitamin D deficiency. Prospective cohort studies and randomized trials are needed to assess the efficiency of screening and supplementing vitamin D deficiency.

Asthma drug ratios and exacerbations: claims data from universal health coverage systems.

In claims data, controller-to-total asthma drug ratios may reflect adequacy of disease management. We verified whether asthma patients with high ratios (≥ 50%) experienced fewer asthma-related outcomes. Two ratios were studied: that of the inhaled corticosteroids to total asthma drug (ICS/R03) and that of the inhaled corticosteroids plus leukotriene antagonist receptors-to-total asthma drug (ICS+LTRA/R03). Patients aged 13-40 years, with ≥ 3 respiratory drugs dispensed prescriptions in 2005 were selected from the French national claims data. After excluding null ratios, two groups were defined according to ratio values in 2007: low-ratio group (0% < ratio < 50%) and high-ratio group (ratio ≥ 50%). For both ratios, asthma-related outcomes and medical-resource utilisation were compared between groups. Of 2162 patients (mean age 27 years and 52% female), patients with non-null ratios were 81% and 85% for ICS/R03 and ICS+LTRA/R03 ratios, respectively. Patients with high ratios were less likely to receive oral corticosteroids than those in the low-ratio group (relative risk 0.79, 95% CI 0.72-0.88, and 0.80, 95% CI 0.72-0.88, for ICS/R03 and ICS+LTRA/R03, respectively). High ratio groups also presented fewer asthma-related hospitalisations. Significant negative correlations were also observed for both ratios, when studied quantitatively, according to patients' dispensed level of oral corticosteroids in 2007. In claims data, both ICS/R03 and ICS+LTRA/R03 ≥ 50% were related to fewer asthma-related outcomes. Ratios should be explored to identify asthma patients at risk of exacerbations. Low ratios can be considered as risk factors of exacerbation whatever the underlying cause.

Factors associated with early adherence to tiotropium in chronic obstructive pulmonary disease.

Tiotropium is an innovative intervention in chronic obstructive pulmonary disease (COPD). Early adherence to tiotropium remains inadequately explored, notably time from initiation to discontinuation (persistence). In patients with COPD, the factors associated with the risk of discontinuing the treatment with tiotropium within 12 months following initiation were identified (12-month persistence). Claim databases from the French Social Security were used. A random sample of patients (aged 50-80 years) who initiated tiotropium soon after launch was selected. Factors associated with the persistence were investigated (Log-rank test and multivariate Cox model). Of the 1147 newly treated patients (mean age 68 years, 33% women), 64% remained in the treatment of tiotropium for over a period of 12 months following initiation. More than 10% of the patients interrupted therapy after a single dispensing, most often those with mild COPD. Lower risks of discontinuing tiotropium within 12 months following initiation were observed when it was initiated by a private sector specialist (hazard ratio (HR) = 0.65, 95% confidence interval (CI) = (0.52-0.82)), by hospital-based physician (HR = 0.58, 95% CI = (0.42-0.78)), when ≥ 2 other respiratory drugs were associated (HR = 0.74, 95% CI = (0.58-0.95)) and in case of long-term disease status (HR = 0.78, 95% CI = (0.63-0.97)). Conversely, no clear effect appeared according to age or gender. In this population of patients with COPD, fewer early discontinuations of tiotropium were observed in patients having a severe condition.

Mixed dyslipidemias in primary care patients in France.

OBJECTIVE: To determine the prevalence of single and mixed dyslipidemias among patients treated with statins in clinical practice in France. METHODS: This is a prospective, observational, cross-sectional, pharmacoepidemiologic study with a total of 2544 consecutive patients treated with a statin for at least 6 months. MAIN OUTCOME MEASURES: Prevalence of isolated and mixed dyslipidemias of low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), and triglycerides among all patients and among patients at high cardiovascular risk; clinical variables associated with attainment of lipid targets/normal levels in French national guidelines. RESULTS: At least one dyslipidemia was present in 50.8% of all patients and in 71.1% of high-risk patients. Dyslipidemias of LDL-C, HDL-C, and triglycerides were present in 27.7%, 12.4%, and 28.7% of all patients, respectively, and in 51.0%, 18.2%, and 32.5% of high-risk patients, respectively. Among all subjects with any dyslipidemia, 30.9% had mixed dyslipidemias and 69.4% had low HDL-C and/or elevated triglycerides, while 30.6% had isolated elevated LDL-C; corresponding values for high-risk patients were 36.8%, 58.9%, and 41.1%. Age, gender, body mass index and Framingham Risk Score >20% were the factors significantly associated with attainment of normal levels for ≥2 lipid levels. CONCLUSIONS: At least one dyslipidemia persisted in half of all patients and two-thirds of high cardiovascular risk patients treated with a statin. Dyslipidemias of HDL-C and/or triglycerides were as prevalent as elevated LDL-C among high cardiovascular risk patients.

[Economic aspects of severe asthma]. / Enjeux économiques de l'asthme sévère.

Severe asthma and difficult-to-treat asthma are major issues in public health, given the mortality and morbidity they induce and their detrimental effects on patients' quality of life. The economic consequences should not be overlooked either. Published studies suggest that asthma-related medical resource use increases with the degree of asthma severity. Medical resource use incurred by severe (and/or difficult-to-treat) asthma could be reduced in part by more appropriate treatment, better patient education, improved coordination of disease management and treatment of comorbid diagnoses. The specific difficulties in the management of severe asthma and/or difficult-to-treat asthma must nonetheless be kept in mind. Recent new treatments appear promising, but their costs and indications in actual medical practice require better definition.

Asthma and allergy medication use and costs among pediatric primary care patients on asthma controller therapy.

As observational studies in children initiating GINA-Step 3 therapies are scarce, we evaluated outcomes and costs in a primary care cohort. Two-yr retrospective cohort study included French children (age: 6-14) continuously followed in BKL-Thalès database who received > or =2 consecutive prescriptions for GINA-Step 3 therapy (=addition of montelukast or other controllers ('other'), such as increasing inhaled-corticosteroid dose (hICS), adding long-acting beta agonist (LABA), or ICS + LABA). After matching on gender and propensity score, medication use [rescue (short-acting beta agonists), acute (antibiotics (AB), oral corticosteroids (OCS)), allergy (antihistamines, nasal steroids) and other respiratory] was estimated via mean number of prescriptions and mean cost (per child/per month), and cost trends. During 12-month follow-up, children adding montelukast (n = 71) vs. 'other' (n = 213) had similar asthma rescue/acute and allergy medication use. Subgroup with asthma and allergic rhinitis (A + AR) adding montelukast used less OCS and AB (p = 0.014). Two-yr cost trends suggest stable asthma/allergy medication use in montelukast group (0.83 euro) compared with increase in 'other' (5.39 euro), which was driven by nasal steroid use [0.32 euro ('other') vs. -0.04 euro (montelukast), p = 0.0013]. In subgroup with A + AR decline in asthma/allergy medication use in montelukast group (-0.47 euro) vs. increase in 'other' (11.05 euro), p = 0.015, was driven by differences in AB and OCS (p = 0.04) and nasal steroid use (p = 0.001). Concomitant asthma/allergy medication use was similar in children adding montelukast or 'other' controllers (hICS, LABA, ICS + LABA), while children with allergic rhinitis on montelukast used less AB. Concomitant medication costs after addition of montelukast remained stable, while 'other' group experienced increase, especially in children with concomitant allergic rhinitis.

Primary care physicians' behaviors towards risk of iatrogenesis in elderly patients.

OBJECTIVES: Iatrogenesis is common in elderly patients. This phenomenon could be reduced by improving awareness of general practitioners (GPs). We studied GPs' prescribing behavior to elderly patients, to identify GP and patient characteristics related to cautious prescribing behaviors. METHODS: The observational study sampled 106 GPs who had consecutively recruited, on average, 12 patients over 75 years of age. GPs completed a questionnaire on their practice and a questionnaire for each patient they recruited, describing their usual care of elderly patients, and criteria for prescribing therapy. GPs' behaviors were studied with five scores and a global prescribing behavior (adequate/inadequate). The relationship between patients' risk of iatrogenesis and GPs' behaviors was studied with hierarchical logistic models. RESULTS: A total of 106 GPs recruited 1,318 patients (mean age 80.7 years, 36% males). A wide variety of behaviors was observed among GPs. Only 40% of GPs had specific prevention-oriented visits, while only 19.2% considered that prevention was optimally implemented in their practice. On average, GPs had behaviors considered adequate in about half of encounters. GPs' global behaviors were more likely to be adequate for patients at higher risk (OR=1.47, 95%CI: 1.10-1.95). Likewise, before prescribing to patients at higher risk of iatrogenesis, GPs were more likely to collect data on financial autonomy, on clinical/biological data, and to adopt good prescription practices, while less attention was paid to patients' physical and psychological autonomy. CONCLUSIONS: GPs tended to be more cautious when prescribing to patients at higher iatrogenesis risk. However, overall prescribing behaviors were not optimal. Efforts are needed to improve the quality of care in elderly patients.

Lipid-modifying therapy and attainment of cholesterol goals in Europe: the Return on Expenditure Achieved for Lipid Therapy (REALITY) study.

BACKGROUND: Few studies have been conducted in actual clinical practice settings to evaluate the ways in which dyslipidemia is managed using lipid-modifying therapies. OBJECTIVE: To determine lipid-modifying therapy practices and their effects on low-density lipoprotein cholesterol (LDL-C) and/or total cholesterol (TC) goal attainment in Europeans based on prevailing guidelines at the time of therapy in each country. METHODS: Retrospective cohort analysis involving 58,223 patients initiated on lipid-modifying therapies in 10 European countries, with a median patient follow-up on lipid-modifying therapy of 15.3 months. Data on prescriptions of lipid-modifying therapies, laboratory data including LDL-C and TC, achievement of cholesterol goals for LDL-C and/or TC, and hospitalizations were obtained from healthcare administrative databases and/or patient chart reviews. RESULTS: Across Europe, statin monotherapy was the initial lipid-modifying treatment in 51,786 (89.3%) of 58,009 patients with available data. In addition, 38,853 (89.5%) of 43,410 patients with available follow-up statin potency data were initiated on statin regimens of medium or lower equipotency. Low-equipotency regimens include atorvastatin 5 mg, simvastatin 10 mg, and pravastatin 20 mg, whereas medium-equipotency regimens include atorvastatin 10 mg, simvastatin 20 mg, and pravastatin 40 mg. Regimens were adjusted to higher equipotency via either up-titration or switches to combination regimens in 16.2% of patients. On average, 40.5% of patients across Europe who were not initially at guideline recommended cholesterol goals (either LDL-C or TC) and had follow-up data attained recommended cholesterol levels, including <30% of patients in Spain, Italy, or Hungary. In many countries, the likelihood of goal attainment was inversely associated with baseline cardiovascular risk and/or LDL-C levels. CONCLUSIONS: Lipid management strategies in Europe during the study period were dominated by statin monotherapy. Even after prolonged follow-up on lipid-modifying therapy, approximately 60% of Europeans studied did not achieve guideline recommended cholesterol goals. Future emphasis must be placed on subsequent lipid panel monitoring, as well as the use of more efficacious, well-tolerated lipid-modifying therapies such as dual cholesterol inhibitors to enable more European patients to attain their recommended cholesterol goals.