Multicentre cohort study of antihypertensive and lipid-lowering therapy cessation after bariatric surgery.

BACKGROUND: Few studies have assessed changes in antihypertensive and lipid-lowering therapy after bariatric surgery. The aim of this study was to assess the 6-year rates of continuation, discontinuation or initiation of antihypertensive and lipid-lowering therapy after bariatric surgery compared with those in a matched control group of obese patients. METHODS: This nationwide observational population-based cohort study used data extracted from the French national health insurance database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009 were matched with control patients. Mixed-effect logistic regression models were used to analyse factors that influenced discontinuation or initiation of treatment over a 6-year interval. RESULTS: In 2009, 8199 patients underwent primary gastric bypass (55·2 per cent) or sleeve gastrectomy (44·8 per cent). After 6 years, the proportion of patients receiving antihypertensive and lipid-lowering therapy had decreased more in the bariatric group than in the control group (antihypertensives: -40·7 versus -11·7 per cent respectively; lipid-lowering therapy: -53·6 versus -20·2 per cent; both P < 0·001). Gastric bypass was the main predictive factor for discontinuation of therapy for hypertension (odds ratio (OR) 9·07, 95 per cent c.i. 7·72 to 10·65) and hyperlipidaemia (OR 11·91, 9·65 to 14·71). The proportion of patients not receiving treatment at baseline who were subsequently started on medication was lower after bariatric surgery than in controls for hypertension (5·6 versus 15·8 per cent respectively; P < 0·001) and hyperlipidaemia (2·2 versus 9·1 per cent; P < 0·001). Gastric bypass was the main protective factor for antihypertensives (OR 0·22, 0·18 to 0·26) and lipid-lowering medication (OR 0·12, 0·09 to 0·15). CONCLUSION: Bariatric surgery is associated with a good discontinuation of antihypertensive and lipid-lowering therapy, with gastric bypass being more effective than sleeve gastrectomy.

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.

Long-term follow-up after bariatric surgery in a national cohort.

BACKGROUND: Lifelong medical follow-up is mandatory after bariatric surgery. The aim of this study was to assess the 5-year follow-up after bariatric surgery in a nationwide cohort of patients. METHODS: All adult obese patients who had undergone primary bariatric surgery in 2009 in France were included. Data were extracted from the French national health insurance database. Medical follow-up (medical visits, micronutrient supplementation and blood tests) during the first 5 years after bariatric surgery was assessed, and compared with national and international guidelines. RESULTS: Some 16 620 patients were included in the study. The percentage of patients with at least one reimbursement for micronutrient supplements decreased between the first and fifth years for iron (from 27.7 to 24.5 per cent; P < 0.001) and calcium (from 14·4 to 7·7 per cent; P < 0·001), but increased for vitamin D (from 33·1 to 34·7 per cent; P < 0·001). The percentage of patients with one or more visits to a surgeon decreased between the first and fifth years, from 87·1 to 29·6 per cent (P < 0·001); similar decreases were observed for visits to a nutritionist/endocrinologist (from 22·8 to 12·4 per cent; P < 0·001) or general practitioner (from 92·6 to 83·4 per cent; P < 0·001). The mean number of visits to a general practitioner was 7·0 and 6·1 in the first and the fifth years respectively. In multivariable analyses, male sex, younger age, absence of type 2 diabetes and poor 1-year follow-up were predictors of poor 5-year follow-up. CONCLUSION: Despite clear national and international guidelines, long-term follow-up after bariatric surgery is poor, especially for young men with poor early follow-up.

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.

[Algorithms based on medico-administrative data in the field of endocrine, nutritional and metabolic diseases, especially diabetes]. / Algorithmes basés sur les données médico-administratives dans le champ des maladies endocriniennes, nutritionnelles et métaboliques, et en particulier du diabète.

BACKGROUND: Medico-administrative databases represent a very interesting source of information in the field of endocrine, nutritional and metabolic diseases. The objective of this article is to describe the early works of the Redsiam working group in this field. METHODS: Algorithms developed in France in the field of diabetes, the treatment of dyslipidemia, precocious puberty, and bariatric surgery based on the National Inter-schema Information System on Health Insurance (SNIIRAM) data were identified and described. RESULTS: Three algorithms for identifying people with diabetes are available in France. These algorithms are based either on full insurance coverage for diabetes or on claims of diabetes treatments, or on the combination of these two methods associated with hospitalizations related to diabetes. Each of these algorithms has a different purpose, and the choice should depend on the goal of the study. Algorithms for identifying people treated for dyslipidemia or precocious puberty or who underwent bariatric surgery are also available. CONCLUSION: Early work from the Redsiam working group in the field of endocrine, nutritional and metabolic diseases produced an inventory of existing algorithms in France, linked with their goals, together with a presentation of their limitations and advantages, providing useful information for the scientific community. This work will continue with discussions about algorithms on the incidence of diabetes in children, thyroidectomy for thyroid nodules, hypothyroidism, hypoparathyroidism, and amyloidosis.

[The REDSIAM network]. / Le réseau REDSIAM (Réseau données Sniiram) ­ Spécial REDSIAM.

The French national health database (SNIIRAM) proved to be very useful for epidemiology, health economics, evaluation, surveillance or public health. However, it is a complex database requiring important resources and expertise for being used. The REDSIAM network has been set up for promoting the collaboration of teams working on the Sniiram. The main aim of REDSIAM is to develop and validate methods for analyzing the Sniiram database for research, surveillance, evaluation and public health purposes by sharing the knowledge and experience of specialized teams in the fields of diseases identification from the Sniiram data. The work conducted within the network is devoted to the development and the validation of algorithms using Sniiram data for identifying specific diseases. The REDSIAM governance includes the Steering Committee composed of the main organizations in charge of producing and using the Sniiram data, the Bureau and the Technical Committee. The network is organized in thematic working groups focused on specific pathological domains, and a charter defines the rules for participation in the network, the functioning of the thematic working groups, the rules for publishing and making available algorithms. The articles in this special issue of the journal present the first results of some of the thematic working groups.

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.

Impact of socio-economic position on health and quality of care in adults with Type 2 diabetes in France: the Entred 2007 study.

AIM: To describe the association between socio-economic position, health status and quality of diabetes care in people with Type 2 diabetes in France, where people may receive full healthcare coverage for chronic disease. METHODS: Data from a national cross-sectional survey performed in people pharmacologically treated for diabetes were used. They combined data from medical claims, hospital discharge, questionnaires for patients (n = 3894 with Type 2 diabetes) and their physicians (n = 2485). Socio-economic position was assessed using educational level (low, intermediate, high) and ability to make ends meet (financial difficulties vs. financially comfortable). RESULTS: People with diabetes reporting financial difficulties were more likely to be smokers (adjusted odds ratio 1.4; 95% CI 1.1-1.6) and obese (adjusted odds ratio 1.3; 95% CI 1.2-1.6) and to have poorer glycaemic control (HbA1c > 64 mmol/mol (8%); adjusted odds ratio 1.4; 95% CI 1.1-1.8), than those who were financially comfortable. They were more likely to have their diabetes diagnosed because of complications (adjusted odds ratio 1.6; 95% CI 1.3-2.0). They were also more likely to have coronary and podiatric complications (adjusted odds ratios 1.3; 95% CI 1.1-1.6 and 1.7; 95% CI 1.4-2.2, respectively). They benefited more often from full coverage (adjusted odds ratio 1.3; 95% CI 1.1-1.6), visited general practitioners more often (ratio of estimated marginal means 1.2; 95% CI 1.1-1.2) but specialists less often (adjusted odds ratio 0.7; 95% CI 0.6-0.8 for a visit to private ophthalmologist). They also felt less well informed about their condition. CONCLUSIONS: Despite frequent access to full healthcare coverage, socio-economic position has an impact on the diagnosis of diabetes, health status and quality of diabetes care in France.

The excess mortality related to cardiovascular diseases and cancer among adults pharmacologically treated for diabetes--the 2001-2006 ENTRED cohort.

AIMS: To compare the 5-year mortality (overall and cause-specific) of a cohort of adults pharmacologically treated for diabetes with that of the rest of the French adult population. METHODS: In 2001, 10 000 adults treated for diabetes were randomly selected from the major French National Health Insurance System database. Vital status and causes of death were successfully extracted from the national registry for 9101 persons. We computed standardized mortality ratios. RESULTS: Over 5 years, 1388 adults pharmacologically treated for diabetes died (15% of the cohort, 32.4/1000 person-years). An excess mortality, which decreased with age, was found for both genders [standardized mortality ratio 1.45 (1.37-1.52)]. Excess mortality was related to: hypertensive disease [2.90 (2.50-3.33)], ischaemic heart disease [2.19 (1.93-2.48)], cerebrovascular disease [1.76 (1.52-2.03)], renal failure [2.14 (1.77-2.56)], hepatic failure [2.17 (1.52-3.00)] in both genders and septicaemia among men [1.56 (1.15-2.09)]. An association was also found with cancer-related mortality: liver cancer in men [3.00 (2.10-4.15)]; pancreatic cancer in women [3.22 (1.94-5.03)]; colon/rectum cancer in both genders [1.66 (1.28-2.12)]. Excess mortality was not observed for breast, lung or stomach cancers. CONCLUSIONS: Adults pharmacologically treated for diabetes had a 45% increased risk of mortality at 5 years, mostly related to cardiovascular complications, emphasizing the need for further prevention. The increased risk of mortality from cancer raises questions about the relationship between cancer and diabetes and prompts the need for improved cancer screening in people with diabetes.

[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.

A first national prevalence estimate of diagnosed and undiagnosed diabetes in France in 18- to 74-year-old individuals: the French Nutrition and Health Survey 2006/2007.

AIMS: To estimate the nationwide prevalence of diagnosed and undiagnosed diabetes and pre-diabetes in adults residing in France. METHODS: A probability sample of a non-institutionalized civilian population residing throughout the whole of continental France was recruited from February 2006 to March 2007 for the French Nutrition and Health Survey. All individuals aged between 18 and 74 years who agreed to participate in the survey were included; thus there were 3115 participants, 2102 of whom were undergoing biochemical assessments. The prevalence of diagnosed diabetes was estimated using self-reported diabetes history and the prevalence of undiagnosed diabetes was estimated using fasting plasma glucose ≥ 7.0 mmol/l or HbA(1c) ≥ 6.5% (≥ 48 mmol/mol). RESULTS: The prevalence of diagnosed diabetes was 4.6%, 95% CI 3.6-5.7. The prevalence of undiagnosed diabetes according to standard fasting plasma glucose criteria was 1% (95% CI 0.6-1.7) and contributed to less than 20% of all cases of diabetes. This proportion decreased with age from 30% in 30- to 54-year-olds to 12% in 55- to 74-year-olds. Based on HbA(1c) criteria, the prevalence of undiagnosed diabetes was 0.8% (95% CI 0.4-1.6). CONCLUSIONS: The prevalence of diagnosed diabetes in adults in France is comparable with recent estimates from Northern Europe. The percentage of total diabetes that is undiagnosed is low in France, which may be explained by a widely practised strategy of opportunist screening. During the past years, improvements in diabetes care and increased awareness may have contributed towards decreasing the prevalence of undiagnosed diabetes more widely in Europe, and studies should further monitor such improvements.

Incidence and characteristics of lower limb amputations in people with diabetes.

AIMS: To estimate the incidence, characteristics and potential causes of lower limb amputations in France. METHODS: Admissions with lower limb amputations were extracted from the 2003 French national hospital discharge database, which includes major diagnoses and procedures performed during hospital admissions. For each patient, diabetes was defined by its record in at least one admission with or without lower limb amputation in the 2002-2003 databases. RESULTS: In 2003, 17 551 admissions with lower limb amputation were recorded, involving 15 353 persons, which included 7955 people with diabetes. The crude incidence of lower limb amputation in people with diabetes was 378/100 000 (349/100 000 when excluding traumatic lower limb amputation). The sex and age standardized incidence was 12 times higher in people with than without diabetes (158 vs. 13/100 000). Renal complications and peripheral arterial disease and/or neuropathy were reported in, respectively, 30% and 95% of people with diabetes with lower limb amputation. Traumatic causes (excluding foot contusion) and bone diseases (excluding foot osteomyelitis) were reported in, respectively, 3% and 6% of people with diabetes and lower limb amputation, and were 5 and 13 times more frequent than in people without diabetes. CONCLUSIONS: We provide a first national estimate of lower limb amputation in France. We highlight its major impact on people with diabetes and its close relationship with peripheral arterial disease/neuropathy and renal complications in the national hospital discharge database. We do not suggest the exclusion of traumatic causes when studying the epidemiology of lower limb amputation related to diabetes, as diabetes may contribute to amputation even when the first cause appears to be traumatic.

A call to incorporate the prevention and treatment of geriatric disorders in the management of diabetes in the elderly.

The prevalence of type 2 diabetes increases with age. However, the management of diabetes in the elderly has received surprisingly little attention. Diabetes in the elderly is associated with a high risk of geriatric syndromes including malnutrition and sarcopenia, functional impairments, falls and fractures, incontinence, depression and dementia. Tight glycaemic control for the prevention of vascular complications is often of limited value in the elderly. However, glycaemic control and non-pharmacological therapy may prevent diabetes symptoms and delay geriatric syndromes. The prevention, screening and treatment of both conventional diabetic complications and geriatric syndromes should be integrated in a management plan to optimize the patients' overall health status and quality of life.