RESUMEN
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.
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Antígeno Prostático Específico/sangre , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/patología , Adulto , Anciano , Anciano de 80 o más Años , Biopsia , Francia , Humanos , Masculino , Persona de Mediana Edad , Hiperplasia Prostática/complicaciones , Neoplasias de la Próstata/complicacionesRESUMEN
AIMS/HYPOTHESIS: Previous studies have suggested an increased risk of bladder cancer with pioglitazone exposure. We aimed to investigate the association between pioglitazone exposure and bladder cancer in France. METHODS: This cohort study involved use of data from the French national health insurance information system (Système National d'Information Inter-régimes de l'Assurance Maladie; SNIIRAM) linked with the French hospital discharge database (Programme de Médicalisation des Systèmes d'Information; PMSI). The cohort included patients aged 40 to 79 years who filled a prescription for a glucose-lowering drug in 2006. The cohort was followed for up to 42 months. Pioglitazone exposure was modelled as a time-dependent variable and defined by having filled at least two prescriptions over a 6-month period. Incident cases of bladder cancer were identified by a discharge diagnosis of bladder cancer combined with specific aggressive treatment. Statistical analyses involved a multivariate Cox model adjusted for age, sex and exposure to other glucose-lowering drugs. RESULTS: The cohort included 1,491,060 diabetic patients, 155,535 of whom were exposed to pioglitazone. We found 175 cases of bladder cancer among exposed patients and 1,841 among non-exposed patients. Incidence rates were 49.4 and 42.8 per 100,000 person-years, respectively. Pioglitazone exposure was significantly associated with bladder cancer incidence (adjusted HR 1.22 [95% CI 1.05, 1.43]). We observed a dose-effect relationship, with a significantly increased risk for high cumulative doses (≥ 28,000 mg, adjusted HR 1.75 [95% CI 1.22, 2.50]) and long duration of exposure (≥ 24 months, adjusted HR 1.36 [1.04, 1.79]). CONCLUSIONS/INTERPRETATION: In this cohort of diabetic patients from France, pioglitazone exposure was significantly associated with increased risk of bladder cancer.
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Diabetes Mellitus Tipo 2/tratamiento farmacológico , Hipoglucemiantes/efectos adversos , Tiazolidinedionas/efectos adversos , Neoplasias de la Vejiga Urinaria/inducido químicamente , Adulto , Anciano , Estudios de Cohortes , Diabetes Mellitus Tipo 2/complicaciones , Esquema de Medicación , Femenino , Estudios de Seguimiento , Francia/epidemiología , Humanos , Hipoglucemiantes/administración & dosificación , Incidencia , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pioglitazona , Modelos de Riesgos Proporcionales , Factores de Riesgo , Tiazolidinedionas/administración & dosificación , Neoplasias de la Vejiga Urinaria/epidemiología , Neoplasias de la Vejiga Urinaria/prevención & controlRESUMEN
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.
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Enfermedad de Alzheimer/diagnóstico , Enfermedad de Alzheimer/tratamiento farmacológico , Antipsicóticos/uso terapéutico , Demencia/diagnóstico , Demencia/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Enfermedad de Alzheimer/epidemiología , Bases de Datos Factuales , Demencia/epidemiología , Femenino , Francia/epidemiología , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Factores de TiempoRESUMEN
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.
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Síndrome del Túnel Carpiano/epidemiología , Síndrome del Túnel Carpiano/cirugía , Síndrome del Túnel Carpiano/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Síndrome del Túnel Carpiano/economía , Comorbilidad , Femenino , Francia/epidemiología , Geografía , Costos de la Atención en Salud , Disparidades en Atención de Salud/economía , Disparidades en Atención de Salud/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Adulto JovenRESUMEN
OBJECTIVES: To measure the seasonal influenza vaccination coverage rate (VCR) in France in 2009, year of the A(H1N1) influenza pandemic, by age and target disease and compare it with the VCR for the 2007 and 2008 influenza seasons. METHOD: At the beginning of each annual seasonal vaccination campaign, the National Health Insurance, covering 86% of the French population, sends free influenza vaccination vouchers to at-risk beneficiaries aged under 65 suffering from diverse chronic diseases and to all individuals aged 65 and over (around 11 million). Vaccination is estimated from refund claims registered in the National Health Insurance Information System. RESULTS: The global VCR for the target population was 51% in 2007, 55.8% in 2008 and 56.9% in 2009. In 2009, the VCR for children under 10 years old was 24.3%, 28.1% in the 10-19 age range, 39.2% in the 20-64 age range and 63.3% for individuals aged 65 and over, of which 72.3% with a targeted chronic disease and 56.9% without. The inclusion of asthma as a target disease, lowered the global VCR for children under 10 years old (30.6% without asthma) but VCR increased proportionally with the number of annual refunds for drugs against asthma and chronic obstructive pulmonary disease. The 2009 vaccine uptake rates in target group children, adolescents, young adults and to a lesser extent the population aged 65 and over suffering from a chronic disease (particularly chronic respiratory disease), could have been positively impacted by the A(H1N1) influenza context. CONCLUSION: The influenza VCR varies considerably according to age and target disease but globally remains inferior to the recommended 75% coverage rate. These results permit the detailed analysis of VCR distribution by disease and target group and highlights areas for reflection and action. Specific studies should be conducted in order to understand why the VCR is lower in certain target groups.
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Brotes de Enfermedades/prevención & control , Subtipo H1N1 del Virus de la Influenza A/inmunología , Vacunas contra la Influenza/administración & dosificación , Gripe Humana/prevención & control , Estaciones del Año , Vacunación/estadística & datos numéricos , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Asma/complicaciones , Asma/epidemiología , Niño , Preescolar , Brotes de Enfermedades/estadística & datos numéricos , Francia/epidemiología , Humanos , Vacunas contra la Influenza/inmunología , Gripe Humana/epidemiología , Pandemias , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Low sunshine exposure might contribute to the pathogenesis of inflammatory bowel disease (IBD). AIM: To assess the geographic distribution of IBD incidence in relation to sunshine exposure in France to test the hypothesis that higher sun exposure is associated with lower IBD risk. METHODS: Using the national health insurance database, incidence rates of Crohn's disease (CD) and ulcerative colitis (UC) were estimated for each of the 94 French administrative areas ('départements'), between 2000 and 2002. The surface UV radiation intensity was obtained by combining modelling and satellite data from Meteosat, the European meteorological satellite. Relationships between incidence rates and sun exposure were tested for significance by using a Poisson regression. We mapped smoothed relative risks (sRR) for CD and UC, using a Bayesian approach and adjusting for sun exposure, to search for geographical variations. RESULTS: Areas with a smoothed RR of CD incidence significantly above 1 corresponded to areas with low sunshine exposure, whereas those with high or medium sunlight exposure had smoothed RRs either lower than 1 or not significantly different from 1. There was no association between sun exposure and UC incidence. CONCLUSIONS: This geographic study suggests that low sunlight exposure is associated with an increased incidence of Crohn's disease. Further studies are needed to determine if this association is causal.
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Enfermedad de Crohn/epidemiología , Luz Solar , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Teorema de Bayes , Colitis Ulcerosa/epidemiología , Femenino , Francia/epidemiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
AIM: The objective of this study was to compare the management of diabetic and non-diabetic patients before, during and after hospitalization for myocardial infarction (MI). METHODS: Hospital admissions for MI in France from January to June 2006 were obtained from the national hospital-discharge database and merged with data on medications, 6 months before and after hospitalization of patients covered by the general health insurance scheme. Diabetic patients were identified by having at least two refunds for antidiabetic medications 6 months before the index hospitalization. Results comparing diabetic and non-diabetic patients were adjusted for age and gender. RESULTS: Of the 14,007 patients included in the study, 2545 were diabetic (18.2%). Before hospital admission, diabetic patients more frequently received secondary cardiovascular preventative medications (12.7% vs 4.2%; P<0.0001) and stent implants (4.2% vs 2.2%; P<0.0001) than did non-diabetic patients. During hospitalization and the following month, angioplasty (56.1% vs 61.7%; P=0.0001) and stent implantation (53.3% vs 59.3%; P<0.0001) were less frequently performed in diabetic patients and only coronary angiography was done in similar proportions of diabetic and non-diabetic patients (16.7% vs 15.2%). In addition, during the 6 months after hospitalization, diabetic vs non-diabetic patients had more admissions for cardiovascular reasons (36.9% vs 29.5%; P<0.0001) and were prescribed more secondary preventative medications (65.9% vs 61.7%; P<0.0001). They were also more frequently treated with insulin only (19.6% 6 months before vs 27.2% 6 months after) or oral antidiabetic drugs (14.6% vs 19.7%, respectively) than were non-diabetics. CONCLUSION: French diabetic patients subsequent to MI undergo fewer angioplasty procedures than do non-diabetic patients. After the acute stage, secondary preventative medications are used more often, with a marked rise in the use of insulin.
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Complicaciones de la Diabetes/terapia , Diabetes Mellitus/tratamiento farmacológico , Infarto del Miocardio/complicaciones , Infarto del Miocardio/terapia , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Angioplastia/estadística & datos numéricos , Distribución de Chi-Cuadrado , Complicaciones de la Diabetes/tratamiento farmacológico , Complicaciones de la Diabetes/cirugía , Femenino , Francia , Hospitales , Humanos , Hipoglucemiantes/uso terapéutico , Masculino , Persona de Mediana Edad , Infarto del Miocardio/tratamiento farmacológico , Infarto del Miocardio/cirugía , Estadísticas no ParamétricasRESUMEN
INTRODUCTION: The French general health insurance scheme has implemented a national influenza vaccination program including full refund for those 65 years old or more and those under 65 years of age with a targeted chronic disease. OBJECTIVES: Our aim was to evaluate vaccination coverage (VC) according to sex, age, targeted chronic disease and geographical regions. METHODS: Data on vaccination refund for patients covered by the general health insurance scheme (85% of French population) was collected from the refund information system for the 2007-2008 campaign. RESULTS: Among the 11,618,719 targeted individuals, the overall VC was 51.5% (9.6% for individuals <10 years of age, 15.0% between 10 and 19, 28.1% between 20 and 64, and 63.3% for 65 individuals years of age or more). For those under 20 years of age, VC rates were inferior to 35% for targeted groups except for cystic fibrosis (67%). Among individuals 65 years of age or more, VC was 63.3%. The VC was 74.1% for people 65 years old or more with at least five refunds 6-months before vaccination (80% of the group) and for the others it was under 30%. The frequency of refund, vaccination for the 2006/2007 campaign, and having an attending physician were associated with an increased VC. CONCLUSION: Refund data is useful to determine and understand VC among target groups, to build specific strategies among those groups and to assess their impact. VC could be underestimated because some target individuals may be vaccinated through non-refundable procedures. Specific studies should improve the understanding of vaccination attitudes in targeted groups.
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Vacunas contra la Influenza/administración & dosificación , Vacunas contra la Influenza/economía , Vacunación Masiva/economía , Vacunación/economía , Adolescente , Adulto , Anciano , Niño , Enfermedad Crónica/epidemiología , Francia , Geografía , Conductas Relacionadas con la Salud , Conocimientos, Actitudes y Práctica en Salud , Humanos , Cobertura del Seguro , Seguro de Salud , Vacunación Masiva/estadística & datos numéricos , Persona de Mediana Edad , Adulto JovenRESUMEN
BACKGROUND: In 2003, US breast cancer incidence rates fell. Recent French data reveal also a decline in 2005-2006. This study aims to present the trends in breast cancer incidence by age and to identify the respective impact of mammography screening and use of hormone replacement therapy (HRT) in the French context. METHODS: Breast cancer incidence rates were calculated from the new cases of breast cancer among affiliates of the general scheme of the French National Health Fund between 2000 and 2006. Data concerning HRT and mammograms were extracted from the reimbursement databanks of the National Health Fund and from the National Screening Programme. RESULTS: Breast cancer incidence decreased between 2003 and 2006 only for women aged 50 or above. The strongest declines were observed among the 55-59 and 60-64-year-old groups (12.9 and 7.7%, respectively). We observed a slight decline in the age groups of 50-54 and 65-69 (0.7 and 2.1%, respectively). Volumes of mammograms increased continuously between 2000 and 2006 from 1,600,000 to 3,470,000 for women aged 50-74 years old. In 2004, the National Screening Programme achieved complete geographic coverage. At the same time, the number of HRT users has dropped by 62% between 2001 and 2006. We observed the highest prevalence of HRT and the highest decrease in breast cancer incidence rates in the age group of 55-59. CONCLUSIONS: The recent reduction in breast cancer incidence in France for women aged 50 years or above, in 2005-2006, was accompanied by a substantial reduction in HRT prescriptions after 2002 for all age groups. The drop in HRT parallels the drop in breast cancer incidence for the women between the ages of 55-59 and 60-64. The high-level of development of screening in France during the same period could not account for the reduction in breast cancer incidence.
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Neoplasias de la Mama/epidemiología , Terapia de Reemplazo de Hormonas/estadística & datos numéricos , Mamografía/estadística & datos numéricos , Adulto , Distribución por Edad , Factores de Edad , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/inducido químicamente , Neoplasias de la Mama/diagnóstico por imagen , Detección Precoz del Cáncer , Femenino , Francia/epidemiología , Terapia de Reemplazo de Hormonas/efectos adversos , Humanos , Incidencia , Persona de Mediana Edad , Programas Nacionales de Salud/estadística & datos numéricosRESUMEN
AIMS: To estimate the prevalence of diabetes mellitus in France from 2000 to 2005, to monitor changes in its medical management and to determine the resultant costs to the French national healthcare system. METHODS: Using patients' data from the permanent sample of healthcare affiliates, we defined a treated diabetic patient as anyone who had been reimbursed for insulin or oral hypoglycaemic drugs at least twice within one calendar year. RESULTS: The prevalence of treated diabetic patients in 2005 in the French population covered by the general healthcare scheme was 3.6% (+/-0.1). The average annual increase between 2000 and 2005 was 5.7%, of which 0.7% can be attributed to population ageing. In 2005, the maximum prevalence of treated diabetic patients among those aged 70-79 years was 17.7% for men and 11.5% for women. Cardiovascular risk factors associated with diabetes were treated more often with drug therapy in 2005 than in 2000. In 2005, 73.8% of diabetic patients were given antihypertensive drugs and 54.9% received cholesterol-lowering agents. In 2005, the annual cost of treatment with antidiabetic drugs and treatment of cardiovascular risk factors was 760 euros per diabetic patient. CONCLUSION: The number of treated diabetic patients greatly increased between 2000 and 2005. At the same time, their associated cardiovascular risk factors were more frequently managed by drug therapy. As a result, the total expenditures for the healthcare system for treating diabetes and its associated cardiovascular risk factors doubled in five years, amounting to 1.8 billion euros in 2005.
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Diabetes Mellitus/epidemiología , Diabetes Mellitus/terapia , Anciano , Atención a la Salud , Femenino , Francia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Medicina EstatalRESUMEN
AIM: To compare the actual practice of bariatric surgery in France with the guidelines of scientific societies regarding surgical indications and followup. METHODS: This a prospective descriptive transversal study performed within a two month period (December 2002 - January 2003) in all patients for which a consent demand has been sent to the Medical Insurance Services (examined by an administrative consultant) and/or patients operated on for morbid obesity (with or without administrative consent). RESULTS: One thousand and three patients have been examined by an administrative consultant before obesity surgery and 1238 patients have been operated in 263 centres including 79 public (non-profit) centres and 184 private centres. In 16.7 % of the cases, there were wrong indications according to recognized criteria (BMI<35 kg/m(2) or lack of comorbidities for BMI between 35 and 39) or even contraindications because of other diseases. Patient informed consent was retrieved in only 54 % of medical files and follow up protocol was done in only 47 % of the cases. Because of several missing data, the practice of bariatric surgery followed the guidelines in only 34 % of cases. In hospital morbidity rate was 5 %. Two patients died postoperatively (mortality rate 0.2 %). CONCLUSIONS: This study demonstrates that the practice of bariatric surgery needs to be improved in France.
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Bariatria/normas , Adhesión a Directriz , Obesidad Mórbida/cirugía , Adolescente , Adulto , Niño , Femenino , Francia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Estudios Prospectivos , Encuestas y CuestionariosRESUMEN
AIM: To measure the change in blood-pressure control in two populations of patients with severe high blood pressure between 1999 and 2003. METHOD: The French National Healthcare Fund performed two observational, cross-sectional surveys on the medical management of high blood pressure, the first in 1999 and the second in 2003. Each survey enrolled patients aged between 20 and 80 years old who filed a first-time request for exemption from co-payments for this long-term disorder. Study data was collected by the health fund's salaried physician advisors who directly examined the patients and from information gathered from each patient's attending physician. Adequate blood pressure control was defined according to the guidelines set out by the ANAES in 1997 and determined by calculating the average of the last three blood pressure figures recorded by the patient's attending physician (systolic [SBP] and diastolic [DBP] arterial blood pressures). RESULTS: 10,665 patients were enrolled in the 1999 survey and 2,584 were enrolled in the 2003 survey. The average age was 63.1 +/- 0.2 years in 1999 and 64.4 +/- 0.4 years in 2003. The proportion of diabetic patients in the two surveys remained stable: 27.5% +/- 1.0 in 1999 and 28.4% +/- 1.7 in 2003. Between 1999 and 2003, the percentage of patient who were treated for hypercholesterolemia increased from 44.0% +/- 1.1 to 54.3% +/- 1.9. Between 1999 and 2003, the proportion of patients who were considered well-controlled (SBP and DBP < 140/90 mmHg) or, if older than 60 years with isolated systolic high blood pressure (DBP < 90 mmHg and SBP < or = 160 mmHg) increased almost 5% points, going from 40.8% +/- 1.1 in 1999 to 45.5% +/- 1.9 in 2003. In diabetic patients, in whom the cut-off threshold is 130/85 mmHg, 6.7% +/- 1.1 were considered well-controlled in 1999 while 5.4% +/- 1.7 were deemed well-controlled in 2003. The proportion of well-controlled patients in the sub-group of hypertensive patients with renal failure (cut-off thresholds: 125/75 mmHg) remained relatively stable between 1999 and 2003: 5.2% [2.5; 7.9] versus 2.8% [0.5; 8.6]. CONCLUSION: There was a significant increase in the proportion of well-controlled hypertensive patients between 1999 and 2003. This increase occurred at the same time as a number of initiatives (scientific societies, federal government as well as the National Health Fund) intended to sensitize physicians to the need to obtain adequate blood pressure control.
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Antihipertensivos/uso terapéutico , Adhesión a Directriz , Hipertensión/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Anciano , Estudios Transversales , Femenino , Francia , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVES: Our aim was to update available data concerning the prevalence and cost of diabetes in metropolitan France. METHODS: We performed a retrospective study using patient reimbursement data from all the 128 local health offices (CPAM) in metropolitan France. We selected patients who received reimbursements for an oral hypoglycemic agent or insulin. Thus, 704,423 patients were studied by using 1998 data and 1,145,603 patients were studied by using data from 2000. The expenditures studied represented the total amount reimbursed by national health insurance to diabetic patients. The cost differential which could be attributed to diabetes was calculated by determining the difference between costs generated by diabetic patients to those generated by the rest of the population of the same age. RESULTS: Between 1998 and 2000, the prevalence of diabetes treated in the population of affiliates covered by the general scheme increased from 2.78% to 2.96%. The total amount paid by the general scheme for care to diabetic patients (related to diabetes or not) was 5.710 billion euros in 2000 compared to 4.862 billion euros in 1998. The amount which can be attributed to diabetes alone can be estimated to be 2.414 billion euros in 2000 compared to 2.021 billion euros in 1998. After considering the impact of the increase in the number of treated diabetics, a modification in the modalities of medical care probably accounts for 183 million euros of the cost increase. Medical equipment (self blood glucose monitoring devices, reagent strips, finger lancets...) accounts for 39.3% (72 million euros) of this cost differential, medications account for 34.4% (63 million euros) and nursing care 16.9% (31 million euros). There was no change in the cost of diabetes with relation to expenses for medical consultations.
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Diabetes Mellitus/economía , Diabetes Mellitus/epidemiología , Costos y Análisis de Costo , Diabetes Mellitus/terapia , Prescripciones de Medicamentos/economía , Francia/epidemiología , Humanos , Hipoglucemiantes/economía , Hipoglucemiantes/uso terapéutico , Insulina/economía , Insulina/uso terapéutico , Pacientes Ambulatorios , Prevalencia , Mecanismo de Reembolso , Estudios Retrospectivos , Población UrbanaRESUMEN
AIM: Within the framework of its long-term public health program aimed at improving the clinical management of hypertension (HBP), the French health care funds performed two nationwide surveys concerning affiliates who were recently waived from making co-payments for severe hypertension. The aim was to measure the difference between observed clinical management and benchmark care, defined by the 1997 ANAES guidelines (National Agency for Accreditation and Health Evaluation), at the onset (May 1999) and during the program (November 1999) in order to detect any changes in clinical management between the two study periods, the timeframe corresponding to the intervention period. METHODS: The patient samples used in the two studies involved affiliates aged between 20 and 80 years old living in France or one of its overseas territories who were recently waived from making co-payments (ETM) for severe hypertension (these patients are reimbursed 100% for all care related to the disorder). The evaluation was based on retrospective data furnished by attending physicians. The indicators isolated in order to compare the two study periods were blood pressure control, suggested life-style changes and prescribed drugs. RESULTS: The first survey took place between May and November 1999 and enrolled 10,665 patients (corresponding to a weighted patient population of 50,383) while the second studied 2,649 patients in November 2000. The study population in 1999 was, on the average, younger than the study population in November 2000: 63.1 years +/- 0.2 vs 65.4 years +/- 0.4. Nearly two patients out of three presented at least one other major cardiovascular risk factor in addition to HBP (cigarette smoking, diabetes mellitus or dyslipidemia): 63.9% in 1999 and 64.4% in 2000. Nearly one patient out of seven had associated coronary artery disease: 14.1% in 1999 and 15.3% in 2000 and more than one out of ten had associated cerebro-vascular disease: 12.7% in 1999 and 12.2% in 2000. There were more diabetic patients in the 1999 group than in the 2000 group: 27.5% +/- 1.0 vs 23.9% +/- 1.6. The proportion of patients who had poorly controlled blood pressure (systolic > 140 mmHg or > 160 mmHg in subjects aged between 60 and 80 years with isolated systolic hypertension, or a diastolic > 90 mmHg) did not change: 46.8% +/- 1.1 in 1999 and 45.7% +/- 1.9 in 2000. If the guideline recommendations for diabetics (blood pressure < 130/85) are applied. 85.4% of the diabetic patients were poorly controlled in 1999 and 86.6% in 2000. Similarly, in hypertensive patients with kidney failure (guideline recommendations: < 125/75 mmHg), 94.5% were poorly controlled in 1999 and 96.3% in 2000. Recommended life-style changes (reduction in salt intake, weight loss, lower alcohol consumption, increased physical activity) were not well followed in both studies: in 1999, fewer than one patient out of four completely implemented the desired changes (23.7%) while only 24.5% did so in 2000. Physicians prescribed specifically indicated therapeutic agents considering associated diseases in 68.0% of the patients in 1999 and in 67.6% in 2000. Prescriptions contained a potentially contraindicated drug in 27.3% of the cases in 1999 and in 28.0% in 2000. CONCLUSION: A comparison of the results of the two surveys performed in 1999 and 2000 concerning the management of patients with severe hypertension failed to demonstrate any significant differences in blood pressure control or treatment modalities. While not questioning the value of the interventions of the health funds, these findings illustrate how difficult it is to change clinical practice over a short time period, especially in a disorder involving a number of different elements which include, among others, individual patient behavior. In order to significantly improve clinical management, it will probably be necessary to continue the dialogue between medical advisors of the health care funds (médecins conseils) and clinicians and to renew campaigns aimed at helping patients become more responsible.
Asunto(s)
Antihipertensivos/uso terapéutico , Enfermedades Cardiovasculares/etiología , Hipertensión/tratamiento farmacológico , Anciano , Dieta , Femenino , Francia , Conductas Relacionadas con la Salud , Encuestas de Atención de la Salud , Humanos , Seguro de Salud/estadística & datos numéricos , Estilo de Vida , Masculino , Persona de Mediana Edad , Salud Pública , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Pérdida de PesoAsunto(s)
Política de Salud , Salud Pública , Vacunación/tendencias , Adulto , Factores de Edad , Anciano , Niño , Francia , Educación en Salud , Vacunas contra Hepatitis B/administración & dosificación , Humanos , Lactante , Vacunas contra la Influenza/administración & dosificación , Seguro de Salud , Rol del Médico , Factores de RiesgoRESUMEN
French national health insurance has carried out two nationwide surveys as part of its programme intended to improve the care given to patients with hypertension, focusing on affiliates diagnosed with severe hypertension entitled to exemption from co-payments (patients are reimbursed 100 per cent for all care related to the corresponding disorder). The objective was to measure the difference between observed care and the quality of care delineated in the guidelines (1997) elaborated by the National Agency for Healthcare Accreditation and Evaluation (ANAES). The before and after comparison was designed to determine whether actual care is in accordance with the guideline's standards. The initial survey took place from 31 May to 12 November 1999 over the entire French territory (metropolitan and overseas departments) and concerned a representative sample of patients whose ages ranged from 20 to 80 years at the time they qualified for exemption from co-payments for severe hypertension. The method used for comparison involved the calculation of a number of different evaluation parameters, the principal one being blood pressure control, using the systolic (PAS) and diastolic (PAD) pressures reported by attending physicians. Other evaluation parameters included the quality of the therapeutic strategy utilized. A total of 10,665 patients were enrolled in the survey by using information gathered from 8377 practicing physicians. Extrapolated to the entire population in 1999, the results can be applied to 50,383 patients. The average age was 63 years and the patients had been treated for hypertension for an average of 9 years. In addition to severe hypertension, 64 per cent of the patients had other significant high-risk factors for cardiovascular disease: 44 per cent had dyslipidemia, 28 per cent had diabetes mellitus, 15 per cent were smokers. In 41 per cent of cases, the patients' blood pressures were well controlled (systolic and diastolic pressures below 140/90 mmHg or, for patients older than 60 years with only isolated systolic hypertension, systolic pressure equal to or lower than 160 mmHg); in 12 per cent of cases the patients' blood pressures were equal to the limit values; in 47 per cent of cases blood pressure was poorly controlled. Diabetics had poorly controlled blood pressure in 85 per cent of cases (systolic or diastolic pressures greater than 130/85 mmHg) and, similarly, 94 per cent of the patients who were in renal failure were poorly controlled (systolic or diastolic pressures greater than 125/75 mmHg). Preferential prescription with a particular therapeutic class, because of an existing comorbidity, was found in 68 per cent of patients whereas potentially contraindicated therapeutic classes were prescribed in 27 per cent. The daily cost of anti-hypertensive drug therapy was estimated at 8.05 francs per day per patient. Extrapolated to the study population in 1999, this represents 148.1 million francs. Less than 1 per cent of this observed cost (1.1 million francs) was economized by prescribing less expensive, alternative drug specialties in spite of the fact that an estimated 9.6 million francs could have been saved if these equivalent, alternative drugs had been prescribed. The potential saving corresponds to 6.5 per cent of the total observed cost. The care given to severely hypertensive patients is sub-optimum when compared with the ANAES guidelines (1997). In public health terms, the most preoccupying feature is poor blood pressure control because it occurs in a patient population with a high cardiovascular risk. These findings fully justify the continuation and amplification of the actions undertaken in this nationwide public health programme concerning the medical care given to hypertensive patients.