[What public health measures could reduce antenatal exposure to smoking and improve the quality of perinatal care? The point of view of a public health physician]. / Quelles sont les mesures de santé publique susceptibles de réduire l'exposition anténatale au tabagisme et d'améliorer les indicateurs de qualité des soins périnatals? Le point de vue du médecin de santé publique.

From the population standpoint of public health, two domains of intervention, healthcare programs and good clinical practices, are concerned by the question of smoking cessation. These two domains imply different targets and methodology to achieve a common objective. To achieve improvement starting from an analysis of the existing situation, it is necessary to elaborate guidelines for good clinical practice and also carefully monitor their application in terms of training, evaluation and certification. Health promotion programs designed to help young women stop or not start smoking necessarily imply the use of recognized criteria of efficacy and predictability.

[Five-year survival of Ile-de-France cancer patients diagnosed in 1994]. / Survie à cinq ans des patients ayant eu un diagnostic de cancer en 1994 en Ile-de-France.

BACKGROUND: This study aimed to estimate survival at 5 years by localization, sex and stage of the patients who presented a new cancer in 1994 in the Ile-de-France area. METHODS: A cohort study began in 1994 by an exhaustive collection of the incidental cancers notified in the Ile-de-France area at the health insurance (27,080 patients). A stratified random sample based on tumor localization was followed at 1 year, 3 years and 5 years. The analysis of the observed survival was carried out according to Kaplan-Meier method. Relative survival was calculated according to Ederer II method. RESULTS: The follow-up sample concerned 4,166 patients. For all cancers, relative survival at 5 years was 65% for the women and 51% for the men. Relative survival rate at 5 years was 82% for the women with a breast cancer (98% for the patients in stage I) and 66% for those with a cancer of the cervix. Relative survival at 5 years for colonic cancer was 67% for men and 54% for women. For lung cancer, the relative survival rate fell from 47% for patients in stage I to 5% for those in stage IV. CONCLUSION: Our study produces population-based survival data for a entire geographical area covering 20% of the French population. Survival improves with earlier diagnosis but depends also on quality of care and availability of care: access to medical care can be a favouring factor. While in terms of incidence the situation in the Ile-de-France area is close to the national situation, survival at 5 years for a set of tumors appears to be better in this area than the nationwide figures. Besides providing information useful to determine mortality and incidence, the health insurance data offer additional insight to cancer epidemiology and contribute to better knowledge of this disease.

[Smoking and pregnancy: survey among women enrolled in an independent worker insurance program]. / Tabac et grossesse. Etude de l'Assurance maladie des professions indépendantes en Ile-de-France.

OBJECTIVES: In order to further improve its prevention program entitled "Maternity childhood follow-up", the Paris region health insurance program for independent workers carried out a survey among female participants. The survey was designed to assess women's smoking behavior and evaluate reception of information concerning smoking-related risks and support available to stop smoking. The women's suggestions were also collected. MATERIALS AND METHODS: A questionnaire was sent by the physicians in charge of the Ile de France region to the 3525 women who had reported a pregnancy. RESULTS: 1099 answers were received (31%) The mean age of responders was 34.3 4.7 years. Their educational level was high (76% had a university degree). Before pregnancy, 37% were smokers. At the first trimester of pregnancy, 17% were smokers, 15% at the second trimester and 14% at the third trimester. Two years after childbirth, 20.5% were smokers. The proportion of women who stopped smoking was higher for those with a low Fagerström score. 29% of women said they did not receive any information about the harmful consequences of smoking. To cease smoking during pregnancy, 70% are helped by family and friends, 20% by health professionals; 3.5% took nicotine substitutes. CONCLUSION: This survey emphasises the need for improving information to pregnant women for alerting them to the dangers of smoking and for training the relevant health professionals.

[Application of medical guidelines for the prescription of statins]. / L'application des recommandations médicales lors de la prescription de statines.

BACKGROUND: The efficacy of statins to prevent coronary heart disease (CHD) is well documented. This class of lipid-lowering drugs is now widely prescribed and was demonstrated to be cost effective in high risk patients. OBJECTIVE: To assess the appropriateness of statins use, regarding initiation and follow-up of the treatment, as compared to the guidelines elaborated in 1996 by National Agency for the Development of Medical Evaluation (ANDEM). These guidelines were based on stratification of patients according to cardiovascular risk. METHODS: Two groups of patients living in Ile-de-France region were defined, using Health Insurance computer database, on reimbursements. The first group named "new users" included patients in whom statin therapy was initiated during March 2000. The second group named "long term users" included patients who have been treated by statin therapy for one year or more. A sample of patients were randomly selected among these two groups. Trained Health Insurance advisors analyzed in depth the patients medical history and diet. All biological results were recorded and a complete history of medical therapy was assessed for each patient. An algorithm allowed the advisor to rate for nonadherence according to French medical guidelines. RESULTS: "New users": the random sample consisted of 460 patients, among whom 398 (87%) were free of CHD in whom the nonadherence rate was 72.4% (68.0% to 76.8%). Nonadherence concerned: LDL cholesterol level not tested (32%) and/or absence of prior fat-free diet (37%) and/or LDL cholesterol value before drug therapy was below the guidelines/threshold. "Long term users": the random sample consisted of 582 patients, among whom 381 (65%) were free of CHD. The nonadherence rate was 71.1% (66.5% to 75.7%). In addition, the nonadherence rate for patients in secondary prevention was 82.1% (79.7% to 84.6%) respectively, corresponding to: LDL cholesterol level not tested (41% and 34%); and/or no change dietary (18% and 12%); and/or unreach the LDL-C target level (24% and 45%). CONCLUSION: This study shows that the implementation of guidelines needs to be improved in clinical practice.

[Secondary prevention of myocardial infarction in the Ile de France]. / Prévention secondaire de l'infarctus du myocarde en Ile-de-France.

This enquiry was carried out to evaluate the measures of secondary prevention at 6 months and over of myocardial infarction in the ile de France region with respect to the recommendations of scientific societies and results of large scale therapeutic trials. A questionnaire was completed for the 1,215 patients selected from data obtained from the hospital discharge summary, interrogation and examination of the patient, and a telephone conversation with the attending physician. The data covered cardiovascular risk factors, the main clinical parameters, the results of biological tests and investigations carried out for risk stratification, plus different elements of therapeutic management. Compared with previous studies of the same type, this enquiry showed a favourable tendency towards the prescription of antithrombotic drugs and betablockers (98.3% and 82.4% of patients, respectively), and to patients with reputedly normal blood pressure values (84.7%). A positive result concerning the reduction in the number of smokers (17.4%) and the increase in lipid lowering prescriptions should be tempered by the fact that advice about stopping smoking was rarely given and that the quantitative target of LDL cholesterol was often ignored. Finally, the prescriptions of ACE inhibitors, physical exercise and cardiac rehabilitation remained well below the recommendations or recent scientific data.

[Description of type 2 diabetes mellitus in residents of Ile-de-France aged at most 70 years]. / Description des diabétiques de type 2 d'Ile-de-France âgés de 70 ans au plus.

Our study of patients with type 2 diabetes mellitus residing in the Paris area (Ile-de-France) aged 70 years or younger included 1 591 patients examined by national health insurance expert physicians who also filled out a self-administrated questionnaire. Their primary care physicians also answered a questionnaire (79% participation, indicating their personal implication). We found that diabetes was most often discovered during regular check-ups. Single-drug regimens were the most widely used. Sulfamides were prescribed for 77% of the patients. Among the 912 patients who were overweight (BMI > 28 Kg/m2), 34.3% were taking sulfamides alone despite the fact that metformin is recommended as the first intention drug for these patients. Blood pressure control was not satisfactory in 30% of the patients who were treated or not for high blood pressure. This proportion rose to about 50% among treated patients alone. The patients appeared to be knowledgeable about the risk of complications, particularly ocular complications. They were aware of a certain number of messages but the results would suggest difficulty in application.