Appropriateness of Prescriptions of Recommended Treatments in Organisation for Economic Co-operation and Development Health Systems: Findings Based on the Long-Term Registry of the European Society of Cardiology on Heart Failure.

OBJECTIVE: This observational study aimed to identify clinical variables and health system characteristics associated with incomplete guideline application in drug treatment of patients with chronic heart failure (HF) across 15 countries. METHODS: Three data sets were used: European Society of Cardiology Heart Failure Registry, Organisation for Economic Co-operation and Development's Health System Characteristics Survey, and Organisation for Economic Co-operation and Development Health Statistics 2013. Patient and country variables were examined by multilevel, multiple logistic regression. The study population consisted of ambulatory patients with chronic HF and reduced ejection fraction. Inappropriateness of prescription of pharmacological treatments was defined as patients not prescribed at least one of the two recommended treatments (angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers and beta-blockers) or treated with both medications but at suboptimal dosage and in absence of documented contraindication/intolerance. RESULTS: Of 4605 patients, 1097 (23.8%) received inappropriate drug prescriptions with a large variation within and across countries, with 18.5% of the total variability accounted for by between-country health structure characteristics. Patient-level characteristics such as having mitral regurgitation (odds ratio 1.4; 95% confidence interval 1.1-1.7) was significantly associated with inappropriate prescription of recommended drugs, whereas chronic obstructive pulmonary disease (odds ratio 0.7; 95% confidence interval 0.5-0.9) was associated with more appropriate prescriptions. Among the country-level variables, incentives or obligation to comply with guidelines increased the probability of prescription appropriateness. CONCLUSIONS: Combining clinical variables with health system characteristics is a promising exercise to explain the appropriateness of recommended drug prescriptions. Such an understanding can help decision makers to design more effective policies to improve adherence to guidelines, improve health care outcomes, and potentially reduce costs.

Implantable cardioverter-defibrillators in France: practices and regional variability.

AIMS: The rates of cardiac defibrillator implantation (ICD) in Europe and within countries are heterogeneous. We examined the characteristics of ICD recipients and device implantation rates in France, with the goal of identifying patterns and regional differences in medical practices. METHODS AND RESULTS: We compiled the information available on devices and patients from a manufacturer's database for the years 2008 and 2009 and the Stidefix national registry from January 2008 to April 2010 and reported the descriptive statistics and comparisons of implantation practices among regions. We analysed data from 10 766 patients enrolled in Stidefix (mean age=63 ± 13 years; 83% men) after implantation of single-chamber (24%), dual-chamber (33%), or triple-chamber (43%) ICD. Implantation was for primary prevention in 63% of patients. Between 2008 and 2009, the national implant rate increased from 126 to 147 per million inhabitants, with regional variations related to the number of cardiologists and of implant centres. Patients were significantly older and more likely to undergo implantation for primary prevention or for cardiac resynchronization therapy (CRT) in higher-volume regions. In Ile de France (Paris and its suburbs), patients tended to be younger, as in low-implantation regions, but with a high rate of CRT implants, as in high-implantation regions. A comparison of the Stidefix data with the manufacturer's database revealed that only 57% of all ICD implanted in 2009 were reported to Stidefix. CONCLUSION: Despite an increasing rate of ICD implantation in France, important regional disparities persist, with a median position occupied by Ile de France.