Cohort of one million patients initiating antidepressant treatment in France: 12-month follow-up.

AIMS: Previous studies have shown that the recommended minimum 6-month period for antidepressant treatment is actually observed for only a minority of patients. The objectives of this study were to characterise patients with newly prescribed antidepressant treatment in France and identify factors possibly associated with insufficient duration of treatment or the occurrence of certain events such as sick leave, hospitalisations and suicide attempts. METHODS: Data were extracted from the French health insurance database (SNIIRAM) and the national hospitalisation database (PMSI) for patients covered by the main French health insurance scheme representing 75% of the French population. Patients were included if they had a newly prescribed antidepressant in 2011, but no prior psychiatric diagnosis identified in the databases and no significant psychiatric medication (such as antipsychotic or mood stabiliser) in 2009-2010. RESULTS: A total of 998 710 patients (2% of the overall population), with a mean age of 50 years and 66% of females, initiated an antidepressant in 2011, which was prescribed by a general practitioner in 89% of cases. Five generic names, including three selective serotonin reuptake inhibitors, accounted for 75% of first prescriptions. Only one reimbursement was observed for 40% of patients. Treatment duration was less than 6 months for more than 80% of patients, more frequently for low income earners, and varied according to age, gender and region. The median time lag between first visit and antidepressant initiation was 27 days. Hospitalisation related to a psychiatric disease over the following 12 months was observed for 3% of patients. CONCLUSION: Duration of treatment and follow-up were both insufficient for the majority of French patients initiating antidepressant treatment in 2011, which may reflect poor quality of care for people with mood or anxiety disorders, possibly because of overdiagnosis and inappropriate drug treatment, or poor adherence and side effects, or poor follow-up.

Isotretinoin and risk of inflammatory bowel disease: a French nationwide study.

OBJECTIVES: Isotretinoin, a drug widely prescribed for severe acne, has been suspected to increase the risk of ulcerative colitis (UC), but data are conflicting. To further examine the association between isotretinoin use and risk for UC and Crohn's disease (CD), we conducted a large nationwide case-control study in France. METHODS: We used information from the National Health Insurance system for all French people covered by the general scheme between 1 January 2008 and 31 December 2010, totaling over 50 million individuals (i.e., 76% of the whole French population). All incident claims for UC and CD and all medical drug reimbursements were automatically recorded in the database. For each case, four controls were matched on age, gender, year of enrollment, and follow-up duration. The association between isotretinoin use and UC or CD claim was estimated by conditional logistic regression. RESULTS: We included 7,593 cases of inflammatory bowel disease (IBD; 3,187 UC, 4,397 CD, and 9 indeterminate colitis) and 30,372 controls; among them, 26 cases (0.3%) (15 UC (0.5%) and 11 CD (0.3%)) and 140 controls (0.4%) were exposed to isotretinoin. Isotretinoin exposure was not associated with an increased risk for UC (odds ratio (OR)=1.36 (95% confidence intervals (CI): 0.76, 2.45)) but was associated with a decreased risk for CD (OR=0.45 (95% CI: 0.24, 0.85)), P value for homogeneity between UC and CD=0.001. Results were similar in analyses restricted to individuals below the age of 40 years, to cases with colonoscopy or intestinal surgery, or when adjusting for other acne treatments. CONCLUSIONS: In this population-based case-control study, isotretinoin use was not associated with increased UC risk but was associated with a decreased CD risk. This study provides reassuring data for people using isotretinoin.

Outcomes associated with antidepressant treatment according to the number of prescriptions and treatment changes: 5-year follow-up of a nation-wide cohort study.

Background: Naturalistic studies regarding clinical outcomes associated with antidepressant treatment duration have yielded conflicting results, possibly because they did not consider the occurrence of treatment changes. This nation-wide population-based study examined the association between the number of filled prescriptions and treatment changes and long-term psychiatric outcomes after antidepressant treatment initiation. Methods: Based on the French national health insurance database, 842,175 adults who initiated an antidepressant treatment in 2011 were included. Cox proportional-hazard multi-adjusted regression models examined the association between the number of filled prescriptions and the occurrence of treatment changes 12 months after initiation and four outcomes during a 5-year follow-up: psychiatric hospitalizations, suicide attempts, sick leaves for a psychiatric diagnosis, new episodes of antidepressant treatment. Results: During a mean follow-up of 4.5 years, the incidence rates of the four above-mentioned outcomes were 13.49, 2.47, 4.57, and 92.76 per 1,000 person-years, respectively. The number of filled prescriptions was associated with each outcome (adjusted HRs [95% CI] for one additional prescription ranging from 1.01 [1.00-1.02] to 1.10 [1.09-1.11]), as was the occurrence of at least one treatment change vs. none (adjusted HRs [95% CI] ranging from 1.18 [1.16-1.21] to 1.57 [1.79-1.65]). Furthermore, the adjusted HRs [95% CI] of the number of filled prescriptions were greater in patients with (vs. without) a treatment change for psychiatric hospitalizations (1.12 [1.11-1.14] vs. 1.09 [1.08-1.10], p for interaction = 0.002) and suicide attempts (1.12 [1.09-1.15] vs. 1.06 [1.04-1.08], p for interaction = 0.006). Limitations: Lack of clinical data about the disorders warranting the prescriptions or their severity. Conclusion: Considering treatment changes is critical when using administrative claims database to examine the long-term psychiatric outcomes of antidepressant treatments in real-life settings.

[Management of patients with end-stage renal disease prior to initiation of renal replacement therapy in 2013 in France]. / Prise en charge des patients avant l'initiation d'un traitement de suppléance de l'insuffisance rénale chronique terminale en 2013 en France.

This study evaluated the management of patients with end-stage renal disease prior to initiation of renal replacement therapy. Among the 51 million national health insurance general scheme beneficiaries (77% of the population), persons 18 years and older, starting dialysis or undergoing preemptive renal transplantation in 2013, were included in this study. Data were derived from the French national health insurance system (SNIIRAM). In this population of 6674 patients (median age: 68 years), 88% initiated renal replacement therapy by haemodialysis, 8% by peritoneal dialysis, and 4% by renal transplantation. During the year preceding initiation of dialysis, 76% of patients had been hospitalised with at least one diagnostic code for renal disease in 83% of cases, 16% had not received any reimbursements for serum creatinine assay and 32% had not seen a nephrologist; 87% were taking at least one antihypertensive drug (60% were taking at least a renin-angiotensin system inhibitor) and 30% were taking a combination of 4 or more classes of antihypertensive drugs. For patients initiating haemodialysis in a haemodialysis centre, 39% had undergone a procedure related to arteriovenous fistula and 10% had been admitted to an intensive care unit. This study, based on the available reimbursement data, shows that, despite frequent use of the health care system by this population, there is still room for improvement of screening and management of patients with end-stage renal disease and preparation for renal replacement therapy.

[The human and economic burden of cancer in France in 2014, based on the Sniiram national database]. / Poids humain et économique des cancers en France en 2014, les données du Sniiram.

INTRODUCTION: The national health insurance information system (Sniiram) can be used to estimate the national medical and economic burden of cancer. This study reports the annual rates, characteristics and expenditure of people reimbursed for cancer. METHODS: Among 57 million general health scheme beneficiaries (86% of the French population), people managed for cancer were identified using algorithms based on hospital diagnoses and full refund for long-term cancer. The reimbursed costs (euros) related to the cancer, paid off by the health insurance, were estimated. RESULTS: In 2014, 2.491 million people (4.4%) covered by the general health scheme had a cancer managed (men 1.1 million, 5.1%; women 1.3 million, 4.9%). The annual (2012-2014) average growth rate of patients was 0.8%. The spending related to the cancer was 13.5 billion: 5 billion for primary health care (drugs 2.3 billion), 7.5 billion for the hospital (drugs 1.3 billions) and 900 million for sick leave and invalidity pensions. Spending annual average growth rate (2012-2014) was 4% (drugs 2%). The rates of patients and the relative spending were 1.8% and 2.5 billion for the breast cancer (women), 1.5% and 1.0 billion for prostate cancer, 0.9% and 1.5 billion for the colon cancer, and 0.19% and 1.3 billion for lung cancer. DISCUSSION: Cancers establish one of the first groups of chronic diseases pathologies in terms of patients and spending. If the numbers of patients remain stables, the spending increases, mainly for medicines.

What is the care pathway of patients who undergo thyroid surgery in France and its potential pitfalls? A national cohort.

CONTEXT: The rate of thyroid cancer is increasing in France, as well as concerns about overdiagnosis and treatment. OBJECTIVES: To examine the care pathway of patients who undergo thyroid surgery in France and detect potential pitfalls. DESIGN: A large observational study based on medical reimbursements, 2009-2011. SETTING: Data from the Sniiram (National Health Insurance Information System). PATIENTS: Patients with thyroid surgery in 2010, classified into 4 groups: thyroid cancer, benign nodule, goitre or multiple nodules, other (hyperthyroidism, head-neck cancer). MAIN OUTCOME MEASURES: Medical investigations during, prior and after thyroidectomy. RESULTS: A total of 35 367 patients underwent surgery (mean age 51 years, 80% women): 17% had a reported diagnosis of thyroid cancer, 20% benign nodule, 38% goitre or multiple nodules and 25% another diagnosis. The ratio of thyroidectomies with cancer over thyroidectomies with benign nodule was 0.8 and varied across regions. In the year preceding surgery, 82% of patients had an investigation by thyroid ultrasonography, 21% thyroid scintigraphy, 34% fine-needle aspiration cytology, 40% serum calcitonin assay and 54% serum calcium assay. In the following year, all patients with total thyroidectomy and 44% of patients with partial thyroidectomy and a diagnosis of benign nodule were taking thyroid hormone therapy. 100 patients had been reoperated for a compressive haematoma and 63 died during the first month, half of whom had been operated for cancer. Mean rates of recurrent laryngeal nerve injury and hypocalcaemia (requiring blood tests plus treatments within 4-12 months) were estimated at 1.5% and 3.4%, respectively, and were higher in the cancer group (2.3% and 5.7%). CONCLUSIONS: This almost nationwide study demonstrates the suboptimal management of patients prior to thyroidectomy in France. It suggests overdiagnosis and potential harms to patients, and calls for a review of the relevance of thyroidectomy, particularly with regard to microcancers.

Two-year outcome of patients after a first hospitalization for heart failure: A national observational study.

BACKGROUND: National population-based management and outcome data for patients of all ages hospitalized for heart failure have rarely been reported. AIM: National population-based management and outcome of patients of all ages hospitalized for heart failure have rarely been reported. The present study reports these results, based on 77% of the French population, for patients hospitalized for the first time for heart failure in 2009. METHODS: The study population comprised French national health insurance general scheme beneficiaries hospitalized in 2009 with a principal diagnosis of heart failure, after exclusion of those hospitalized for heart failure between 2006 and 2008 or with a chronic disease status for heart failure. Data were collected from the national health insurance information system (SNIIRAM). RESULTS: A total of 69,958 patients (mean age, 78 years; 48% men) were studied. The hospital mortality rate was 6.4%, with 1-month, 1-year and 2-year survival rates of 89%, 71% and 60%, respectively. Heart failure and all-cause readmission-free rates were 55% and 43% at 1 year and 27% and 17% at 2 years, respectively. Compared with a reference sample of 600,000 subjects, the age- and sex-standardized relative risk of death was 29 (95% confidence interval [CI] 28-29) at 2 years, 82 (95% CI 72-94) in subjects aged<50 years and 3 (95% CI 3-3) in subjects aged ≥ 90 years. For subjects aged < 70 years who survived 1 month after discharge, factors associated with a reduction in the 2-year mortality rate were: female sex; age < 55 years; absence of co-morbidities; and use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers, lipid-lowering agents or oral anticoagulants during the month following discharge. Poor prognostic factors were treatment with a loop diuretic before or after hospitalization and readmission for heart failure within 1 month after discharge. CONCLUSIONS: This large population-based study confirms the severe prognosis of heart failure and the need to promote the use of effective medications and management designed to improve survival.

First hospitalization for heart failure in France in 2009: patient characteristics and 30-day follow-up.

BACKGROUND: The incidence of heart failure (HF) is stable in industrialized countries, but its prevalence continues to increase, especially due to the ageing of the population, and mortality remains high. OBJECTIVE: To estimate the incidence in France and describe the management and short-term outcome of patients hospitalized for HF for the first time. METHOD: The study population comprised French national health insurance general scheme beneficiaries (77% of the French population) hospitalized in 2009 with a principal diagnosis of HF after exclusion of those hospitalized for HF between 2006 and 2008 or with a chronic disease status for HF. Data were collected from the national health insurance information system (SNIIRAM). RESULTS: A total of 69,958 patients (mean age 78 years; 48% men) were included. The incidence of first hospitalization for HF was 0.14% (≥ 55 years, 0.5%; ≥ 90 years, 3.1%). Compared with controls without HF, patients more frequently presented cardiovascular or other co-morbidities. The hospital mortality rate was 6.4% and the mortality rate during the 30 days after discharge was 4.4% (3.4% without readmission). Among 30-day survivors, all-cause and HF 30-day readmission rates were 18% (< 70 years, 22%; ≥ 90 years, 13%) and 5%, respectively. Reimbursements among 30-day survivors comprised at least a beta-blocker in 54% of cases, diuretics in 85%, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in 67%, a diuretic and ACEI/ARB combination in 23% and a beta-blocker, ACEI/ARB and diuretic combination in 37%. CONCLUSION: Patients admitted for HF presented high rates of co-morbidity, readmission and death at 30 days, and there remains room for improvement in their drug treatments; these findings indicate the need for improvement in return-home and therapeutic education programmes.