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

Days Spent at Home and Mortality After Critical Illness: A Cluster Analysis Using Nationwide Data

BACKGROUND

Beyond the question of short-term survival, days spent at home could be considered a patient-centered outcome in critical care trials.

RESEARCH QUESTION

What are the days spent at home and health care trajectories during the year after surviving critical illness?

STUDY DESIGN AND METHODS

Data were extracted on adult survivors spending at least 2 nights in a French ICU during 2018 who were treated with invasive mechanical ventilation or vasopressors or inotropes. Trauma, burn, organ transplant, stroke, and neurosurgical patients were excluded. Stays at home, death, and hospitalizations were reported before and after ICU stay, using state sequence analysis. An unsupervised clustering method was performed to identify cohorts based on post-ICU trajectories.

RESULTS

Of 77,132 ICU survivors, 89% returned home. In the year after discharge, these patients spent a median of 330 (interquartile range [IQR], 283-349) days at home. At 1 year, 77% of patients were still at home and 17% had died. Fifty-one percent had been re-hospitalized, and 10% required a further ICU admission. Forty-eight percent used rehabilitation facilities, and 5.7%, hospital at home. Three clusters of patients with distinct post-ICU trajectories were identified. Patients in cluster 1 (68% of total) survived and spent most of the year at home (338 [323-354] days). Patients in cluster 2 (18%) had more complex trajectories, but most could return home (91%), spending 242 (174-277) days at home. Patients in cluster 3 (14%) died, with only 37% returning home for 45 (15-90) days.

INTERPRETATION

Many patients had complex health care trajectories after surviving critical illness. Wide variations in the ability to return home after ICU discharge were observed between clusters, which represents an important patient-centered outcome.

rFVIII-Fc in severe haemophilia A: The incentive switch in case of high risk of joint bleedings

BACKGROUND

Efmoroctocog alfa, the first recombinant factor VIII fusion protein with extended half-life (rFVIII-Fc), has been hypothesized to lower FVIII consumption in patients with severe Haemophilia A (pwSHA), without reducing clinical efficacy. What about real life?

METHOD

MOTHIF-II was a noninterventional, multicentre, before/after study, via the collection of retrospective data from July 2015 to June 2016 (called T1), and from July 2017 to June 2018 (called T2), in 7 French haemophilia treatment centres. We examined the prescriptions and dispensations of factor VIII and the Annual Bleeding Rate (ABR), in pwSHA without current inhibitors on prophylaxis, before and after the introduction of rFVIII-Fc. The data gathered from the BERHLINGO research database and from the French Healthcare claims database with a determinist pairing process based on the national unique identification number.

RESULTS

A total of 156 pwSHA were included in the prescription cohort and 83 in the ABR cohort. For switched patients, the mean amounts of prescribed FVIII were significantly higher during T1 compared to T2 (4333 (2052) vs. 3921 (2029) IU/kg/year/patient, p: 0.028); a significant decrease in their ABR was also observed between T1 and T2 (6.3 (6.0) vs. 4.4 (5.4), p: 0.047). These patients had a more severe bleeding profile centred on haemarthrosis.

CONCLUSION

The results are related to those of the pivotal clinical trials for the reduction in FVIII consumption following the switch to rFVIII-Fc, with a significant improvement in the haemorrhagic phenotype for pwSHA.

Benefits and Risks Associated With Continuation of Anti-Tumor Necrosis Factor After 24 Weeks of Pregnancy in Women With Inflammatory Bowel Disease : A Nationwide Emulation Trial

BACKGROUND

Continuation of biologics for inflammatory disorders during pregnancy is still a difficult decision. Many women with inflammatory bowel diseases (IBDs) stop anti-tumor necrosis factor (anti-TNF) treatment after 24 weeks.

OBJECTIVE

To evaluate the benefits and risks of anti-TNF continuation after 24 weeks of pregnancy for mothers with IBD and their offspring.

DESIGN

Target trial emulation between 2010 and 2020.

SETTING

Nationwide population-based study using the Système National des Données de Santé.

PATIENTS

All pregnancies with birth exposed to anti-TNF between conception and 24 weeks of pregnancy in women with IBD.

INTERVENTION

Continuation of anti-TNF after 24 weeks of pregnancy.

MEASUREMENTS

Occurrence of maternal IBD relapse up to 6 months after pregnancy, adverse pregnancy outcomes, and serious infections in the offspring during the first 5 years of life was compared according to anti-TNF continuation after 24 weeks of pregnancy using inverse probability-weighted marginal models.

RESULTS

A total of 5293 pregnancies were included; among them, anti-TNF treatment was discontinued before 24 weeks for 2890 and continued beyond 24 weeks for 2403. Continuation of anti-TNF was associated with decreased frequencies of maternal IBD relapse (35.8% vs. 39.0%; adjusted risk ratio [aRR], 0.93 [95% CI, 0.86 to 0.99]) and prematurity (7.6% vs. 8.9%; aRR, 0.82 [CI, 0.68 to 0.99]). No difference according to anti-TNF continuation was found regarding stillbirths (0.4% vs. 0.2%; aRR, 2.16 [CI, 0.64 to 7.81]), small weight for gestational age births (13.1% vs. 12.9%; aRR, 1.01 [CI, 0.88 to 1.17]), and serious infections in the offspring (54.2 vs. 50.2 per 1000 person-years; adjusted hazard ratio, 1.08 [CI, 0.94 to 1.25]).

LIMITATION

Algorithms rather than clinical data were used to identify patients with IBD, pregnancies, and serious infections.

CONCLUSION

Continuation of anti-TNF after 24 weeks of pregnancy appears beneficial regarding IBD activity and prematurity, while not affecting neonatal outcomes and serious infections in the offspring.

PRIMARY FUNDING SOURCE

None.

The Economic Burden of Severe Osteoporotic Fractures in the French Healthcare Database: The FRACTOS Study

Osteoporosis carries a high medical, economic, and societal burden principally because of the risk of severe fractures. The objective of this cost-of-illness study was to describe health resource utilization and associated costs in all patients aged ≥50 years hospitalized for a severe osteoporotic fracture over a 6-year period (2009 to 2014) in France. Data were extracted from the French national healthcare database (SNDS) on all health care resource utilization between the index date (date of hospitalization for first fracture during the enrollment period) and study end (December 31, 2016) or until the patient died. Costing was restricted to direct costs and determined from the payer perspective. Variables related to costs were identified through multivariate logistic regression analysis. A total of 356,895 patients were included (median follow-up 39.1 months). In the year after the index fracture, 36,622 patients (10.5%) were rehospitalized for a fracture-related reason. Only 18,474 (5.3%) underwent bone densitometry and 58,220 (16.7%) received a specific treatment. The total annual per capita osteoporosis-related cost in the year after the index severe osteoporotic fracture was €18,040 (from €8598 for multiple ribs to €21,085 for hip fracture) of which €17,905 was incurred by fracture-related costs. The cost incurred by management of osteoporosis was €135. Over years 2 to 5, the mean annual per capita costs of fracture treatment (€806, mostly attributable to the treatment of refractures) continued to dominate those of osteoporosis management (€99). Total annual cost of care was €1260 million (year 2014). Variables associated with higher cost were older age, male sex, site of fracture, a history of prior osteoporotic fracture, and the number of refracture events. The 5-year cost of severe osteoporotic fractures to the French health care system is high and mostly attributable to the treatment of refractures. Improved fracture prevention measures in patients with osteoporosis is crucial to reduce the economic burden of the disease. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Projection of age of individuals living with HIV and time since ART initiation in 2030: estimates for France

Introduction

Thanks to antiretroviral treatment (ART), people living with HIV (PLHIV) are living longer and ageing. However, ageing involves increased risks of co‐morbidities, which also depend on when PLHIV individuals started ART. To tackle the HIV age‐related upcoming challenges, knowledge of the current and future age structure of the HIV population is needed. Here, we forecast the demographic profile of the adult population living with diagnosed HIV (aPLdHIV) in France until 2030, accounting for the impact of the ART initiation period on mortality.

Methods

We used national data from the French Hospital Database on HIV (ANRS CO4‐FHDH) and a sample of the National Health Data System to, first, characterize the aPLdHIV in 2018 and estimate their mortality rates according to age, sex and ART initiation period. Second, we used national HIV surveillance data to define three scenarios for the numbers of newly diagnosed HIV cases over 2019–2030: 30% decrease in HIV cases (S1), status quo situation (S2) and epidemic elimination (S3). We then combined these data using a matrix model, to project the age structure of aPLdHIV and time since ART initiation.

Results

In 2018, there was an estimated 161,125 aPLdHIV (33% women), of which 55% were aged 50 or older (50+), 22% aged 60+ and 8% aged 70+. In 2030, the aPLdHIV would grow to 195,246 for S1, 207,972 for S2 and 167,221 for S3. Whatever the scenario, in 2030, the estimated median time since ART initiation would increase and age distribution would shift towards older ages: with 65–72% aPLdHIV aged 50+, 42–48% 60+ and 17–19% 70+. This corresponds to ∼83,400 aPLdHIV (28% women) aged 60+, among which ∼69% started ART more than 20 years ago (i.e. before 2010) and ∼39% ≥30 years ago (i.e. before 2000), and to ∼33,100 aPLdHIV (27% women) aged 70+, among which ∼72% started ART ≥20 years ago and ∼43% ≥30 years ago.

Conclusions

By 2030, in France, close to 20% of the aPLdHIV will be aged 70+, of which >40% would have started ART more than 30 years ago. These estimates are essential to adapt co‐morbidities screening and anticipate resource provision in the aged care sector.

The Economic Burden of Disease in France From the National Health Insurance Perspective: The Healthcare Expenditures and Conditions Mapping Used to Prepare the French Social Security Funding Act and the Public Health Act

BACKGROUND

Identifying the most frequently treated and the costliest health conditions is essential for prioritizing actions to improve the resilience of health systems.

OBJECTIVES

Healthcare Expenditures and Conditions Mapping describes the annual economic burden of 58 health conditions to prepare the French Social Security Funding Act and the Public Health Act.

DESIGN

Annual cross-sectional study (2015-2019) based on the French national health database.

SUBJECTS

National health insurance beneficiaries (97% of the French residents).

MEASURES

All individual health care expenditures reimbursed by the national health insurance were attributed to 58 health conditions (treated diseases, chronic treatments, and episodes of care) identified by using algorithms based on available medical information (diagnosis coded during hospital stays, long-term diseases, and specific drugs).

RESULTS

In 2019, €167.0 billion were reimbursed to 66.3 million people (52% women, median age: 42 y). The most prevalent treated diseases were diabetes (6.0%), chronic respiratory diseases (5.5%), and coronary diseases (3.2%). Coronary diseases accounted for 4.6% of expenditures, neurotic and mood disorders 3.7%, psychotic disorders 2.8%, and breast cancer 2.1%. Between 2015 and 2019, the expenditures increased primarily for diabetes (+€906 million) and neurotic and mood disorders (+€861 million) due to the growing number of patients. "Active lung cancer" (+€797 million) represented the highest relative increase (+54%) due to expenditures for the expensive drugs and medical devices delivered at hospital.

CONCLUSIONS

These results have provided policy-makers, evaluators, and public health specialists with key insights into identifying health priorities and a better understanding of trends in health care expenditures in France.

Apixaban versus other anticoagulants in patients with nonvalvular fibrillation: a comparison of all-cause and event-related costs in real-life setting in France

OBJECTIVES

Compare costs associated with all-cause healthcare resource use (HCRU), stroke/systemic thromboembolism (STE) and major bleedings (MB) between patients with non-valvular atrial fibrillation (NVAF) initiating apixaban or other oral anticoagulants (OACs).

METHODS

We performed a retrospective cohort study using the French healthcare claims database, including NVAF patients between 2014/01/01 and 2016/12/31, followed until 2016/12/31. We used 4 sub-cohorts of OAC-naive patients, respectively initiating apixaban, dabigatran, rivaroxaban or VKAs. We matched patients initiating apixaban with patients initiating each other OACs using 1:n propensity score matching. All-cause HCRU and event-related costs by OAC treatment were estimated and compared between matched patients using generalised-linear models with gamma-distribution and two-part models.

RESULTS

There were 175,766 patients in the apixaban-VKA, 181,809 in the apixaban-rivaroxaban, and 42,490 in the apixaban-dabigatran matched cohorts. Patients initiating apixaban had significantly lower HCRU costs than patients initiating VKA (€1,105 vs. €1,578, p < 0.0001), dabigatran (€993 vs. €1,140, p < 0.0001) and rivaroxaban (€1,013 vs. €1,088 p < 0.0001). They have had significantly lower costs related to stroke/STE and MB than patients initiating VKA (respectively, €183 vs. €449 and €147 vs. €413; p < 0.0001), rivaroxaban (respectively, €145 vs. €197 and €129 vs. €193; p < 0.0001), and lower costs related to stroke/STE than patients initiating dabigatran (€135 vs. €192, p < 0.02). Costs related to MB were not significantly different in patients initiating apixaban and those initiating dabigatran (€119 vs. €149, p = 0.07).

CONCLUSIONS

HCRU and most event-related costs were lower in patients initiating apixaban compared to other OACs. Apixaban may be cost-saving compared to VKAs, and significantly cheaper than other DOACs, although cost differences are limited.

Epidemiology and disease burden of tuberous sclerosis complex in France: A population-based study based on national health insurance data

OBJECTIVE

Tuberous sclerosis complex (TSC) is a rare multisystem disorder, often associated with epilepsy. This retrospective study aimed to identify patients with TSC, including those with epilepsy, from a French healthcare claims database, and to report incidence, prevalence, and healthcare costs and resource utilization.

METHODS

The anonymized French health insurance database (SNDS) covers almost the entire French population. Patients with TSC were identified as having ≥1 International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code Q85.1 or a long-term disease (LTD) registration over the inclusion period (2006-2017). Patients with an ICD-10 epilepsy code or who were dispensed ≥1 antiseizure medication (ASM) in the same year or after their TSC diagnosis were identified as having TSC with epilepsy. Newly diagnosed patients over the inclusion period constituted the incident cohort. Healthcare costs (patients with recorded costs only), healthcare resource use, and ASM dispensation are reported for patients with 2018 data.

RESULTS

In 2018, 3139 prevalent patients with TSC were identified (crude prevalence, 4.69 per 100 000); the incident cohort comprised 2988 patients (crude incidence, 0.44 per 100 000). Among patients with TSC, 67% (2101/3139) had epilepsy (mean [standard deviation, SD] age: 28.8 [18.8] years; male: 48%). Among patients with epilepsy, total mean (SD) annual healthcare costs were €11 413 (27 620) per capita (outpatient, 63%; inpatient, 37%), 46% were hospitalized during 2018 (mean [SD]: 1.8 [10.9] acute care visits per patient), and 65% visited a hospital specialist. Among patients with epilepsy, medication (mean [SD]: €4518 [12 102] per capita) was the greatest contributor (63%) to outpatient costs, and in 2018, 74% were dispensed ≥1 different ASM and 9% were dispensed ≥4 ASMs.

SIGNIFICANCE

TSC with epilepsy was associated with substantial healthcare costs and resource utilization, particularly outpatient and medication costs. Many patients with TSC with epilepsy were prescribed multiple ASMs, suggesting refractory epilepsy.

Abiraterone acetate versus docetaxel for metastatic castration-resistant prostate cancer: a cohort study within the French Nationwide Claims Database

OBJECTIVES

To conduct the direct comparison of abiraterone acetate and docetaxel for first-line treatment of metastatic castration-resistant prostate cancer (mCRPC) in real-life settings.

METHODS

Data were extracted from the French nationwide claims database (SNDS) on all men aged ≥40 years starting first-line treatment with abiraterone acetate or docetaxel for mCRPC in 2014. A high-dimensional propensity score including 100 baseline characteristics was used to match patients of both groups and form two comparative cohorts. Three-year overall survival and treatment discontinuation-free survival were determined using Kaplan-Meier analysis.

RESULTS

In 2014, 2,444 patients started abiraterone for treatment of mCRPC and 1,214 started docetaxel. After trimming and matching, 716 patients were available in each group. Median overall survival tended to be longer in the abiraterone acetate cohort (23.8 months, 95% confidence interval = [21.5; 26.0]) than in the docetaxel cohort (20.3 [18.4; 21.6] months). Survival at 36 months was 34.6% for abiraterone acetate and 27.9% for docetaxel (p = 0.0027). Treatment discontinuation-free median was longer in the abiraterone acetate cohort compared to the docetaxel cohort (10.8 [10.1; 11.7] versus 7.4 [7.0; 8.0] months).

CONCLUSION

The findings underline the interest of oral abiraterone acetate over intravenous docetaxel as the first-line treatment option in mCRPC.

Interactive exploration of a global clinical network from a large breast cancer cohort

Despite unprecedented amount of information now available in medical records, health data remain underexploited due to their heterogeneity and complexity. Simple charts and hypothesis-driven statistics can no longer apprehend the content of information-rich clinical data. There is, therefore, a clear need for powerful interactive visualization tools enabling medical practitioners to perceive the patterns and insights gained by state-of-the-art machine learning algorithms. Here, we report an interactive graphical interface for use as the front end of a machine learning causal inference server (MIIC), to facilitate the visualization and comprehension by clinicians of relationships between clinically relevant variables. The widespread use of such tools, facilitating the interactive exploration of datasets, is crucial both for data visualization and for the generation of research hypotheses. We demonstrate the utility of the MIIC interactive interface, by exploring the clinical network of a large cohort of breast cancer patients treated with neoadjuvant chemotherapy (NAC). This example highlights, in particular, the direct and indirect links between post-NAC clinical responses and patient survival. The MIIC interactive graphical interface has the potential to help clinicians identify actionable nodes and edges in clinical networks, thereby ultimately improving the patient care pathway.

Healthcare costs of a telemonitoring programme for heart failure: indirect deterministic data linkage analysis

AIMS

We aim to evaluate the costs associated with healthcare resource consumption for chronic heart failure (HF) management in patients allocated to telemonitoring versus standard of care (SC).

METHODS AND RESULTS

OSICAT-ECO involved 745 patients from the OSICAT trial (NCT02068118) who were successfully linked to the French national healthcare database through an indirect deterministic data linkage approach. OSICAT compared a telemonitoring programme with SC follow-up in adults hospitalized for acute HF ≤ 12 months. Healthcare resource costs included those related to hospital and ambulatory expenditure for HF and were restricted to direct costs determined from the French health data system over 18 months of follow-up. Most of the total costs (69.4%) were due to hospitalization for HF decompensation, followed by ambulatory nursing fees (11.8%). During 18-month follow-up, total costs were 2% lower in the telemonitoring versus the SC group, due primarily to a 21% reduction in nurse fees. Among patients with NYHA class III/IV, a 15% reduction in total costs (€3131 decrease) was observed over 18-month follow-up in the telemonitoring versus the SC group, with the highest difference in hospital expenditure during the first 6 months, followed by a shift in costs from hospital to ambulatory at 12 months.

CONCLUSIONS

HF hospitalization and ambulatory nursing fees represented most of the costs related to HF. No benefit was observed for telemonitoring versus SC with regard to cost reductions over 18 months. Patients with severe HF showed a non-significant 15% reduction in costs, largely related to hospitalization for HF decompensation, nurse fees, and medical transport.

Underuse of primary healthcare in France during the COVID-19 epidemic in 2020 according to individual characteristics: a national observational study

Background

The organization of healthcare systems changed significantly during the COVID-19 pandemic. The impact on the use of primary care during various key periods in 2020 has been little studied.

Methods

Using individual data from the national health database, we compared the numbers of people with at least one consultation, deaths, the total number of consultations for the population of mainland France (64.3 million) and the mean number of consultations per person (differentiating between teleconsultations and consultations in person) between 2019 and 2020. We performed analyses by week, by lockdown period (March 17 to May 10, and October 30 to December 14 [less strict]), and for the entire year. Analyses were stratified for age, sex, deprivation index, epidemic level, and disease.

Results

During the first lockdown, 26% of the population consulted a general practitioner (GP) at least once (-34% relative to 2019), 7.4% consulted a nurse (-28%), 1.6% a physiotherapist (-80%), and 5% a dentist (-95%). For specialists, consultations were down 82% for ophthalmologists and 37% for psychiatrists. The deficit was smaller for specialties making significant use of teleconsultations. During the second lockdown, the number of consultations was close to that in 2019, except for GPs (-7%), pediatricians (-8%), and nurses (+ 39%). Nurses had already seen a smaller increase in weekly consultations during the summer, following their authorization to perform COVID-19 screening tests. The decrease in the annual number of consultations was largest for dentists (-17%), physiotherapists (-14%), and many specialists (approximately 10%). The mean number of consultations per person was slightly lower for the various specialties, particularly for nurses (15.1 vs. 18.6). The decrease in the number of consultations was largest for children and adolescents (GPs: -10%, dentists: -13%). A smaller decrease was observed for patients with chronic diseases and with increasing age. There were 9% excess deaths, mostly in individuals over 60 years of age.

Conclusions

There was a marked decrease in primary care consultations in France, especially during the first lockdown, despite strong teleconsultation activity, with differences according to age and healthcare profession. The impact of this decrease in care on morbidity and mortality merits further investigation.

Childhood cancer risks estimates following CT scans: an update of the French CT cohort study

OBJECTIVES

Increased risks of central nervous system (CNS) tumors and leukemia associated with computed tomography (CT) exposure during childhood have been reported in recent epidemiological studies. However, no evidence of increased risks was suggested in a previous analysis of the French CT cohort. This study benefits from an updated cohort with a longer follow-up and a larger sample size of patients.

METHODS

The patients were followed from the date of their first CT (between 2000 and 2011) until their date of cohort exit defined as the earliest among the following: 31 December 2016, date of death, date of first cancer diagnosis or date of their 18^th birthday. Cancer incidence, vital status, cancer predisposing factors (PFs), and additional CT scans were collected via external national databases. Hazard ratios (HRs) associated to cumulative organ doses and sex were estimated from Cox models.

RESULTS

At the end of follow-up, mean cumulative doses were 27.7 and 10.3 mGy for the brain and the red bone marrow (RBM), respectively. In patients without PFs, an HR per 10 mGy of 1.05 (95% CI: 1.01-1.09) for CNS tumors, 1.17 (95% CI: 1.09-1.26) for leukemia, and 0.96 (95% CI: 0.63-1.45) for lymphoma was estimated. These estimates were not modified by the inclusion of CT scans performed outside the participating hospitals or after the inclusion period.

CONCLUSIONS

This study shows statistically significant dose-response relationships for CNS tumors and leukemia for patients without PFs.

KEY POINTS

• Computed tomography is the most important contributor to the collective dose for diagnostic imaging to the French population. • Concerns have been raised about possible cancer risks, particularly after exposure to CT in childhood, due to the greater radiation sensitivity of children and to their longer life expectancy. • Analysis of the updated French CT cohort shows statistically significant dose-response relationships for CNS tumors and leukemia.

Impact of active surveillance for prostate cancer on the risk of depression and anxiety

Active surveillance (AS) is a standard treatment option for low risk localized prostate cancer. However, the risk of anxiety and depression compared to other curative strategies, namely radical prostatectomy (RP) and radiotherapy (RT), is controversial. This study consisted in a French representative sample of 4174 5-years cancer survivors. Self-reported data, including quality-of-life assessment, were prospectively collected through telephone interviews. Among the 447 survivors with PC, we selected 292 patients with localized prostate cancer, T1–T2 stage, Gleason score ≤ 7 and we compared anxiety and depressive symptoms according to treatment strategy. Among patients on AS, 14.9% received curative treatment during the 5 years of follow-up. Anxiety was reported in 34.3% of cases in the AS group versus 28.6% in the RP group and 31.6% in the RT group (p = 0.400), while depressive symptoms were reported in 14.9% of cases in the AS group versus 10.7% in the RP group and 22.8% in the RT group (p = 0.770). Consumption of anxiolytics reported did not vary significantly between the 3 groups (p = 0.330). In conclusion, patients managed with AS for localized prostate cancer do not report more anxiety or depressive symptoms than patients managed with curative treatment, encouraging the extended use of active surveillance.

Pneumococcal and influenza vaccination coverage among at-risk adults: A 5-year French national observational study

INTRODUCTION

The risk of developing pneumococcal infections increases with certain chronic conditions and in immunocompromised patients. We aimed to monitor pneumococcal vaccination coverage in at-risk patients and to examine factors associated with pneumococcal vaccination in France.

MATERIAL AND METHODS

In this annual cross-sectional study, at-risk patients were extracted between 2014 and 2018 from the National Health Insurance's (NHI) General scheme's claims database with their vaccine reimbursements. Descriptive analyses and a logistic model were performed to assess the influence of healthcare use and medical and demographic factors on pneumococcal vaccination.

RESULTS AND DISCUSSION

In 2018, 4.5% of 4,045,021 at-risk adults were up to date with their pneumococcal vaccination. During the study period, the number of patients with chronic medical conditions (86% of 4,045,021) increased by 10.1%, but vaccination coverage decreased from 12.9% to 2.9%. The population with immunocompromised status (14% of 4,045,021) increased by 16.2% and vaccination coverage from 10.3% to 18.8%. Influenza vaccination coverage was much higher and stable (around 45.0%). Factors associated with pneumococcal vaccination were: immunocompromised status vs. having a chronic medical condition (odds ratio [OR] 4.72), influenza vaccination (OR 2.36-3.42), hepatitis B vaccination (OR 2.82), DTPolio vaccination (OR 1.52), ≥5 specialist physicians' visits (OR 1.17), and age above 74 (OR 1.12). Pneumococcal vaccine dispensing was extremely low (median of 9per GP,1per specialist over 9 years) despite frequent healthcare visits.

CONCLUSION

Pneumococcal and influenza vaccination coverage of adults at risk of pneumococcal disease fell well below public health expectations. Invitations for pneumococcal vaccination should be sent by the NHI to high-risk patients. Patient management protocols should include pneumococcal vaccination. Patients with multiple comorbidities are a high-priority population given the large potential health gains offered by pneumococcal vaccination. Commitment of both scientific societies and health authorities is urgently needed to increase vaccination coverage in at-risk populations.

Social inequalities and gender differences in health care management of acute ischemic strokes in France

INTRODUCTION

There are regional disparities in access to stroke units in France. Several studies have shown that living in disadvantaged areas is associated with higher frequency of stroke, worse severity at presentation, increased level of dependency, and higher mortality rates. However, few studies have explored the association between an individual's socioeconomic characteristics and stroke care. Our study aimed to determine if living standards are associated with stroke unit access for patients admitted to hospital for acute ischemic stroke.

METHODS

Using the EDP-Santé French administrative database, we selected all patients admitted to hospital for acute ischemic stroke between 2014 and 2017. Acute ischemic stroke corresponded to hospital stay with ICD-10 codes I63 or I64 as the main diagnosis. Multivariate logistic regression was used to identify if standard of living was associated with likelihood of admission to a stroke unit.

RESULTS

We identified 14 123 acute-care episodes, corresponding to 335 273 episodes in the general population when appropriately weighted. Of these, 52.9 % were admitted to a stroke unit. Being in the first (i.e., poorest) living standard quartile was associated with lower likelihood of admission to a stroke unit compared with the fourth (i.e., wealthiest) quartile, and was associated with a higher likelihood of paralysis and language disorder, and death at 1 year.

CONCLUSION

A low living standard was associated with lower likelihood of admission to a stroke unit as well as a greater chance of paralysis and aphasia at the end of hospitalization and a higher possibility of death at 1 year after stroke. Greater access to stroke units in disadvantaged people should be promoted.

Oral Morphine as an Alternative Substitution Treatment for Opioid Use Disorder, a Rare but Non-risk-free Use

Background

National health monitoring agencies have reported the alternative use of morphine sulfate painkiller for maintenance treatment of opioid use disorder (OUD), associated with a potential increase in overdose risk.

Objectives

This study sought to assess the prevalence of regular and occasional legally prescribed morphine use in patients treated for OUD and compare their characteristics to those of patients receiving conventional opioid maintenance treatment (OMT), buprenorphine or methadone. Then, we assessed the factors associated with opioid overdose risk.

Methods

Data were extracted from the French national healthcare system database, covering the entire population in 2015. Diagnosis associated with hospital discharge and long-term disease codes were extracted to select the population and identify outcomes and covariates. OUD non-chronic pain patients were divided into regular (≤35 days between dispensing and ≥3 months of continuous treatment duration) morphine users, and occasional users. Their sociodemographic and health characteristics were compared to OMT controls. A multivariate logistic regression model was performed to determine factors associated with opioid overdose.

Results

In patients treated for OUD, 2,237 (2.2%) morphine users (1,288 regular and 949 occasional), 64,578 (63.7%) buprenorphine and 34,638 (34.1%) methadone controls were included. The prevalence of regular morphine use among patients treated for OUD regularly receiving an opioid was 1.3%. Compared to users who receive morphine regularly, occasional users had an increased risk of overdose [OR = 2.2 (1.5-3.3)], while the risk was reduced in the buprenorphine group [OR = 0.5 (0.4-0.7)] and not significantly different for methadone [OR = 1.0 (0.7-1.4)]. Other overdose risk factors were low-income, comorbidity, i.e., psychiatric conditions, alcohol use disorder or complications related to intravenous drug use, and coprescription with benzodiazepines or pregabalin. These factors were more frequent in morphine groups.

Conclusions

Patients that were prescribed oral morphine represented a small minority of the treated for OUD. The poorer health condition affected by numerous comorbidities and higher risk of opioid overdose in patients treated with oral morphine compared with OMT controls points toward the need to better supervise the practices of these patients, to strengthen multidisciplinary care and risk reduction measures.

Hospitalization and Death in the First 30 days After Outpatient Lower Extremity Arterial Stenting

PURPOSE

To compare the safety of outpatient versus inpatient endovascular treatment of lower extremity arterial disease (LEAD) using real-life data.

MATERIALS AND METHODS

This retrospective observational study used real-life data from the French national health data information system on adult patients who underwent stenting for LEAD between 2013 and 2016. The outcomes of interest were all-cause mortality, all-cause hospitalization, planned hospitalization, and unplanned hospitalization at day 3 and day 30 after the index endovascular intervention for LEAD revascularization. A propensity score was used to control for indication bias. Outcome rates in outpatient and inpatient settings were compared with the Poisson regression model. Sensitivity analyses were performed by varying the definition of the outcomes of interest.

RESULTS

During the study period, 26,715 interventions were performed among which 2819 (10.6%) were in outpatient settings. Outpatients were slightly younger than inpatients (64.73 ± 10.68 vs. 68.10 ± 11.50, respectively). The percentage of women patients was similar: 19.8% in the outpatient group and 27.2% in the inpatient group. Within 30 days after discharge, 73 patients (.31%) and 2 (.07%) patients (p = .02) died in the inpatient group and outpatient group, respectively. The death and rehospitalization rate were similar: 3.8 and 3.5 per 1000 person-months for inpatients and outpatients, respectively. No difference was observed after adjusting for patients' case-mix in the regression model (RR = .99; 95% CI [.82-1.19]).

CONCLUSIONS

Outpatient stenting for LEAD did not present any additional risk of early postoperative rehospitalization or death compared with inpatient stenting.

Association of Statins for Primary Prevention of Cardiovascular Diseases With Hospitalization for COVID-19: A Nationwide Matched Population-Based Cohort Study

Background There is little evidence on the relationship between statin use and the risk of hospitalization attributable to COVID-19. Methods and Results The French National Healthcare Data System database was used to conduct a matched-cohort study. For each adult aged ≥40 years receiving statins for the primary prevention of cardiovascular diseases, one nonuser was randomly selected and matched for year of birth, sex, residence area, and comorbidities. The association between statin use and hospitalization for COVID-19 was examined using conditional Cox proportional hazards models, adjusted for baseline characteristics, comorbidities, and long-term medications. Its association with in-hospital death from COVID-19 was also explored. All participants were followed up from February 15, 2020, to June 15, 2020. The matching procedure generated 2 058 249 adults in the statin group and 2 058 249 in the control group, composed of 46.6% of men with a mean age of 68.7 years. Statin users had a 16% lower risk of hospitalization for COVID-19 than nonusers (adjusted hazard ratio [HR], 0.84; 95% CI, 0.81-0.88). All types of statins were significantly associated with a lower risk of hospitalization, with the adjusted HR ranging from 0.75 for fluvastatin to 0.89 for atorvastatin. Low- and moderate-intensity statins also showed a lower risk compared with nonusers (HR, 0.78 [95% CI, 0.71-0.86] and HR, 0.84 [95% CI, 0.80-0.89], respectively), whereas high-intensity statins did not (HR, 1.01; 95% CI, 0.86-1.18). We found similar results with in-hospital death from COVID-19. Conclusions Our findings support that the use of statins for primary prevention is associated with lower risks of hospitalization for COVID-19 and of in-hospital death from COVID-19.

Fourteen-Year Temporal Trends in Patients Hospitalized for Mitral Regurgitation: The Increasing Burden of Mitral Valve Prolapse in Men

Mitral regurgitation (MR) is the second most common valvular heart disease in Europe. The aging of the population and the increase in post-infarction survival could increase the prevalence of MR. To estimate the burden of patients hospitalized for MR in France in 2019 and temporal trends by etiology and sex from 2006 to 2020, we selected all patients hospitalized for MR using the national hospital database. In 2019, 49.2% of such patients had mitral valve prolapse (MVP), 17.1% had ischemic MR, 9.9% had rheumatic MR and 4.4% had MR with cardiomyopathy. The mean age of MVP patients was 67.8 years, and 34% were women. Among 89% of MVP inpatients who had received mitral valve repair or replacement, 55% received surgical repair, 13% received percutaneous repair and 25% received replacement. The all-cause mortality of one year after a mitral procedure of MVP was 5.4%. Among ischemic MR inpatients, 29% have had a mitral valve replacement, 16% a surgical repair and 19% a percutaneous repair. Between 2006 and 2019, the age-standardized rates of patients hospitalized for MVP have increased by 60%, especially in men (+80%) with 5.3/100,000 Person-Years (PY). The age-standardized rates of patients hospitalized for ischemic MR have increased by 25% with 1.8/100,000 PY; that of rheumatic MR has decreased by 36%. The study found that the burden of MVP in hospitals has increased substantially, especially among men. These results emphasize the need to monitor these temporal trends and anticipate care needs in the coming years.

Serious Infections in Children Born to Mothers With Inflammatory Bowel Disease With In Utero Exposure to Thiopurines and Anti-Tumor Necrosis Factor

BACKGROUND & AIMS

We aimed to compare the risk of serious infections in children with in utero exposure to thiopurines and/or anti-tumor necrosis factor (TNF) born to mothers with inflammatory bowel disease (IBD).

METHODS

Using the French national health database, which covers 99% of the French population (around 66,000,000 people), we identified live births among women with IBD in France between 2010 and 2018. The risks of serious infections in children during the first 5 years of life were compared according to treatment exposures during pregnancy using propensity score-weighted marginal Cox models.

RESULTS

A total of 26,561 children were included: 3392 were exposed to thiopurine monotherapy, 3399 to anti-TNF monotherapy, 816 to combination therapy, and 18,954 were not exposed to any of these drugs. The risks of serious infections during the first year of life among children exposed to thiopurine monotherapy (adjusted hazard ratio [aHR], 0.94; 95% confidence interval [CI], 0.83-1.07) and anti-TNF monotherapy (aHR, 1.10; 95% CI, 0.95-1.27) were similar to those of unexposed children; a higher risk was observed in children exposed to combination therapy (aHR, 1.36; 95% CI, 1.04-1.79). The highest increased risks were observed for nervous system infections and viral infections. The risk of serious infections during the second to fifth years of life was not associated with IBD treatments.

CONCLUSIONS

In children born to mothers with IBD, in utero exposure to thiopurine and anti-TNF monotherapies do not increase the risk of serious infections during the first 5 years of life. Combination therapy is associated with an increased risk of serious infections during the first year of life.

Effects of social deprivation and healthcare access on major amputation following a diabetic foot ulcer in a French administrative area: Analysis using the French claim data

AIM

The link between social deprivation and the development of diabetic foot ulcer (DFU) is still widely debated. The study objective was to evaluate the relationship between lower limb amputation, social deprivation level, and inequalities in access to care service among people with DFU. This regional pilot study was conducted at the living area level and based on the French National Health Data System (SNDS).

METHODS

We conducted a retrospective cohort study using hospital and primary care claim data in the Languedoc-Roussillon region. DFUs were determined using an original algorithm of care consumption or hospital diagnosis. The primary end point was amputation at 1 year. Secondary end points were mortality at 1 year and impact of potential access to care on amputation.

RESULTS

We included 15,507 people from 2015 to 2017. Amputation and mortality rates were 17.5 and 117 per 1000 person-years. The least precarious living areas showed better prognoses (relative risk = 0.46; 95% CI 0.27-0.66). Territorial accessibility to a private-practice nurse, unlike physician accessibility, was associated with better results on major outcomes (p = 0.004).

CONCLUSION

This is the first study using SNDS to study the care pathway of DFU management within and outside the hospital. High social deprivation in a living areas seems to be associated with more major amputations after a DFU.

Risk of malignancy in rheumatoid arthritis patients initiating biologics: an historical propensity score matched cohort study within the French nationwide healthcare database

Objective

To compare the risk of malignancy between patients with rheumatoid arthritis (RA) initiating their first biological disease-modifying antirheumatic drug (bDMARD) and those continuing conventional synthetic DMARDs (csDMARDs).

Methods

Nine-year historical Propensity Score (PS) matched cohort study within the French national healthcare database (87% of the French population; ~57 million people), including adults RA without malignancy. Exposures started with the first use of any systemic treatment (csDMARDs and/or bDMARDs). Incident users of bDMARDs were matched on a dynamic PS to patients continuing csDMARDs. Their risk of malignancy was compared by Cox model.

Results

From 1 January 2007 to 31 December 2014, 83 706 patients with RA started their first systemic treatment (63 837 remained on csDMARDs and 19 869 initiated a bDMARD during follow-up). After dynamic PS matching, 19 727 bDMARD initiators were compared with 19 727 RA remaining on csDMARDs. They did not statistically differ in risk of overall malignancies (HR 0.99 (95% CI 0.86 to 1.14)), solid cancer (HR 0.95 (95% CI 0.82 to 1.11)), nor lymphoma (HR 1.35 (95% CI 0.72 to 2.53)). Results were similar when bDMARDs were given as monotherapy or in association with csDMARDs. Analyses restricted to patients starting TNF inhibitor as first bDMARD compared with matched RA remaining on csDMARDs, provided similar results (HR for overall malignancy 1.03 (95% CI 0.88 to 1.21)). Sensitivity analyses, varying carry-over periods (up to 5 years) to define risk periods, provided similar results.

Conclusions

In this historical cohort study within the French nationwide healthcare database, the risk of overall, solid or haematological malignancies did not significantly differ between patients with RA initiating bDMARD and those continuing csDMARDs.

Health care expenditures among long-term survivors of pediatric solid tumors: Results from the French Childhood Cancer Survivor Study (FCCSS) and the French network of cancer registries (FRANCIM)

Background

Childhood cancer survivors (CCS) may require lifelong medical care due to late effects of cancer treatments. Little is known about of their healthcare utilization and expenditures at long-term especially in publicly funded health care system. We aim to estimate and describe the health care expenditures among long-term CCS in France.

Methods

A total of 5319 five-year solid CCS diagnosed before the age of 21 between 1945 and 2000 in France were identified in the French Childhood Cancer Survivors Study cohort (FCCSS) and the French cancer registry. Information about health care expenditure was taken from the French national health data system between 2011 and 2016, and was described according to survivors’ characteristics. Generalized linear models were used to determine associations between health care expenditures and survivors’ characteristics.

Results

Mean annual amount of healthcare expenditures was € 4,255. Expenditures on hospitalizations and pharmacy represents 60% of total expenditures. Mean annual of healthcare expenditures were higher at increasing age, among women survivors (€ 4,795 vs € 3,814 in men) and in central nervous system (CNS) tumor survivors (€ 7,116 vs € 3,366 in lymphoma and € 3,363 in other solid tumor survivors).

Conclusions

Childhood cancer survivorship is associated with a substantial economic burden in France. We found that female gender and CNS primary cancer were associated with increased healthcare expenditures.

The French Early Breast Cancer Cohort (FRESH): A Resource for Breast Cancer Research and Evaluations of Oncology Practices Based on the French National Healthcare System Database (SNDS)

Simple Summary

Because of an important disparity of care pathways and quality of care among women diagnosed with an early-stage breast cancer, we aimed to create a unique cohort of patients including all French women aged 18 years or over, treated by surgery and registered in the general health insurance coverage plan. After aggregating and annotating medico-administrative data on 235,368 early breast cancer patients, we open up perspectives for research on adverse effects, morbidity, mortality, the monitoring of care consumption, or medical-economic studies. We describe data sources, inclusion, and exclusion criteria, basic descriptive analyses, and longitudinal trends over time.

Abstract

Background: Breast cancer (BC) is the most frequent cancer and the leading cause of cancer-related death in women. The French National Cancer Institute has created a national cancer cohort to promote cancer research and improve our understanding of cancer using the National Health Data System (SNDS) and amalgamating all cancer sites. So far, no detailed separate data are available for early BC. Objectives: To describe the creation of the French Early Breast Cancer Cohort (FRESH). Methods: All French women aged 18 years or over, with early-stage BC newly diagnosed between 1 January 2011 and 31 December 2017, treated by surgery, and registered in the general health insurance coverage plan were included in the cohort. Patients with suspected locoregional or distant metastases at diagnosis were excluded. BC treatments (surgery, chemotherapy, targeted therapy, radiotherapy, and endocrine therapy), and diagnostic procedures (biopsy, cytology, and imaging) were extracted from hospital discharge reports, outpatient care notes, or pharmacy drug delivery data. The BC subtype was inferred from the treatments received. Results: We included 235,368 patients with early BC in the cohort (median age: 60 years). The BC subtype distribution was as follows: luminal (80.2%), triple-negative (TNBC, 9.5%); HER2⁺ (10.3%), or unidentifiable (n = 44,388, 18.9% of the cohort). Most patients underwent radiotherapy (n = 200,685, 85.3%) and endocrine therapy (n = 165,655, 70.4%), and 38.3% (n = 90,252) received chemotherapy. Treatments and care pathways are described. Conclusions: The FRESH Cohort is an unprecedented population-based resource facilitating future large-scale real-life studies aiming to improve care pathways and quality of care for BC patients.

Breast reconstruction and quality of life five years after cancer diagnosis: VICAN French National cohort

PURPOSE

Women with breast cancer (BC) who have a mastectomy may subsequently undergo breast reconstruction (BR). This study aimed to identify (1) factors associated with having BR, (2) factors associated with immediate BR (IBR) and delayed BR (DBR), and (3) associations between no BR, IBR and DBR and physical and mental quality of life (QoL) 5 years after diagnosis.

METHODS

Analyses were based on data from the national French cancer cohort VICAN, which followed a representative sample of cancer survivors, including BC survivors, for 5 years after diagnosis. BR and BR type (IBR/DBR) were identified using medico-administrative databases. The SF12 scale was used to measure mental and physical QoL. Multivariate logistic regressions were used to identify factors associated with BR, and linear models to evaluate associations between BR and BR type with QoL.

RESULTS

Of the 1192 BC survivors in VICAN, 32.6% (n = 388) had a mastectomy. Among them, 60.1% (n = 233) had BR. Of these, 38.6% (n = 90) and 61.4% (n = 143) had IBR and DBR, respectively. Compared with women who had BR, women who did not were more likely to be older and to have a lower level of health literacy. Compared with women who did not have BR, those with IBR had better mental QoL, while those who had either IBR or DBR had better physical QoL.

CONCLUSION

Older women and those with inadequate health literacy were less likely to have BR. This may reflect women's preferences, inequalities in care options offered after a mastectomy, and socioeconomic barriers to accessing BR. These issues need further exploration. Furthermore, BR was associated with a better long-term physical QoL. IBR was associated with better mental QoL and should be promoted when possible.

Trends in bacterial sepsis incidence and mortality in France between 2015 and 2019 based on National Health Data System (Système National des données de Santé (SNDS)): a retrospective observational study

OBJECTIVE

This study aims to provide a case definition of sepsis of presumed bacterial aetiology based on 10th revision of the International Classification of Diseases (ICD-10) codes, to assess trends in sepsis incidence and mortality between 2015 and 2019 in France, and to describe the characteristics of affected patients and hospital stays.

DESIGN

Nationwide, population-based, retrospective observational study.

SETTING

Metropolitan France between 2015 and 2019.

PARTICIPANTS

Between 2015 and 2019, 1 224 433 patients with sepsis of presumed bacterial aetiology were selected from the French National Hospital Discharge Database (Programme de Médicalisation des Systèmes d'Information) and were identified from corresponding ICD-10 codes for explicit sepsis or implicit sepsis.

MAIN OUTCOMES MEASURES

Annual overall and age-specific and gender-specific incidence and 95% CI, as well as trends in sepsis incidence and mortality, were estimated. Comorbidities, length of hospital stay and outcomes were described.

RESULTS

The sex-standardised and age-standardised incidence per 100 000 (95% CI) increased from 357 (356.0 to 359.0) in 2015 to 403 (401.9 to 405.0) in 2019 and remained higher for males compared with females. Children under 1 year and patients over 75 years consistently had the highest incidence. The most common comorbidities were cancer and chronic heart failure. The median hospital length of stay was 12 days. Most patients came from home, but only half returned home after their hospital stay and approximately 15% were discharged to long-term care. In-hospital mortality was about 25% and declined along the study period.

CONCLUSIONS

Medico-administrative databases can be used to provide nationwide estimates of the in-hospital burden of bacterial sepsis. The results confirm the high burden of sepsis in France. These data should be complemented by estimating the additional burden associated with fungal and viral infections during the COVID-19 pandemic.

Outpatient Antibiotic Prescriptions in France: Patients and Providers Characteristics and Impact of the COVID-19 Pandemic

In France, despite several successive plans to control antimicrobial resistance, antibiotic use remains high in the outpatient setting. This study aims to better understand outpatient antibiotic use and prescription in order to identify tailored targets for future public health actions. Using data from the French National Health Data System, we described and compared the individual characteristics of patients with and without an antibiotic prescription. The prescribed antibiotics (ATC-J01) were detailed and compared between 2019 and 2020. Antibiotic prescribing indicators that take prescriber activity into account were estimated and compared. Patients who were female, advanced age, and the presence of comorbidities were associated with antibiotic prescriptions. The overall prescription rate was estimated at 134 per 1000 consultations and 326 per 1000 patients seen in 2019. General practitioners (GPs), dentists and paediatricians were associated with 78.0%, 12.2% and 2.2% of antibiotic prescriptions, respectively, with high prescription rates (391, 447, and 313 p. 1000 patients seen, respectively). In comparison with 2019, this rate decreased in 2020 for paediatricians (−30.4%) and GPs (−17.9%) whereas it increased among dentists (+17.9%). The reduction was twice as high among the male prescribers than among their female counterparts (−26.6 and −12.0, respectively). The reduction in prescriptions observed in 2020 (−18.2%) was more marked in children (−35.8%) but less so among individuals ≥65 years (−13.1%) and those with comorbidities (−12.5%). The decrease in penicillin prescriptions represents 67.3% of the overall reduction observed in 2020. The heterogeneous decrease in prescriptions by age and antibiotic class could be explained by the impact of COVID-19 control measures on the spread of respiratory viruses; thus, a substantial proportion of the prescriptions avoided in 2020 is likely inappropriate, particularly among children. In order to keep the rate of prescriptions comparable to that observed in 2020, male prescribers, paediatricians and GPs should be encouraged to maintain that level, while a campaign to raise awareness of the appropriate use of antibiotics should be aimed at dentists in particular.

Ability of municipality-level deprivation indices to capture social inequalities in perinatal health in France: A nationwide study using preterm birth and small for gestational age to illustrate their relevance

BACKGROUND

Evidence-based policy-making to reduce perinatal health inequalities requires an accurate measure of social disparities. We aimed to evaluate the relevance of two municipality-level deprivation indices (DIs), the French-Deprivation-Index (FDep) and the French-European-Deprivation-Index (FEDI) in perinatal health through two key perinatal outcomes: preterm birth (PTB) and small-for-gestational-age (SGA).

METHODS

We used two data sources: The French National Perinatal Surveys (NPS) and the French national health data system (SNDS). Using the former, we compared the gradients of the associations between individual socioeconomic characteristics (educational level and income) and "PTB and SGA" and associations between municipality-level DIs (Q1:least deprived; Q5:most deprived) and "PTB and SGA". Using the SNDS, we then studied the association between each component of the two DIs (census data, 2015) and "PTB and SGA". Adjusted odds ratios (aOR) were estimated using multilevel logistic regression with random intercept at the municipality level.

RESULTS

In the NPS (N = 26,238), PTB and SGA were associated with two individual socioeconomic characteristics: maternal educational level (≤ lower secondary school vs. ≥ Bachelor's degree or equivalent, PTB: aOR = 1.43 [1.22-1.68], SGA: (1.31 [1.61-1.49]) and household income (< 1000 € vs. ≥ 3000 €, PTB: 1.55 [1.25-1.92], SGA: 1.69 [1.45-1.98]). For both FDep and FEDI, PTB and SGA were more frequent in deprived municipalities (Q5: 7.8% vs. Q1: 6.3% and 9.0% vs. 5.9% for PTB, respectively, and 12.0% vs. 10.3% and 11.9% vs. 10.2% for SGA, respectively). However, after adjustment, neither FDep nor FEDI showed a significant gradient with PTB or SGA. In the SNDS (N = 726,497), no FDep component, and only three FEDI components were significantly associated (specifically, the % of the population with ≤ lower secondary level of education with both outcomes (PTB: 1.5 [1.15-1.96]); SGA: 1.25 [1.03-1.51]), the % of overcrowded (i.e., > 1 person per room) houses (1.63 [1.15-2.32]) with PTB only, and unskilled farm workers with SGA only (1.52 [1.29-1.79]).

CONCLUSION

Some components of FDep and FEDI were less relevant than others for capturing ecological inequalities in PTB and SGA. Results varied for each DI and perinatal outcome studied. These findings highlight the importance of testing DI relevance prior to examining perinatal health inequalities, and suggest the need to develop DIs that are suitable for pregnant women. .

The Association Between Antibiotic Use and Outcome Among Metastatic Melanoma Patients Receiving Immunotherapy

BACKGROUND

Several observational studies have reported a decreased response to immune checkpoint inhibitors (ICI) following antibiotic use. ICI activity has been hypothesized to be impaired by antibiotic-induced gut dysbiosis.

METHODS

Patients with advanced melanoma receiving an anti-PD-1 antibody as a first-line therapy between 2015 and 2017 in France were selected using the French Health Insurance database. We compared overall survival and time-to-treatment discontinuation according to antibiotic exposure in the 3 months prior to the initiation of anti-PD-1 antibody. To disentangle a causal effect of antibiotics from a confounding bias, we balanced characteristics of patients exposed and nonexposed to antibiotics using an overlap weighting method based on a propensity score. We also evaluated a control cohort of patients with advanced melanoma receiving first-line targeted therapy, as there is no rationale for decreased efficacy of targeted therapy following antibiotic treatment.

RESULTS

The anti-PD-1 antibody cohort comprised 2605 individuals. Antibiotic exposure in the 3 months prior to anti-PD-1 antibody initiation was not associated with shorter overall survival (weighted hazard ratio = 1.01, 95% confidence interval = 0.88 to 1.17) or time-to-treatment discontinuation (weighted hazard ratio = 1.00, 95% confidence interval = 0.89 to 1.11). Consistent results were observed when the time frame of antibiotics was narrowed to 1 month prior to anti-PD-1 initiation or when exposure was restricted to antibiotics leading to more profound gut dysbiosis. Similar results were observed in the targeted therapy cohort.

CONCLUSIONS

In a large cohort of advanced melanoma patients, we showed that antibiotic use preceding anti-PD-1 antibody was not associated with worse outcome. Physicians should not delay immunotherapy for patients who have recently received antibiotics.

Long-term Persistence of First-line Biologics for Patients With Psoriasis and Psoriatic Arthritis in the French Health Insurance Database

Importance

Treatment options for psoriasis (PsO) and psoriatic arthritis (PsA) have evolved significantly throughout the era of biologics. Clinical trials are inadequate to assess the relative long-term efficacy of biologics and are often insufficient regarding safety.

Objectives

To assess the long-term persistence of different biologic classes to treat PsO and PsA.

Design, Setting, and Participants

This nationwide cohort study involved the administrative health care database of the French health insurance scheme linked to the hospital discharge database. All adults with PsO and PsA who were new users of biologics (not in the year before the index date) from January 1, 2015, to May 31, 2019, were included and followed up through December 31, 2019. Patients hospitalized for PsA in the PsO cohort and for PsO in the PsA cohort in the year before the index date were excluded. Data were analyzed from June 1 to October 31, 2021.

Main Outcomes and Measures

Persistence was defined as the time from biologic therapy initiation to discontinuation and was estimated using the Kaplan-Meier method. Comparison of persistence by biologic class involved using propensity score-weighted Cox proportional hazards regression models and adjustment on specific systemic nonbiologics (time-dependent variables).

Results

A total of 16 892 patients with PsO were included in the analysis (mean [SD] age, 48.5 [13.8] years; 9152 men [54.2%] men). Of these, 10 199 patients (60.4%) started therapy with a tumor necrosis factor (TNF) inhibitor; 3982 (23.6%), with an interleukin 12 and interleukin 23 (IL-12/23) inhibitor; and 2711 (16.0%), with an interleukin 17 (IL-17) inhibitor. An additional 6531 patients with PsA (mean [SD] age, 49.1 [12.8] years; 3565 [54.6%] women) were included; of these, 4974 (76.2%) started therapy with a TNF inhibitor; 803 (12.3%), with an IL-12/23 inhibitor; and 754 (11.5%), with an IL-17 inhibitor. Overall 3-year persistence rates were 40.9% and 36.2% for PsO and PsA, respectively. After inverse probability of treatment weighting and adjustment, the IL-17 inhibitor was associated with higher persistence compared with the TNF inhibitor for PsO (weighted hazard ratio [HR], 0.78 [95% CI, 0.73-0.83]) and PsA (weighted HR, 0.70 [95% CI, 0.58-0.85]) and compared with the IL-12/23 inhibitor for PsA (weighted HR, 0.69 [95% CI, 0.55-0.87]). No difference between the IL-17 inhibitor and IL-12/23 inhibitor for PsO was noted. The IL-12/23 inhibitor was associated with higher persistence than the TNF inhibitor for PsO (weighted HR, 0.76 [95% CI, 0.72-0.80]), with no difference observed for PsA.

Conclusions and Relevance

The findings of this cohort study suggest that IL-17 inhibitors are associated with higher treatment persistence than the TNF inhibitor for PsO and PsA. Interleukin 17 inhibitors were also associated with higher persistence than the IL-12/23 inhibitor for PsA, with no difference for PsO. However, the persistence rates of all biologics remained globally low at 3 years.

Nationwide Initiation of Cardiovascular Risk Treatments During the COVID-19 Pandemic in France: Women on a Slippery Slope?

Objectives

This study examines the initiation of prescribed medication treatments for cardiovascular risk (antihypertensives, lipid-lowering drugs, oral anticoagulants in atrial fibrillation, and smoking cessation medications) during the COVID-19 pandemic in the French population.

Methods

For each year between 2017 and 2021, we used the French National Insurance Database to identify the number of people with at least one reimbursement for these medications but no reimbursement in the previous 12 months. We computed incidence rate ratios (IRRs) between 2017–2019 and, respectively 2020 and 2021 using Poisson regression adjusted for age and 2017–2019 time trends. We recorded the number of lipid profile blood tests, Holter electrocardiograms, and consultations with family physicians or cardiologists.

Results

In 2020, IRR significantly decreased for initiations of antihypertensives (−11.1%[CI95%, −11.4%;−10.8%]), lipid-lowering drugs (−5.2%[CI95%, −5.5%;−4.8%]), oral anticoagulants in atrial fibrillation (−8.6%[CI95%, −9.1%;−8.0%]), and smoking cessation medications (−50.9%[CI95%, −51.1%;−50.7%]) compared to 2017–2019. Larger decreases were found in women compared to men except for smoking cessation medications, with the sex difference increasing with age. Similar analyses comparing 2021 to 2017–2019 showed an increase in the initiation of lipid-lowering drugs (+ 11.6%[CI95%, 10.7%;12.5%]) but even lower rates for the other medications, particularly in women. In addition, the 2020 number of people visiting a family physician or cardiologist decreased by 8.4 and 7.4%. A higher decrease in these visits was observed in those over 65 years of age compared to those under 65 years of age. A greater use of teleconsultation was found in women.

Conclusion

The COVID-19 pandemic heavily impacted the initiation of medication treatments for cardiovascular risk in France, particularly in women and people over 65 years.

The economic burden of infertility treatment and distribution of expenditures overtime in France: a self-controlled pre-post study

Background

Recent cost studies related to infertility treatment have focused on assisted reproductive technologies. None has examined lower-intensity infertility treatments or analyzed the distribution of infertility treatment expenditures over time.

The Purpose of the study was to analyse the size and distribution of infertility treatment expenditures over time, and estimate the economic burden of infertility treatment per 10,000 women aged 18 − 50 in France from a societal perspective.

Methods

We used French National individual medico-administrative database to conduct a self-controlled before-after analytic cohort analysis with 556 incidental women treated for infertility in 2014 matched with 9,903 controls using the exact matching method. Infertility-associated expenditures per woman and per 10,000 women over the 3.5-year follow-up period derived as a difference-in-differences.

Results

The average infertility related expenditure per woman is estimated at 6,996 (95% CI: 5,755–8,237) euros, the economic burden for 10,000 women at 70.0 million (IC95%: 57.6–82.4) euros. The infertility related expenditures increased from 235 (IC95%: 98–373) euros in semester 0, i.e. before treatment, to 1,509 (IC95%: 1,277–1,741) euros in semester 1, mainly due to ovulation stimulation treatment (47% of expenditure), to reach a plateau in semesters 2 (1,416 (IC95%: 1,161–1,670)) and 3 (1,319 (IC95%: 943–1,694)), where the share of expenses is mainly related to hospitalizations for assisted reproductive technologies (44% of expenditure), and then decrease until semester 6 (577 (IC95%: 316–839) euros).

Conclusion

This study informs public policy about the economic burden of infertility estimated at 70.0 million (IC95%: 57.6–82.4) euros for 10,000 women aged between 18 and 50. It also highlights the importance of the share of drugs in infertility treatment expenditures. If nothing is done, the increasing use of infertility treatment will lead to increased expenditure. Prevention campaigns against the preventable causes of infertility should be promoted to limit the use of infertility treatments and related costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07725-9.

Analysis of vitreoretinal surgery activity in metropolitan France in 2016: impact on training capacities

PURPOSE

The purpose of the study was to describe vitreoretinal surgery activity and vitreoretinal surgeons in private or public practice in metropolitan France over the year 2016 to anticipate surgical training needs.

METHODS

Patients aged ≥20 years who had undergone vitreoretinal surgery, alone or combined with cataract surgery were included using the French National Healthcare system database. For surgery performed by ophthalmologists carrying out ≥50 procedures during the year, the incidence per 100 000 of population ≥ 20 years of age, the number and mean age of surgeons and the number of surgeons aged >55 years were calculated.

RESULTS

Overall, 57 947 posterior segment surgical procedures were included, 40% in the public sector and 49% in the private sector for private surgeons and/or public centres performing ≥50 procedures/year. The remaining 11% of procedures were from private surgeons and/or public centres performing <50 procedures/year. The analysis included 356 surgeons with a mean age of 41 ± 10 years (39% female) in the public sector and 47 ± 10 years (14% female) in the private sector. The majority of urgent surgery was for retinal detachment (n = 30 290 [52% of total surgical procedures]). Scheduled surgery involved surgery for macular holes and epiretinal membranes (n = 16 454 [28% of total surgical procedures]). Combined vitrectomy-phacoemulsification surgery (n = 10 120) represented 17% of all vitreoretinal surgery. University regions with the fewest surgeons and regions with surgeons >55 years of age were identified, to anticipate the training need for new surgeons.

CONCLUSION

This study demonstrated disparities in the geographic distribution of vitreoretinal surgery in France and identified regions that need increased training capacities to ensure a sufficient number of surgeons.

Healthcare cost by primary tumour, functioning status and treatment among patients with metastatic neuroendocrine tumours: The LyREMeNET study

The annual prevalence of metastatic neuroendocrine tumours (mNETs) is rising, leading to significant healthcare costs. The present study aimed to describe healthcare resource use (HRU) and the corresponding costs among patients with mNETs, according to primary tumour location, functioning status and type of treatments. The LyREMeNET study included consecutive mNET patients with a diagnosis performed between January 2010 and December 2017, who were seen at least once in the ENETS center of excellence in Lyon. The median HRU and costs per patient were estimated, up to 3 years before and after the diagnosis. The Cancer database of the center was linked to the French national health data system. HRU and related costs were described per person per month (PPPM). Among 316 patients presenting with a mNET, 48.4% had a small-intestinal mNET, 32.3% had a pancreatic mNET and 39.2% had carcinoid syndrome. The mean overall cost increased from €615 to €2875 PPPM between the years preceding and following the diagnosis, and remained above €2500 in the two subsequent years. The two main cost drivers of total healthcare expenditure were drugs (€1161) and hospital stay (€662). Median costs of mNETs arising from pancreas and small intestine were €2325 and €2540 PPPM, respectively. Costs were higher in patients with a functional mNET (€2807 PPPM for carcinoid syndrome) and during peptide receptor radionuclide therapy (PRRT) (€8835 PPPM). The highest overall cost was found during the first year following the diagnosis. Cost of care was higher for small intestine mNETs, for functional mNETs and during peptide receptor radionuclide therapy.

Functional Outcome After Spinal Meningioma Surgery. A Nationwide Population-Based Study

Objective

To describe and analysed the functional outcome (FO) after spinal meningioma (SM) surgery.

Methods

We processed the système national des données de santé (SNDS) i.e. , the French national administrative medical database to retrieve appropriate cases. We analysed the International Classification of Diseases 10 codes to assess the FO. Logistic models were implemented to search for variables associated with a favourable FO i.e. , a patient being independent at home without disabling symptom.

Results

A total of 2,844 patients were identified of which 79.1% were female. Median age at surgery was 66 years, interquartile range (IQR) (56–75). Ninety-five point nine percent of the SMs were removed through a posterior ± lateral approach and 0.7% need an associated stabilisation. Benign meningioma represented 92.9% and malignant 2.1%. Median follow-up was 5.5 years, IQR (2.1–8), and at data collection 9% had died. The FO was good and increased along the follow-up: 84.3% of the patients were alive and had not associated symptoms at one year, 85.9% at 2 and 86.8% at 3 years. Nonetheless, 3 years after the surgery 9.8% of the alive patients still presented at least one disabling symptom of which 2.7% motor deficit, 3.3% bladder control problem, and 2.5% gait disturbance. One point seven percent were care-provider dependent and 2.1% chair or bedfast. In the multivariable logistic regression an older age at surgery (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.29–0.47, p<0.001), a high level of comorbidities (OR, 0.71; 95% CI, 0.66–0.75, p<0.001), and an aggressive tumor (OR, 0.49; 95% CI, 0.33–0.73; p<0.001) were associated with a worse FO.

Conclusion

FO after meningioma surgery is favourable but, may be impaired for older patients with a high level of comorbidities and aggressive tumor.

Impact of a school-based and primary care-based multicomponent intervention on HPV vaccination coverage among French adolescents: a cluster randomised controlled trial protocol (the PrevHPV study)

INTRODUCTION

Vaccination is an effective and safe strategy to prevent Human papillomavirus (HPV) infection and related harms. Despite various efforts by French authorities to improve HPV vaccine coverage (VC) these past few years, VC has remained far lower than in most other high-income countries. To improve it, we have coconstructed with stakeholders a school-based and primary care-based multicomponent intervention, and plan to evaluate its effectiveness, efficiency and implementation through a cluster randomised controlled trial (cRCT).

METHODS AND ANALYSIS

This pragmatic cRCT uses an incomplete factorial design to evaluate three components applied alone or in combination: (1) adolescents and parents' education and motivation at school, using eHealth tools and participatory learning; (2) general practitioners' training on HPV using motivational interviewing techniques and provision of a decision aid tool; (3) free-of-charge access to vaccination at school. Eligible municipalities (clusters) are located in one of 14 preselected French school districts and must have only one secondary school which enrols at least 2/3 of inhabitants aged 11-14 years. A randomisation stratified by school district and deprivation index allocated 90 municipalities into 6 groups of 15. The expected overall sample size estimate is 41 940 adolescents aged 11-14 years. The primary endpoint is the HPV VC (≥1 dose) among adolescents aged 11-14 years, at 2 months, at the municipality level (data from routine databases). Secondary endpoints include: HPV VC (≥1 dose at 6 and 12 months; and 2 doses at 2, 6 and 12 months); differences in knowledge, attitudes, behaviours, and intention among adolescents, parents and general practitioners between baseline and 2 months after intervention (self-administered questionnaires); incremental cost-effectiveness ratio. Implementation measures include dose, fidelity, adaptations, reached population and satisfaction (activity reports and self-administered questionnaires).

ETHICS AND DISSEMINATION

This protocol was approved by the French Ethics Committee 'CPP Sud-Est VI' on 22 December 2020 (ID-RCB: 2020-A02031-38). No individual consent was required for this type of research; all participants were informed of their rights, in particular not to participate or to oppose the collection of data concerning them. Findings will be widely disseminated (conference presentations, reports, factsheets and academic publications).

TRIAL REGISTRATION NUMBER

NCT04945655.

Risk of first ischaemic stroke and use of antidopaminergic antiemetics: nationwide case-time-control study

OBJECTIVE

To estimate the risk of ischaemic stroke associated with antidopaminergic antiemetic (ADA) use.

DESIGN

Case-time-control study.

SETTING

Data from the nationwide French reimbursement healthcare system database Système National des Données de Santé (SNDS).

PARTICIPANTS

Eligible participants were ≥18 years with a first ischaemic stroke between 2012 and 2016 and at least one reimbursement for any ADA in the 70 days before stroke. Frequencies of ADA reimbursements were compared for a risk period (days -14 to -1 before stroke) and three matched reference periods (days -70 to -57, -56 to -43, and -42 to -29) for each patient. Time trend of ADA use was controlled by using a control group of 21 859 randomly selected people free of the event who were individually matched to patients with stroke according to age, sex, and risk factors of ischaemic stroke.

MAIN OUTCOME MEASURES

Association between ADA use and risk of ischaemic stroke was assessed by estimating the ratio of the odds ratios of exposure evaluated in patients with stroke and in controls. Analyses were adjusted for time varying confounders (anticoagulants, antiplatelets, and prothrombotic or vasoconstrictive drugs).

RESULTS

Among the 2612 patients identified with incident stroke, 1250 received an ADA in the risk period and 1060 in the reference periods. The comparison with the 5128 and 13 165 controls who received an ADA in the same periods yielded a ratio of adjusted odds ratios of 3.12 (95% confidence interval 2.85 to 3.42). Analyses stratified by age, sex, and history of dementia showed similar results. Ratio of adjusted odds ratios for analyses stratified by ADA was 2.51 (2.18 to 2.88) for domperidone, 3.62 (3.11 to 4.23) for metopimazine, and 3.53 (2.62 to 4.76) for metoclopramide. Sensitivity analyses suggested the risk would be higher in the first days of use.

CONCLUSIONS

Using French nationwide exhaustive reimbursement data, this self-controlled study reported an increased risk of ischaemic stroke with recent ADA use. The highest increase was found for metopimazine and metoclopramide.

Patients Hospitalized for Ischemic Stroke and Intracerebral Hemorrhage in France: Time Trends (2008-2019), In-Hospital Outcomes, Age and Sex Differences

BACKGROUND

Rates of patients hospitalized for stroke increased among people aged under 65 years in France, as has been found in other countries.

METHODS

To analyze time trends in the rates of patients hospitalized for ischemic stroke (IS) and intracerebral hemorrhage (ICH) in France between 2008 and 2019 and determine related short-term outcomes mainly, we selected all patients hospitalized for stroke using the French national hospital database.

RESULTS

The average annual percentage change in the rates of patients hospitalized for IS increased significantly in men and women aged 50-64 years (+2.0%) and in men aged 18-34 years (+1.5%) and 35-44 years (+2.2%). A decrease in the average annual percentage change was observed for IS among people aged over 75 years and among those over 50 years for ICH. After adjustment on confounding factors, women were less likely to die in hospital. Case fatality rates decreased overtime in all age groups for both sexes, with a more pronounced decrease for IS than ICH.

CONCLUSIONS

The increasing trend of IS among adults under 65 years is ongoing, highlighting the urgent need for stroke prevention programs in that age. For the first time, we recorded a decrease in the rates of patients hospitalized for ICH among the population over 50 years.

One Year Prevalence of Venous Thromboembolism in Hospitalized COVID-19 Patients in France: Patients' Characteristics, Time Trends, and Outcomes

BACKGROUND

 Patients hospitalized with coronavirus disease-2019 (COVID-19) are at high risk of deep venous thrombosis (DVT) and pulmonary embolism (PE).

OBJECTIVES

 The aims were to provide time trends in the 2020 nation-wide prevalence of venous thromboembolism (VTE) in patients hospitalized with a COVID-19 diagnosis in France, and to describe in-hospital and up to 30-day postdischarge death.

METHODS

 All patients hospitalized in France with a COVID-19 diagnosis in 2020 were selected. Crude and age-adjusted prevalence of VTE and PE was computed by 4-week intervals and for the overall study period using Poisson regression. Time trends in in-hospital and 30-day postdischarge case-fatality rates were evaluated by comparing each 4-week intervals to weeks 10 to 14 corresponding to the first part of the first lockdown using logistic regression models.

RESULTS

 Among the 287,638 patients hospitalized with a COVID-19 diagnosis in 2020 in France, 14,985 (5.2%) had a concomitant VTE, with 10,453 (3.6%) having PE and 4,532 (1.6%) having DVT. In patients admitted to intensive care units, the crude prevalence of VTE and PE reached 16.1 and 11.0% respectively during the first lockdown. After adjustment, the prevalence of VTE and PE decreased during the year 2020 but a rebound was observed during the second lockdown. In-hospital case-fatality rates among hospitalized COVID-19 patients with PE globally decreased between the first and the second epidemic waves.

CONCLUSION

 Our study showed a decrease in the incidence of symptomatic VTE and PE in hospitalized COVID-19 patients, and a decreased time trend of outcomes during the second wave compared with the first one.

Monitoring the impact of COVID-19 in France on cancer care: a differentiated impact

The COVID-19 pandemic has had a substantial and lasting impact on care provision, particularly in the field of cancer care. National steering has helped monitor the health situation and adapt the provision and organisation of care. Based on data from the French administrative healthcare database (SNDS) on the entire French population (67 million people), screening, diagnostic and therapeutic activity was monitored and compared 2019 on a monthly basis. A noteworthy decline in all activities (with the exception of chemotherapy) was observed during the first lockdown in France. Over the months that followed, this activity returned to normal but did not make up for the shortfall from the first lockdown. Finally, during the lockdown in late 2020, cancer care activity was conserved. In brief, in 2020, the number of mammograms decreased by 10% (− 492,500 procedures), digestive endoscopies by 19% (− 648,500), and cancer-related excision by 6% (− 23,000 surgical procedures). Hospital radiotherapy activity was down 3.8% (− 4400 patients) and that in private practice was down 1.4% (− 1600 patients). Chemotherapy activity increased by 2.2% (7200 patients), however. To summarize, COVID-19 had a very substantial impact during the first lockdown. Safeguarding cancer care activity helped limit this impact over the months that followed, but the situation remains uncertain. Further studies on the medium- and long-term impact on individuals (survival, recurrence, after-effects) will be conducted.

Estimating the Future Burden of Myocardial Infarction in France Until 2035: An Illness-Death Model-Based Approach

Purpose

In France, myocardial infarction (MI) was the second leading cause of years of life lost in 2019. Estimating the burden of MI in future years could help policymakers and other actors anticipate care and prevention needs and guide them in public health decision-making.

Materials and Methods

Using data from the French hospital discharge database from 2007 to 2015 (n = 519,400), demographic data, and an illness-death model, we projected incidence, prevalence, number of prevalent cases and mean age of incident MI cases in France. The methodology took into account the age-cohort effect on MI incidence, mortality of healthy and diseased subjects, and the time since disease onset.

Results

Projections highlighted an increase in MI prevalence in men between 2015 and 2035 from 2.52% (95% uncertainty interval (UI): [2.48-2.56]) in 2015 to 4.02% ([3.92-4.12]) in 2035, and from 0.85% ([0.83-0.87]) to 1.44% ([1.38-1.50]) in women. This corresponds to an increase of 365,000 cases between 2015 and 2035 (+81.1%) for men and 146,000 cases for women (+88.0%). The difference in the mean age of incident cases between men and women decreased from 9.52 in 2015 to 5.49 years in 2035.

Conclusion

Our projections forecast an increase in MI prevalence between 2015 and 2035 in men and women, especially in relatively younger women. Using statistical models such as ours can help assess the impact of prevention campaigns for the main cardiovascular disease risk factors on the future MI prevalence.

Exposure to High Precariousness Prevalence Negatively Impacts Drug Prescriptions of General Practitioners to Precarious and Non-Precarious Populations: A Retrospective Pharmaco-Epidemiological Study

(1) Background: Precarious patients are more difficult to care for due to low literacy rates and poor adherence to treatment and hospitalization. These difficulties have detrimental effects on general practitioners (GPs), deteriorating medical communication, advice, diagnoses, and drug prescriptions. To better understand how precariousness affects primary care, we tested whether, among GPs, exposure to high precariousness prevalence more severely impacts drug prescriptions to precarious and non-precarious populations compared to low precariousness prevalence. Materials and methods: This pharmaco-epidemiological study, using linear regression analyses, compared the defined daily dose of 20 drugs prescribed by GPs to precarious and non-precarious patients in four French regions with low and high precariousness prevalence in 2015. (2) Findings: Exposure to high precariousness prevalence significantly impacted the prescriptions of nine medications to precarious patients and two medications to non-precarious patients, and distributed into three interaction patterns. (3) Interpretation: The selective over-prescription of drugs with easy intake modalities to precarious patients probably reflects GPs’ attempts to compensate for poor patient compliance. In contrast, the under-prescription of drugs targeting fungal infections in precarious populations and diabetes and cardiovascular diseases in non-precarious populations was seemingly due to a breakdown of empathy and professional exhaustion, causing medical neglect.

Potential determinants of unfavourable healthcare utilisation trajectories during the last year of life of people with incident Alzheimer Disease or Related Syndromes: a nationwide cohort study using administrative data

BACKGROUND

people approaching the end-of-life frequently face inappropriate care. With Alzheimer Disease or Related Syndromes (ADRS), end-of-life is characterised by progressive decline, but this period remains difficult to identify. This leads to a lack of anticipation and sometimes with unfavourable healthcare utilisation trajectories (HUTs).

OBJECTIVE

to quantify unfavourable HUTs during the last year of life and identify their potential determinants in both community and nursing-home settings.

DESIGN

nationwide cohort study using administrative database.

SETTING

French community and nursing-home residents.

SUBJECTS

incident ADRS people identified in 2012, who died up to 31 December 2017.

METHODS

we used multidimensional clustering to identify 15 clusters of HUTs, using 11 longitudinal healthcare dimensions during the last year of life. Clusters were qualitatively assessed by pluri-disciplinary experts as favourable or unfavourable HUTs. Individual and contextual potential determinants of unfavourable HUTs were studied by setting using logistic random-effect regression models.

RESULTS

62,243 individuals died before 31 December 2017; 46.8% faced unfavourable end-of-life HUTs: 55.2% in the community and 31.8% in nursing-homes. Individual potential determinants were identified: younger age, male gender, ADRS identification through hospitalisation, shorter survival, life-limiting comorbidities, psychiatric disorders, acute hospitalisations and polypharmacy. In the community, deprivation and autonomy were identified as potential determinants. Contextual potential determinants raised mostly in the community, such as low nurse or physiotherapist accessibilities.

CONCLUSIONS

Nearly half of people with ADRS faced unfavourable HUTs during their last year of life. Individual potential determinants should help anticipate advance care planning and palliative care needs assessment. Contextual potential determinants suggest geographical disparities and health inequalities.

Measuring severe neonatal morbidity using hospital discharge data in France

BACKGROUND

Measuring infant health at birth is key for surveillance and research in obstetrics and neonatology, but there is no international consensus on morbidity indicators. The Neonatal Adverse Outcome Indicator (NAOI) is a composite indicator, developed in Australia, which measures the burden of severe neonatal morbidity using hospital discharge data.

OBJECTIVE

To evaluate the applicability of the NAOI in France for surveillance and research.

METHODS

We constituted a cohort of live births ≥24 weeks' gestational age in Metropolitan France from 2014 to 2015 using hospital discharge, insurance claims and cause of death data. Outlier hospitals were identified using funnel plots of standardised morbidity ratios (SMR), and their coding patterns were assessed. We compared the NAOI and its component codes with published Australian and English data and estimated unadjusted and adjusted risk ratios for known risk factors for neonatal morbidity.

RESULTS

We included 1,459,123 births (511 hospitals). Twenty-eight hospitals had SMR above funnel plot control limits. Newborns with NAOI morbidities in these hospitals had lower mortality and shorter stays than in other hospitals. Amongst within-limit hospitals, NAOI prevalence was 4.8%, comparable to Australia (4.6%) and England (5.4%). Most individual components had a similar prevalence, with the exception of respiratory support, intravenous fluid procedures and infection. NAOI was lowest at 39 weeks (2.2%) with higher risks for maternal age ≥40 (relative risk [RR] 1.47, 95% confidence interval [CI] 1.42, 1.51), state medical insurance (RR 1.60, 95% CI 1.52, 1.68), male sex (RR 1.21, 95% CI 1.19, 1.23) and birthweight <3^rd percentile (RR 4.60, 95% CI 4.51, 4.69).

CONCLUSIONS

The NAOI provides valuable information on population prevalence of severe neonatal morbidity and its risk factors. Whilst the prevalence was similar in high-income countries with comparable neonatal mortality levels, ensuring valid comparisons between countries and hospitals will require further work to harmonize coding procedures, especially for infection and respiratory morbidity.

Machine learning versus regression modelling in predicting individual healthcare costs from a representative sample of the nationwide claims database in France

BACKGROUND

Innovative provider payment methods that avoid adverse selection and reward performance require accurate prediction of healthcare costs based on individual risk adjustment. Our objective was to compare the performances of a simple neural network (NN) and random forest (RF) to a generalized linear model (GLM) for the prediction of medical cost at the individual level.

METHODS

A 1/97 representative sample of the French National Health Data Information System was used. Predictors selected were: demographic information; pre-existing conditions, Charlson comorbidity index; healthcare service use and costs. Predictive performances of each model were compared through individual-level (adjusted R-squared (adj-R²), mean absolute error (MAE) and hit ratio (HiR)), and distribution-level metrics on different sets of covariates in the general population and by pre-existing morbid condition, using a quasi-Monte Carlo design.

RESULTS

We included 510,182 subjects alive on 31st December, 2015. Mean annual costs were 1894€ (standard deviation 9326€) (median 393€, IQ range 95€; 1480€), including zero-claim subjects. All models performed similarly after adjustment on demographics. RF model had better performances on other sets of covariates (pre-existing conditions, resource counts and past year costs). On full model, RF reached an adj-R² of 47.5%, a MAE of 1338€ and a HiR of 67%, while GLM and NN had an adj-R² of 34.7% and 31.6%, a MAE of 1635€ and 1660€, and a HiR of 58% and 55 M, respectively. RF model outperformed GLM and NN for most conditions and for high-cost subjects.

CONCLUSIONS

RF should be preferred when the objective is to best predict medical costs. When the objective is to understand the contribution of predictors, GLM was well suited with demographics, conditions and base year cost.