Severe intestinal malabsorption associated with olmesartan: a French nationwide observational cohort study

OBJECTIVES

Severe sprue-like enteropathy associated with olmesartan has been reported, but there has been no demonstration of an increased risk by epidemiological studies.

AIM

To assess, in a nationwide patient cohort, the risk of hospitalisation for intestinal malabsorption associated with olmesartan compared with other angiotensin receptor blockers (ARB) and ACE inhibitors (ACEIs).

DESIGN

From the French National Health Insurance claim database, all adult patients initiating ARB or ACEI between 1 January 2007 and 31 December 2012 with no prior hospitalisation for intestinal malabsorption, no serology testing for coeliac disease and no prescription for a gluten-free diet product were included. Incidence of hospitalisation with a discharge diagnosis of intestinal malabsorption was the primary endpoint.

RESULTS

4 546 680 patients (9 010 303 person-years) were included, and 218 events observed. Compared with ACEI, the adjusted rate ratio of hospitalisation with a discharge diagnosis of intestinal malabsorption was 2.49 (95% CI 1.73 to 3.57, p<0.0001) in olmesartan users. This adjusted rate ratio was 0.76 (95% CI 0.39 to 1.49, p=0.43) for treatment duration shorter than 1 year, 3.66 (95% CI 1.84 to 7.29, p<0.001) between 1 and 2 years and 10.65 (95% CI 5.05 to 22.46, p<0.0001) beyond 2 years of exposure. Median length of hospital stay for intestinal malabsorption was longer in the olmesartan group than in the other groups (p=0.02). Compared with ACEI, the adjusted rate ratio of hospitalisation for coeliac disease was 4.39 (95% CI 2.77 to 6.96, p<0.0001) in olmesartan users and increased with treatment duration.

CONCLUSIONS

Olmesartan is associated with an increased risk of hospitalisation for intestinal malabsorption and coeliac disease.

Low dose oestrogen combined oral contraception and risk of pulmonary embolism, stroke, and myocardial infarction in five million French women: cohort study

OBJECTIVE

To assess the risk of pulmonary embolism, ischaemic stroke, and myocardial infarction associated with combined oral contraceptives according to dose of oestrogen (ethinylestradiol) and progestogen.

DESIGN

Observational cohort study.

SETTING

Data from the French national health insurance database linked with data from the French national hospital discharge database.

PARTICIPANTS

4 945 088 women aged 15-49 years, living in France, with at least one reimbursement for oral contraceptives and no previous hospital admission for cancer, pulmonary embolism, ischaemic stroke, or myocardial infarction, between July 2010 and September 2012.

MAIN OUTCOME MEASURES

Relative and absolute risks of first pulmonary embolism, ischaemic stroke, and myocardial infarction.

RESULTS

The cohort generated 5 443 916 women years of oral contraceptive use, and 3253 events were observed: 1800 pulmonary embolisms (33 per 100 000 women years), 1046 ischaemic strokes (19 per 100 000 women years), and 407 myocardial infarctions (7 per 100 000 women years). After adjustment for progestogen and risk factors, the relative risks for women using low dose oestrogen (20 µg v 30-40 µg) were 0.75 (95% confidence interval 0.67 to 0.85) for pulmonary embolism, 0.82 (0.70 to 0.96) for ischaemic stroke, and 0.56 (0.39 to 0.79) for myocardial infarction. After adjustment for oestrogen dose and risk factors, desogestrel and gestodene were associated with statistically significantly higher relative risks for pulmonary embolism (2.16, 1.93 to 2.41 and 1.63, 1.34 to 1.97, respectively) compared with levonorgestrel. Levonorgestrel combined with 20 µg oestrogen was associated with a statistically significantly lower risk than levonorgestrel with 30-40 µg oestrogen for each of the three serious adverse events.

CONCLUSIONS

For the same dose of oestrogen, desogestrel and gestodene were associated with statistically significantly higher risks of pulmonary embolism but not arterial thromboembolism compared with levonorgestrel. For the same type of progestogen, an oestrogen dose of 20 µg versus 30-40 µg was associated with lower risks of pulmonary embolism, ischaemic stroke, and myocardial infarction.

Use of Fibrates Monotherapy in People with Diabetes and High Cardiovascular Risk in Primary Care: A French Nationwide Cohort Study Based on National Administrative Databases

Background and Aim

According to guidelines, diabetic patients with high cardiovascular risk should receive a statin. Despite this consensus, fibrate monotherapy is commonly used in this population. We assessed the frequency and clinical consequences of the use of fibrates for primary prevention in patients with diabetes and high cardiovascular risk.

Design

Retrospective cohort study based on nationwide data from the medical and administrative databases of French national health insurance systems (07/01/08-12/31/09) with a follow-up of up to 30 months.

Methods

Lipid-lowering drug-naive diabetic patients initiating fibrate or statin monotherapy were identified. Patients at high cardiovascular risk were then selected: patients with a diagnosis of diabetes and hypertension, and >50 (men) or 60 (women), but with no history of cardiovascular events. The composite endpoint comprised myocardial infarction, stroke, amputation, or death.

Results

Of the 31,652 patients enrolled, 4,058 (12.8%) received a fibrate. Age- and gender-adjusted annual event rates were 2.42% (fibrates) and 2.21% (statins). The proportionality assumption required for the Cox model was not met for the fibrate/statin variable. A multivariate model including all predictors was therefore calculated by dividing data into two time periods, allowing Hazard Ratios to be calculated before (HR_<540) and after 540 days (HR_>540) of follow-up. Multivariate analyses showed that fibrates were associated with an increased risk for the endpoint after 540 days: HR_<540 = 0.95 (95% CI: 0.78–1.16) and HR_>540 = 1.73 (1.28–2.32).

Conclusion

Fibrate monotherapy is commonly prescribed in diabetic patients with high cardiovascular risk and is associated with poorer outcomes compared to statin therapy.

Comparison of the short-term risk of bleeding and arterial thromboembolic events in nonvalvular atrial fibrillation patients newly treated with dabigatran or rivaroxaban versus vitamin K antagonists: a French nationwide propensity-matched cohort study

Supplemental Digital Content is available in the text.

Background—

The safety and effectiveness of non–vitamin K antagonist (VKA) oral anticoagulants, dabigatran or rivaroxaban, were compared with VKA in anticoagulant-naive patients with nonvalvular atrial fibrillation during the early phase of anticoagulant therapy.

Methods and Results—

With the use of the French medico-administrative databases (SNIIRAM and PMSI), this nationwide cohort study included patients with nonvalvular atrial fibrillation who initiated dabigatran or rivaroxaban between July and November 2012 or VKA between July and November 2011. Patients presenting a contraindication to oral anticoagulants were excluded. Dabigatran and rivaroxaban new users were matched to VKA new users by the use of 1:2 matching on the propensity score. Patients were followed for up to 90 days until outcome, death, loss to follow-up, or December 31 of the inclusion year. Hazard ratios of hospitalizations for bleeding and arterial thromboembolic events were estimated in an intent-to-treat analysis using Cox regression models. The population was composed of 19 713 VKA, 8443 dabigatran, and 4651 rivaroxaban new users. All dabigatran- and rivaroxaban-treated patients were matched to 16 014 and 9301 VKA-treated patients, respectively. Among dabigatran-, rivaroxaban-, and their VKA-matched–treated patients, 55 and 122 and 31 and 68 bleeding events and 33 and 58 and 12 and 28 arterial thromboembolic events were observed during follow-up, respectively. After matching, no statistically significant difference in bleeding (hazard ratio, 0.88; 95% confidence interval, 0.64–1.21) or thromboembolic (hazard ratio, 1.10; 95% confidence interval, 0.72–1.69) risk was observed between dabigatran and VKA new users. Bleeding (hazard ratio, 0.98; 95% confidence interval, 0.64–1.51) and ischemic (hazard ratio, 0.93; 95% confidence interval, 0.47–1.85) risks were comparable between rivaroxaban and VKA new users.

Conclusions—

In this propensity-matched cohort study, our findings suggest that physicians should exercise caution when initiating either non-VKA oral anticoagulants or VKA in patients with nonvalvular atrial fibrillation.

Risk of bleeding and arterial thromboembolism in patients with non-valvular atrial fibrillation either maintained on a vitamin K antagonist or switched to a non-vitamin K-antagonist oral anticoagulant: a retrospective, matched-cohort study

BACKGROUND

Patients with non-valvular atrial fibrillation who are receiving or have been previously exposed to a vitamin K antagonist could be switched to a non-vitamin K-antagonist oral anticoagulant (NOAC) but little information is available about the risk of bleeding and arterial thromboembolism after such a switch. We aimed to compare the risk of bleeding between individuals who switched and those who remained on a vitamin K antagonist (non-switchers) in real-world conditions.

METHODS

We did a matched-cohort study with information from French health-care databases. We extracted data for adults (aged ≥18 years) with non-valvular atrial fibrillation who received their first prescription for a vitamin K antagonist (fluindione, warfarin, or acenocoumarol) between Jan 1, 2011, and Nov 30, 2012, and who were either switched to a NOAC (dabigatran or rivaroxaban) or maintained on the vitamin K antagonist. Each switcher was matched with up to two non-switchers on the basis of eight variables, including sex, age, and international normalised ratio number. The primary endpoint was incidence of bleeding (intracranial haemorrhage, gastrointestinal haemorrhage, or other) in switchers versus non-switchers, and switchers stratified by type of NOAC versus non-switchers, noted from databases of hospital admissions. Each patient was followed up to 1 year; the study closed on Oct 1, 2013.

FINDINGS

Of 17,410 participants, 6705 switched to a NOAC (switchers) and 10,705 remained on vitamin K-antagonist therapy (non-switchers). Median age of participants was 75 years (IQR 67-82), 8339 (48%) were women, and the median duration of vitamin K-antagonist exposure before a switch was 8.1 months (IQR 3.9-14.0). After a median follow-up of 10.0 months (IQR 9.8-10.0), we noted no difference between groups for bleeding events (99 [1%] in switchers vs 193 [2%] in non-switchers, p=0.54). In adjusted multivariate analyses, the risk of bleeding in switchers was not different from that in non-switchers (hazard ratio [HR] 0.87; 95% CI 0.67-1.13, p=0.30). Additionally, no differences were noted when the risk of bleeding was compared between switchers from a vitamin K antagonist to dabigatran (HR 0.78, 95% CI 0.54-1.09, p=0.15), switchers from a vitamin K antagonist to rivaroxaban (HR 1.04, 95% CI 0.68-1.58, p=0.86), and non-switchers.

INTERPRETATION

In this matched-cohort study, our findings suggest that patients with non-valvular atrial fibrillation who switch their oral anticoagulant treatment from a vitamin K antagonist to a non-vitamin K antagonist are not at increased risk of bleeding. Future studies with longer follow-up might be needed.

FUNDING

None.

Compliance with pregnancy prevention plan recommendations in 8672 French women of childbearing potential exposed to acitretin

PURPOSE

Acitretin is an oral synthetic aromatic analogue of retinoic acid available in most European countries since 1988. It is mainly used to treat severe psoriasis. Like all systemic retinoids, acitretin is teratogenic. Strict pregnancy prevention is required in women of childbearing potential who use acitretin. This study assessed compliance with Pregnancy Prevention Plan (PPP) recommendations, specifically looking at compliance with pregnancy testing (PT) and pregnancy occurrence.

METHODS

A cohort of 8672 women aged 15-49 years initiating acitretin treatment from 1 January 2007 through 31 December 2013 was identified using French SNIIRAM (administrative claims data) and PMSI (hospitalisations data) databases. Pregnancy tests (PTs) were identified from reimbursed serum βHCG and urine laboratory PTs. To satisfy PT criteria, patients who started treatment had to undergo a PT within 3 days before acitretin was dispensed. Pregnancies were identified by a pregnancy-related hospital stay or an outpatient medical abortion.

RESULTS

A PT was performed in only 12% of women starting treatment and was rarely performed during treatment or during the 24 months following discontinuation of treatment. Compliance with PPP recommendations although poor appeared to be better among private dermatologists, as a PT was performed for 16% of treatment initiations (vs. 4% for general practitioners, p < 0.001). Moreover, 470 pregnancies were reported corresponding to 27 pregnancies per 1000 person-years at risk of teratogenicity.

CONCLUSIONS

This study highlights poor compliance with acitretin PPP recommendations in France. Physicians and pharmacists must more rigorously apply the acitretin PPP recommendations, and patients must be better informed about acitretin's risk of teratogenicity.

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

OBJECTIVES

Isotretinoin, a drug widely prescribed for severe acne, has been suspected to increase the risk of ulcerative colitis (UC), but data are conflicting. To further examine the association between isotretinoin use and risk for UC and Crohn's disease (CD), we conducted a large nationwide case-control study in France.

METHODS

We used information from the National Health Insurance system for all French people covered by the general scheme between 1 January 2008 and 31 December 2010, totaling over 50 million individuals (i.e., 76% of the whole French population). All incident claims for UC and CD and all medical drug reimbursements were automatically recorded in the database. For each case, four controls were matched on age, gender, year of enrollment, and follow-up duration. The association between isotretinoin use and UC or CD claim was estimated by conditional logistic regression.

RESULTS

We included 7,593 cases of inflammatory bowel disease (IBD; 3,187 UC, 4,397 CD, and 9 indeterminate colitis) and 30,372 controls; among them, 26 cases (0.3%) (15 UC (0.5%) and 11 CD (0.3%)) and 140 controls (0.4%) were exposed to isotretinoin. Isotretinoin exposure was not associated with an increased risk for UC (odds ratio (OR)=1.36 (95% confidence intervals (CI): 0.76, 2.45)) but was associated with a decreased risk for CD (OR=0.45 (95% CI: 0.24, 0.85)), P value for homogeneity between UC and CD=0.001. Results were similar in analyses restricted to individuals below the age of 40 years, to cases with colonoscopy or intestinal surgery, or when adjusting for other acne treatments.

CONCLUSIONS

In this population-based case-control study, isotretinoin use was not associated with increased UC risk but was associated with a decreased CD risk. This study provides reassuring data for people using isotretinoin.

Perforations and haemorrhages after colonoscopy in 2010: a study based on comprehensive French health insurance data (SNIIRAM)

BACKGROUND AND OBJECTIVE

To estimate the perforation and haemorrhage rate after colonoscopy in the French population in 2010 and to identify risk factors for these complications.

METHOD

Study based on SNIIRAM and the PMSI databases. Patients treated for IBD or colorectal cancer were excluded. Two types of complications were investigated: perforation and haemorrhage. OR adjusted for patient (gender, age, chronic disease) and colonoscopy (polypectomy, emergency) characteristics were calculated by using a logistic regression model.

RESULTS

The cohort was composed of 947,061 individuals. The estimated perforation rate was between 4.5 and 9.7 per 10,000 procedures and the estimated haemorrhage rate was between 9.9 and 11.0 per 10,000 procedures. The main risk factors associated with perforation and haemorrhage were the patient's age (over 80 years compared to under 40, OR=7.51 and 3.23), resection of polyps larger than 1 cm or more than 4 polyps (compared to no polypectomy, OR=2.72 and 5.12) and emergency colonoscopy (OR=4.63 and 5.99). Colonoscopy performed by a gastroenterologist performing less than 244 colonoscopies per year was associated with an increased risk of perforation (OR=2.29). Complication rates were higher in institutions performing less than 510 colonoscopies per year, but this was no longer the case after adjustment for emergency colonoscopies.

CONCLUSIONS

This study, which includes nearly one million colonoscopies, suggests taking the gastroenterologist's number of colonoscopies into account to ensure optimal organization of the management of very elderly patients requiring colonoscopy.

Elderly patients with colorectal cancer: treatment modalities and survival in France. National data from the ThInDiT cohort study

BACKGROUND

Few data exist on how elderly patients with colorectal cancer (CRC) are actually treated in real-life practice. Based on a national cohort, we analysed routine treatment modalities of the elderly who were diagnosed with CRC in France in 2009.

PATIENTS AND METHODS

The characteristics of patients and tumours and the cancer treatments received during the first year of all national incident cases of CRC diagnosed between 1st April and 31st December 2009, were compared between a 'younger group' (YG), under 75 years of age (N = 18,410 patients), and an 'older group' (OG), aged 75 and over (N = 13,255 patients). In the OG with metastases at baseline, we analysed two-year overall survival (OS) according to the treatment received (e.g. chemotherapy, surgery) and well-known prognostic factors.

RESULTS

Among patients with localised CRC (N = 25,353), surgery was equally performed in both groups in more than 80% of the cases (p=0.52); time to surgery was shorter in the OG (8 versus 23 days) because there was more emergency surgery for occlusion among the OG. Adjuvant chemotherapy was performed in 15% of the OG (versus 29% in the YG) and consisted of 5-fluorouracil (5FU) monotherapy in more than 50% of OG patients. Among patients with metastatic CRC (N = 6,312), palliative chemotherapy was given to 48% of the OG versus 85% of the YG. Chemotherapy regimens included 30% monotherapy with 5FU, 30% oxaliplatin combination and 20% bevacizumab combination in the OG; compared to 10%, 34% and 35%, respectively, in the YG. The median OS for the OG was 8.4 months (versus 22.3 months in the YG) and 17.1 months among elderly patients who received chemotherapy.

CONCLUSION

CRC is more frequently complicated at diagnosis among elderly patients. Adjuvant and palliative chemotherapy is less frequently prescribed among elderly patients. This could be explained by the fact that unfit elderly patients do not deserve chemotherapy, but certainly also reflect the fact that some fit elderly patients are undertreated.

Comparative effectiveness of rosuvastatin versus simvastatin in primary prevention among new users: a cohort study in the French national health insurance database

Purpose

Using the French claims database (Système National d'Information Inter-Régimes de l'Assurance Maladie) linked to the hospital discharge database (Programme de Médicalisation des Systèmes d'Information), this observational study compared the effectiveness of rosuvastatin and simvastatin prescribed at doses with close LDL-cholesterol-lowering potency on all-cause mortality and cardiovascular and cerebrovascular diseases (CCDs) in primary prevention.

Methods

This historical cohort included patients with no prior CCD, aged 40–79 years, who initiated statin therapy with rosuvastatin 5 mg or simvastatin 20 mg in 2008–2009 in general practice. Follow-up started after a 1-year period used to select patients who regularly received the initial treatment.

In an intention-to-treat analysis, patients were followed up to December 2011. In a per-protocol analysis, they were censored prematurely when they discontinued their initial treatment. Adjustment for baseline covariates (age, deprivation index, comedications, comorbidities, prior hospital admissions) was carried out by a Cox proportional hazards model. In the per-protocol analysis, estimation was done by “inverse probability of censoring weighting” using additional time-dependent covariates. Analyses were gender-specific.

Results

A total of 106 941 patients initiated statin therapy with rosuvastatin 5 mg and 56 860 with simvastatin 20 mg. Mean follow-up was 35.8 months. For both genders and both types of analyses, the difference in incidence rates of mortality and/or CCD between rosuvastatin 5 mg and simvastatin 20 mg users was not statistically significant after adjustment (e.g., for CCD and/or mortality in men, in intention-to-treat analysis HR = 0.94 [95% CI = 0.85–1.04], in per-protocol analysis HR = 0.98 [0.87–1.10]).

Conclusions

The results of this real-life study based on medico-administrative databases do not support preferential prescription of rosuvastatin compared to simvastatin for primary prevention of CCD.

Does insulin glargine increase the risk of cancer compared with other basal insulins?: A French nationwide cohort study based on national administrative databases

OBJECTIVE

To explore in France the relationship between insulin glargine use and overall and specific cancer risks in type 2 diabetic patients compared with other basal insulins.

RESEARCH DESIGN AND METHODS

Data were extracted from French health insurance information system (Système National d'Information Inter-Régimes de l'Assurance Maladie) linked with data from the French Hospital Discharge database (Programme de Médicalisation des Systèmes d'Information). Included were 70,027 patients aged 40-79 years who started a basal insulin in 2007-2009. Cox proportional hazards models with age as time-scale were used to calculate multivariate-adjusted hazard ratios for associations between type of basal insulin and risk of overall cancer, breast cancer, and seven other cancer sites.

RESULTS

The median follow-up was 2.67 years in patients exposed to insulin glargine. Absolute event rates for all cancer in patients exposed to glargine versus other basal insulin users were 1,622 and 1,643 per 100,000 person-years, respectively. No significant association was observed between glargine exposure and overall cancer incidence after adjustment for sex, with a hazard ratio of 0.97 (95% CI 0.87-1.07), or after additional adjustment for any other hypoglycemic agent use and duration of diabetes. No increased risk of breast cancer was observed for glargine users compared with other basal insulins users, with a fully adjusted hazard ratio of 1.08 (0.72-1.62).

CONCLUSIONS

In a large cohort of patients newly treated by basal insulin, no increased risk of any cancer was observed in insulin glargine users compared with other basal insulin users. Because follow-up did not exceed 4 years, longer-term studies are needed.

[Vaccination against seasonal influenza in France in 2010 and 2011: decrease of coverage rates and associated factors]

AIM

To measure the seasonal influenza vaccination coverage rate (VCR) in France in 2010, one year after the A(H1N1) influenza pandemic, and 2011 by age and target disease and to identify risk factors associated with a lack of vaccination in 2010 for those previously vaccinated in 2009.

METHODS

At the beginning of each vaccination campaign, the National Health Insurance, covering 86% of the French population, sends free influenza vaccination vouchers to at-risk beneficiaries aged under 65 suffering from diverse target diseases and to all individuals aged 65 and over (around 11.5 million).

RESULTS

The global VCR (50.4%), except people with asthma identified by drug refunds, decreased in 2010 compared with the previous three years when it was close to 60% (51.0% in 2011). For people under 65 years old, it fell from 40.3% in 2009 to 31.6% in 2010 (33.1% in 2011) and those aged 65 years and over from 63.3% to 53.8% (54.0% in 2011). The VCR of each target disease also decreased, especially for asthma, but not for HIV infection with campaign modification in 2010. It decreased among those aged 65 years and over with target disease (72.3% in 2009, 60.4% in 2010, 60.7% in 2011). Vaccination lack in 2010 was found to be associated with younger age, low number of drug deliveries and consultations with a general practitioner or a specialist, hospitalisation and the residence in a region of South of France or in overseas regions.

CONCLUSION

An important decline of the VCR was observed in France since 2010 while the recommended VCR is 75%. Efforts must be led to improve the confidence of the insurant, especially towards the most fragile groups.

Pioglitazone and risk of bladder cancer among diabetic patients in France: a population-based cohort study

AIMS/HYPOTHESIS

Previous studies have suggested an increased risk of bladder cancer with pioglitazone exposure. We aimed to investigate the association between pioglitazone exposure and bladder cancer in France.

METHODS

This cohort study involved use of data from the French national health insurance information system (Système National d'Information Inter-régimes de l'Assurance Maladie; SNIIRAM) linked with the French hospital discharge database (Programme de Médicalisation des Systèmes d'Information; PMSI). The cohort included patients aged 40 to 79 years who filled a prescription for a glucose-lowering drug in 2006. The cohort was followed for up to 42 months. Pioglitazone exposure was modelled as a time-dependent variable and defined by having filled at least two prescriptions over a 6-month period. Incident cases of bladder cancer were identified by a discharge diagnosis of bladder cancer combined with specific aggressive treatment. Statistical analyses involved a multivariate Cox model adjusted for age, sex and exposure to other glucose-lowering drugs.

RESULTS

The cohort included 1,491,060 diabetic patients, 155,535 of whom were exposed to pioglitazone. We found 175 cases of bladder cancer among exposed patients and 1,841 among non-exposed patients. Incidence rates were 49.4 and 42.8 per 100,000 person-years, respectively. Pioglitazone exposure was significantly associated with bladder cancer incidence (adjusted HR 1.22 [95% CI 1.05, 1.43]). We observed a dose-effect relationship, with a significantly increased risk for high cumulative doses (≥ 28,000 mg, adjusted HR 1.75 [95% CI 1.22, 2.50]) and long duration of exposure (≥ 24 months, adjusted HR 1.36 [1.04, 1.79]).

CONCLUSIONS/INTERPRETATION

In this cohort of diabetic patients from France, pioglitazone exposure was significantly associated with increased risk of bladder cancer.

Evaluation of the agreement between guidelines and initial antihypertensive drug treatment using a national health care reimbursement database

RATIONALE, AIMS AND OBJECTIVES

To test the agreement between guidelines for the management of hypertension and medical practices while avoiding frequent limitations such as the use of non-representative samples of practitioners and self-reporting of their practices over a short period of time.

METHODS

The characteristics of initial antihypertensive drug treatment in a large representative sample of the French population aged 50-80 (n = 17 855) were collected from a national health care reimbursement database and compared with national guidelines over a 5-year period.

RESULTS

Major discrepancies are observed including the use of non-recommended drug classes such as loop and potassium sparing diuretics alone or in association and the absence of distinction between patients according to their age. More minor discrepancies are the preferential use of mono-therapies over drug combinations and of some bi-therapies among those recommended. Some degree of concordance with the guidelines is also observed including the specific characteristics of the treatment of diabetics compared with other categories of patients and the preferential use of long-acting dihydropyridine calcium antagonists and of low-dose thiazide diuretics when these drug classes are chosen. Several of these discrepancies or concordances, which mainly reflect general practitioner (GP) activity, show time trends over the entire follow-up period with no significant effect of the guideline released during this period.

CONCLUSIONS

At the French national level, the agreement between initial antihypertensive drug treatment and guidelines varies considerably depending on the characteristics of the treatment that are considered. The GPs who delivered the treatment do not seem to have been influenced by the guidelines released over the last decade.

Elderly patients with colorectal cancer: Treatment modalities and survival in France from the ThInDiT observational cohort study

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Background: More than 40% of the colorectal cancers (CRC) occur in elderly patients. Epidemiological data suggests that treatment modalities in this population differ from younger patients. We analysed the management of CRC patients in the real life in France using the French national health insurance system database. Methods: ThInDiT (Therapeutic Innovations in Digestive Tumors) is an observational cohort of 31 665 incident CRC diagnosed between April 1st and December 31th 2009 and registered in the French national health insurance system database. Using this cohort, we compared disease characteristics and treatment modalities within the first year of diagnosis between elderly (age >= 75) and younger patients (<75 years). Results: Elderly patients (pts) represented 42% (13 255/31 665) of the cases. They had more frequently an advanced stage at diagnosis (synchronous metastases: 20.5% vs 19.5% p=0.02, occlusion: 17% vs 11% p<0.0001). Pts with a localised disease (n=25 353): Surgery was performed in more than 80% of the cases in both age groups, delay between diagnosis and surgery was significantly shorter in elderly pts (8 vs 23 days p<0.0001) suggesting that emergency surgery was more frequent in this age group. An adjuvant chemotherapy (CT) was less frequently prescribed among elderly pts (15% vs 29% p<0.0001), 50% of the elderly received a 5FU alone whereas 79% of the younger pts had an oxaliplatin-based adjuvant CT. Pts with synchronous metastases (n= 6 312): Administration of palliative CT in elderly vs younger pts: 48% vs 85%, p<0.0001. CT regimen: LV5FU2 or capecitabine (30% vs 10%), Oxaliplatin-5FU (30% vs 34%), CT + bevacizumab (20% vs 35%) respectively. Elderly pts received less frequently a second or third line of CT than younger pts. Median overall survival was 8.4 months in elderly and 22.1 months in younger pts. Conclusions: Elderly patients represent more than 40% of incident CRC in France, they have a more advanced disease at diagnosis than younger pts. Treatment modalities are different among elderly and younger pts. Elderly pts have a worse prognosis than younger pts.

Underrepresentation of elderly people in randomised controlled trials. The example of trials of 4 widely prescribed drugs

BACKGROUND

We aimed to determine the representation of elderly people in published reports of randomized controlled trials (RCTs). We focused on trials of 4 medications--pioglitazone, rosuvastatin, risedronate, and valsartan-frequently used by elderly patients with chronic medical conditions.

METHODS AND FINDINGS

We selected all reports of RCTs indexed in PubMed from 1966 to April 2008 evaluating one of the 4 medications of interest. Estimates of the community-based "on-treatment" population were from a national health insurance database (SNIIR-AM) covering approximately 86% of the population in France. From this database, we evaluated data claims from January 2006 to December 2007 for 1,958,716 patients who received one of the medications of interest for more than 6 months. Of the 155 RCT reports selected, only 3 studies were exclusively of elderly patients (2 assessing valsartan; 1 risedronate). In only 4 of 37 reports (10.8%) for pioglitazone, 4 of 22 (18.2%) for risedronate, 3 of 29 (10.3%) for rosuvastatine and 9 of 67 (13.4%) for valsartan, the proportion of patients aged 65 or older was within or above that treated in clinical practice. In 62.2% of the reports for pioglitazone, 40.9% for risedronate, 37.9% for rosuvastatine, and 70.2% for valsartan, the proportion of patients aged 65 or older was lower than half that in the treated population. The representation of elderly people did not differ by publication date or sample size.

CONCLUSIONS

Elderly patients are poorly represented in RCTs of drugs they are likely to receive.

First-line treatment of advanced colorectal cancer with bevacizumab in France: The ThInDiT observational cohort study

655

Background: ThInDiT (Therapeutic Innovations in Digestive Tumors) is an ambispective observational cohort study based on the database of the French national health insurance system. Using this database, we analysed the use of bevacizumab in the front-line treatment of metastatic colorectal cancer.

Methods: Patients and treatment characteristics were collected for 4 273 incident cases of colorectal cancer with synchronous metastases diagnosed between April 1st and September 30th 2009. A logistic regression was used to identify factors predictive of non-prescription of bevacizumab among patients receiving chemotherapy within the first three months.

Results: 2 757 (64.5%) received chemotherapy, in combination with bevacizumab in 827 patients (30% of the treated patients). Median age was 64 years in the bevacizumab group against 70 years in the no bevacizumab group (p<0.0001). Major factors significantly associated with the non-prescription of bevacizumab in multivariate analysis were: age ≥ 75 years (OR= 2.47, IC95% 1.9-3.1), unresected primary tumour (OR=1.44, IC95% 1.2-1.8), rectal site (OR= 1.37, IC95% 1.1-1.8), peritoneal carcinosis (OR=1.37, IC95% 1.1-1.7), radiotherapy within the last month (OR=3.59, IC95% 2.1-6.1), arterial (OR= 1.72, IC95% 1.1-2.6) or venous (OR=2.04, IC95% 1.3-3.1) thromboembolic event within 6 months, arterial hypertension (OR=1.37, IC95% 1.1-1.7), wound (OR=3.35, IC95% 1.3-8.7), chronic bronchopneumopathy (OR=1.66, IC95%: 1.0-2.7), nephropathy (OR=2.69, IC95% 1.5-4.7). Brain metastasis and colonic endoprothesis were not associated. 1-year overall survival rate was 81% in the bevacizumab group and 76% in the no bevacizumab group.

Conclusions: Based on the database of the national health insurance system, this analysis reports data on the use of chemotherapy in combination with bevacizumab in the French population, reflecting the real life practice among non-selected patients. About 2/3 of the patients with synchronous metastatic colorectal cancer are treated with chemotherapy, in combination with bevacizumab in 30% of the cases. Patients receiving bevacizumab are younger with less comorbidities.

[Carpal tunnel syndrome surgery in France in 2008: patients' characteristics and management]

INTRODUCTION

Carpal tunnel syndrome (CTS) is the most common upper limb neuropathy. There has been a dramatic increase in CTS surgery since the 1990s. This study focuses on changing incidence of CTS surgery in France and associated factors.

PATIENTS AND METHOD

Cases of CTS surgery were identified using the national hospital discharge database for persons living in metropolitan France. Patient characteristics, comorbidities and care management were studied using the reimbursement database of the beneficiaries covered by the general health insurance scheme (76% of the 64-million French population) comparing those with or without CTS surgery in 2008.

RESULTS

In 2008, hospital admissions for CTS surgery were identified in 127,269 patients aged 20 years and older, giving an overall incidence of 2.7/1000 (females 3.6/1000, males 1.7/1000) in metropolitan France. Between 1999 and 2008, the number of patients with CTS surgery increased 25%. Half of this increase was directly related to increasing demographics. For people in the 20 to 59-year age range, incidences were respectively 2.5/1000, 3.6/1000 and 1.3/1000 with high regional variations (1.1/1000-5.5/1000). Individuals aged 60 years and older accounted for 36% of the patients. Using a negative binomial regression, regional incidence variation was significantly and positively associated with the regional density of surgeons practising CTS surgery, proportion of manual workers in the population and proportion of employment in the industrial sector and negatively associated with densities of primary care physicians, rheumatologists and physiotherapists. Certain comorbidities were found to be significantly associated with CTS surgery: diabetes mellitus (Relative Risk [RR]=1.6), hypothyroidism (RR=1.3), end-stage renal disease treated with dialysis (RR=3.3), depression (RR=1.5), hereditary metabolic disease (RR=1.3), ankylosing spondylosis (RR=1.5). Interestingly, a significant negative association was found for full healthcare coverage linked with very low income (RR=0.7) and certain chronic diseases: Alzheimer's disease (RR=0.3), Parkinson's disease (RR=0.7), neuroleptic medications (RR=0.4), multiple sclerosis (RR=0.7). This could be associated with lower frequency of occupational risk factors and a lack of complaint or investigation. After surgery, 55.0% of the patients in the 18 to 59 years age range had a period of sick leave and 36.8% returned to work later than the upper limit of the recommended recovery period of 56 days. The annual cost of sick leaves was estimated at 81 million euros for the general health insurance scheme.

CONCLUSION

The number of CTS surgical procedures is increasing in France. Prevention of CTS in the workplace must be sustained and encouraged. Recommendations for sick leave periods should be followed.

Seasonal influenza vaccination coverage in France during two influenza seasons (2007 and 2008) and during a context of pandemic influenza A(H1N1) in 2009

OBJECTIVES

To measure the seasonal influenza vaccination coverage rate (VCR) in France in 2009, year of the A(H1N1) influenza pandemic, by age and target disease and compare it with the VCR for the 2007 and 2008 influenza seasons.

METHOD

At the beginning of each annual seasonal vaccination campaign, the National Health Insurance, covering 86% of the French population, sends free influenza vaccination vouchers to at-risk beneficiaries aged under 65 suffering from diverse chronic diseases and to all individuals aged 65 and over (around 11 million). Vaccination is estimated from refund claims registered in the National Health Insurance Information System.

RESULTS

The global VCR for the target population was 51% in 2007, 55.8% in 2008 and 56.9% in 2009. In 2009, the VCR for children under 10 years old was 24.3%, 28.1% in the 10-19 age range, 39.2% in the 20-64 age range and 63.3% for individuals aged 65 and over, of which 72.3% with a targeted chronic disease and 56.9% without. The inclusion of asthma as a target disease, lowered the global VCR for children under 10 years old (30.6% without asthma) but VCR increased proportionally with the number of annual refunds for drugs against asthma and chronic obstructive pulmonary disease. The 2009 vaccine uptake rates in target group children, adolescents, young adults and to a lesser extent the population aged 65 and over suffering from a chronic disease (particularly chronic respiratory disease), could have been positively impacted by the A(H1N1) influenza context.

CONCLUSION

The influenza VCR varies considerably according to age and target disease but globally remains inferior to the recommended 75% coverage rate. These results permit the detailed analysis of VCR distribution by disease and target group and highlights areas for reflection and action. Specific studies should be conducted in order to understand why the VCR is lower in certain target groups.

HPV vaccination in France: uptake, costs and issues for the National Health Insurance

INTRODUCTION

Two vaccines for primary prevention of cervical cancer are available in France, Gardasil® and Cervarix®, since 2007 and 2008 respectively. Currently, the French guidelines indicate vaccination of girls aged 14 with a catch-up program for females from 15 to 23 years old. In France, the reimbursement rate for these vaccines is 65% of the vaccine price, resulting in Gardasil® being the fifth highest drug expenditure of the main scheme of the French National Health Insurance in 2008. The purpose of this study is to provide data on vaccination coverage and costs in France until 31 December 2009. In addition, the current vaccination coverage rate is compared with the coverage rates assumed in cost-effectiveness studies.

METHODS

Data were extracted from the National Health Insurance Information System (SNIIRAM). The SNIIRAM records all reimbursements of medical costs to patients--including drugs--by the French public Health Insurance Schemes since 2004. The analysis was performed for the period of July 2007 until December 2009 using the data of the general scheme of National Health Insurance covering about 88% of the French population, i.e., 56.5 million people. Vaccination rates for one or three doses were determined for the target and catch-up population using the 2009 reference population from the general health insurance scheme as the denominator.

RESULTS

The cumulative number of doses reached 2,900,000 at the end of 2009. About 1,200,000 girls and young women have been reimbursed for at least one vaccine dose, of these 96.5% females aged 14-23 years. Among the target group, reimbursement for at least one dose remained low, from 50.8% for girls aged 14 years in 2007 to 41.7% and 20.5% for girls aged 14 years in 2008 and 2009 respectively. In terms of complete vaccination, only 33.3% of girls of the age of 14 years in 2007 and 23.7% in 2008 were reimbursed for 3 doses of HPV vaccine. The maximum uptake in the catch-up group for both 1 and 3 doses was observed for women born in 1992 (15 years in 2007) with 52.5% and 35.6% respectively.

CONCLUSION

Low rates of coverage have been observed both in the target and catch-up groups in France. Considering this, the cost-effectiveness of vaccination in combination with opportunistic screening or organized screening needs to be re-evaluated.

Benfluorex and valvular heart disease: a cohort study of a million people with diabetes mellitus

PURPOSE

To evaluate and quantify in diabetic patients treated with benfluorex in France, a fenfluramine-derivated product, a possible increase in risk of valvular heart disease, previously suggested by several published case reports.

METHODS

This was a French comparative cohort study using data from two large national linked databases, health insurance system (SNIIRAM) and hospitalization (PMSI). Patients aged 40-69 years with reimbursement for oral antidiabetic and/or insulin in 2006 were eligible. Exposed patients were defined as patients with at least one benfluorex reimbursement in 2006. Selected admission diagnoses of interest in 2007 and 2008 PMSI databases were valvular insufficiency for any cause, mitral insufficiency, aortic insufficiency, and valvular replacement surgery with cardiopulmonary bypass. Relative risks (RR) were adjusted on gender, age, and history of chronic cardiovascular disease.

RESULTS

A total of 1,048173 diabetic patients were included, with 43,044 (4.1%) exposed to benfluorex. The risk of hospitalization in 2007 and 2008 for any cardiac valvular insufficiency was higher in the benfluorex group: crude RR=2.9 [95% confidence interval 2.2-3.7] and adjusted RR=3.1 [2.4-4.0], with a lower risk for patients with lower cumulative dose of benfluorex. Adjusted RR for mitral insufficiency and aortic insufficiency admissions were 2.5 [1.9-3.7] and 4.4 [3.0-6.6], respectively. Adjusted RR for valvular replacement surgery was 3.9 [2.6-6.1].

CONCLUSIONS

Benfluorex in diabetic patients was significantly associated with hospitalization for valvular heart disease in the 2 years following benfluorex exposure. Linkage between SNIIRAM and PMSI databases is in France a valuable tool to quantify the risk of serious adverse drug reactions.

Evidence-based pharmacotherapy after myocardial infarction in France: adherence-associated factors and relationship with 30-month mortality and rehospitalization

BACKGROUND

International guidelines recommend long-term use of evidence-based treatment (EBT) combining beta-blockers, aspirin/clopidogrel, statins and either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs) after a myocardial infarction (MI), to reduce cardiac morbidity and mortality.

AIMS

To evaluate medication adherence after hospital admission for MI and the relationship with mortality and readmission for acute coronary syndrome.

METHODS

Observational, 30-month follow-up of patients admitted for acute MI in France in the first half of 2006 and still alive 6 months later. Data from the national hospital discharge database and the outpatient medications reimbursement database were linked for all patients covered by the general health insurance scheme (70% of the French population). A patient was considered as adherent when the proportion of days covered by a filled prescription was greater than 80%.

RESULTS

The proportion of nonadherent patients was 32.0% for beta-blockers, 24.0% for statins, 22.7% for ACEIs/ARBs, 18.3% for aspirin/clopidogrel and 50.0% for combined EBT. Adherence to EBT was decreased significantly by age greater than 74 years, comorbidities and full healthcare coverage for low earners. Prior EBT use and stent implantation, before or during index hospitalization, increased adherence. After adjustment for patient characteristics and management, prior use of each class decreased mortality. Nonadherence to EBT after MI increased mortality and readmission (hazard ratio=1.43, P<0.0001).

CONCLUSION

After MI, nonadherence to EBT is associated with a marked increase in all-cause mortality and readmission for acute coronary syndrome. Cost-effective strategies for adherence improvement should be developed among patient groups with poor adherence.

French national health insurance information system and the permanent beneficiaries sample

In France, in the early 2000s, legislators ordered that the National Health Insurance regime develop an inter-regime information system (SNIIR-AM) aimed at better understanding and evaluating beneficiaries' health care consumption and associated expenditures. In 2009, it contained data from the general health insurance regime that covers 86% of the French population; approximately 53 million people. Data are only available for a period of two years plus the current year. In addition, a permanent sample of health insurance beneficiaries (EGB) was created from the SNIIR-AM database. This is a permanent, representative cross-sectional sample of the population covered by National Health Insurance which, since 2004, monitors beneficiaries' health care consumption over a period of 20 years. It contains anonymous sociodemographic and medical characteristics and records of health care reimbursements. It was created using a systematic sampling method (1/97) on the two-digit control key of beneficiaries' national identification number and includes both current year reimbursement recipients and non-recipients. In 2009, it grouped together almost 500,000 beneficiaries covered by the National Health Insurance Fund for Salaried Workers; 77% of the population residing in France excluding public service employees and students. The EGB is used to conduct longitudinal studies as it permits tracing back patients' care paths and use of care in both hospital and office-based care environments and to calculate individual expenditures. It also permits the study of certain relatively frequent diseases characterised by a 100% reimbursement rate for certain chronic diseases and the reimbursement of tracer drugs. Eventually, the SNIIR-AM will include beneficiaries covered by all the different Health Insurance regimes in France.