Surmortalité et hospitalisations plus fréquentes des bénéficiaires de la couverture médicale universelle complémentaire en 2009

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.

Forgoing health care under universal health insurance: the case of France

OBJECTIVES

We investigate the reliability of a survey question on forgone healthcare services for financial reasons, based on analysis of actual healthcare use over the 3-year period preceding response to the question. We compare the actual use of different health services by patients who report having forgone health care to those who do not.

METHODS

Based on a prospective cohort study (CONSTANCES), we link survey data from enrolled participants to the Universal Health Insurance (UHI) claims database and compare use of health services of those who report having forgone health care to controls. We present multivariable logistic regression models and assess the odds of using different health services.

RESULTS

Compared to controls, forgoing care participants had lower odds of consulting GPs (OR = 0.83; 95% CI 0.73, 0.93), especially specialists outside hospitals (gynecologists: 0.74 (0.69, 0.78); dermatologists: 0.81 (0.78-0.85); pneumologists 0.82 (0.71-0.94); dentists 0.71 (0.68, 0.75)); higher odds of ED visits (OR = 1.25; 95% CI 1.19, 1.31); and no difference in hospital admissions (OR = 1.02; 95% CI 0.97, 1.09). Participants with lower occupational status and income had higher odds of forgoing health care.

CONCLUSIONS

The perception of those who report having forgone health care for financial reasons is consistent with their lower actual use of community-based ambulatory care (CBAC). While UHI may be necessary to improve healthcare access, it does not address the social factors associated with the population forgoing health care for financial reasons.

The Characteristics of Care Provided to Population(s) in Precarious Situations in 2015. A Preliminary Study on the Universal Health Cover in France

Background: The French Universal Health Cover (CMU) aims to compensate for inequalities between precarious and non-precarious populations, enabling the former to access to free healthcare. These measures rely on the principle that precarious populations' health improves if healthcare is free. We designed a study to examine whether CMU fails to compensate for inequalities in reimbursed drugs prescriptions in precarious populations. Material and method: This retrospective pharmaco-epidemiological study compared the Defined Daily Dose relative to different reimbursed drugs prescribed by general practitioners (GPs) to precarious and non-precarious patients in France in 2015. Data were analysed using Mann-Whitney tests. Findings: 6 out of 20 molecules were significantly under-reimbursed in precarious populations. 2 were over-reimbursed. The 12 remaining molecules did not differ between groups. Interpretation: The under-reimbursement of atorvastatin, rosuvastatin, tamsulosine and timolol reflects well-documented epidemiological differences between these populations. In contrast, the equal reimbursement of amoxicillin, pyostacine, ivermectin, salbutamol and tiopropium is likely an effect of lack of compensation for inequalities. Precarious patients are more affected by diseases that these molecules target (e.g., chronic bronchitis, bacterial pneumonia, cutaneous infections). This could also be the case for the equal and under-reimbursement of insulin glargine and metformin (targeting diabetes), respectively, although this has to be considered with caution. In conclusion, the French free healthcare cover does not fail to compensate for all but only for some selective inequalities in access to reimbursed drugs prescriptions. These results are discussed with respect to the interaction of the doctor-patient relationship and the holistic nature of primary care, potentially triggering burnout and empathy decrease and negatively impacting the quality of care in precarious populations.

Management of pregnancy based on healthcare consumption of women who delivered in France in 2015: Contribution of the national health data system (SNDS)

OBJECTIVE

This study was designed to further our knowledge of the management of pregnant women based on the national health data system (SNDS).

MATERIAL AND METHODS

Women covered by the national health insurance general scheme or a local mutualist section, who delivered in 2015.

RESULTS

Among the 672,182 women included (mean age: 31 years, SD 5.3), 0.3% were under the age of 18 years, 4% lived in a French overseas department (<18 years: 21%), 17% had complementary universal health insurance coverage (<18 years: 75%), 1.2% presented a mental illness, 0.6% had a cancer, and 0.4% had cardiovascular disease. At least one outpatient visit with a gynaecologist or midwife was detected for 93% of women (first trimester (T1): 75%), specific or nonspecific pelvic ultrasound was performed in 98% (T1: 92%), blood glucose assay was performed in 78% (T1: 61%), and an oral glucose tolerance test was performed in 58%. Before delivery, 0.2% of women had at least one admission to the intensive care unit and 22% had at least one hospital stay (<18 years: 38%), for which the principal diagnoses were: false labour (4.5%), threatened preterm labour (2.5%), surveillance of high-risk pregnancy (2.6%), diabetes (2.6%), and hypertension (0.7%). The preterm delivery rate was 6.7% (<18 years: 14%, ≥40 years: 9%). Although 20% of deliveries were performed by caesarean section, 16% of vaginal deliveries required instrumental extraction.

DISCUSSION

SNDS data enrich the data derived from periodic national perinatal surveys, such as the poor follow-up of adolescent girls. These data can promote the elaboration and monitoring of annual indicators.

Asthma exacerbations and socio-economic status in French adults with persistent asthma: A prospective cohort study

INTRODUCTION

Adults disadvantaged by poor socio-economic status (SES) are more severely affected by asthma compared to those with better SES. We aimed to determine whether the frequency of asthma exacerbations (AEx), as well as aspects related to AEx management, differed based on SES in patients treated with daily treatments.

METHODS

This study, part of the prospective observational cohort ASTRO-LAB, included French adult patients with persistent asthma. Patients were considered as low SES if they benefited from publicly funded special health insurance and/or were perceived as low SES by their general practitioner. AEx was defined as at least one of the following: asthma-related oral corticosteroid course, medical contact, hospitalization, and death. We examined associations between SES and AEx frequency, perceived triggering factors and type of medical contact after AEx.

RESULTS

In our sample of 255 patients, 11.40% were considered as low SES. Patients with low SES did not report significantly more AEx than medium/high SES patients during one-year follow-up (0.79 versus 0.55, p = 0.38). The type of medical contact during AEx differed significantly between the two groups (p = 0.03): patients with medium/high SES consulted their general practitioner more frequently (OR = 2.23, 95% CI = 0.91-5.50, p = 0.08) and were less likely to visit an emergency department or be hospitalized (OR = 0.27, 95% CI = 0.09-0.84, p = 0.02).

CONCLUSIONS

AEx frequency did not differ significantly between low and medium/high SES patients, but differences were found in the management of AEx. Studies are needed to better understand the relation between precariousness and management of asthma.

[Health care use by free complementary health insurance coverage beneficiaries in France in 2012]

BACKGROUND

The objective was to investigate healthcare use among people covered by one of the two complementary healthcare insurance schemes available for people with low annual income: CMUC (universal complementary healthcare insurance) and, for people whose income exceeds the CMUC ceiling, ACS (aid for complementary healthcare insurance). Comparisons were made between CMUC and ACS beneficiaries versus CMUC and ACS non-beneficiaries and between CMUC beneficiaries and ACS beneficiaries.

METHODS

Using the national health insurance information system (SNIIRAM), people less than 60 years old covered by the general national health insurance (86% of the 66 million inhabitants) and with ACS or CMUC coverage in 2012 were selected. Diseases were identified using hospital diagnosis, drugs refunds and long-term chronic disease status. Hospital related diagnoses were categorized in major hospital activity groups. Sex- and age-standardized relative risk (RR) were calculated.

RESULTS

There were 4.4 million (9.6%) CMUC beneficiaries and 732,000 (1.6%) ACS beneficiaries (56% and 54% women; mean age: 24 years and 29 years respectively versus 52% and 30 years for CMUC or ACS non-beneficiaries). CMUC or ACS beneficiaries had more often cardiovascular diseases (RR=1.4;2.1) and diabetes (RR=2.2;2.4). Their sex- and age-standardized hospitalisation rates for all diagnosis were higher (18%; 17%, RR=1.3;1.4) than CMUC or ACS non-beneficiaries (13%). This was especially the case for the following major groups: toxicology, intoxications, alcohol major group (RR=3.8;4.0); psychiatry (RR=2.8;4.1); respiratory disease (RR=1.9;2.3); infectious disease (RR=1.9;2.7). Compared with CMUC beneficiaries, ACS beneficiaries had more often cancer (RR=1.5), cardiovascular disease (RR=1.5), neurological disease (RR=2.7), psychiatric illness (RR=2.6), end-stage renal disease (RR=2.8), hemophilia (RR=1.4) or cystic fibrosis (RR=1.6) and they received also more often disability allowance (20%, 4%).

CONCLUSION

The disease and hospitalisation rates of ACS beneficiaries are similar or higher than those of CMUC beneficiaries, especially for disabling diseases. Both CMUC and ACS beneficiaries received healthcare for chronic diseases that can be targeted by prevention and screening programs for more optimal healthcare.

[Hospitalization rates for immigrant-related illness among individuals with low income and full health insurance coverage in France, 2009]

Complementary Universal Health Insurance (CMUC) which provides free access to health care has been available in France since 2000 for people with an annual income less than 60% of the poverty threshold. Hospitalization rates in 2009 for common diseases among immigrants were compared between beneficiaries of the general scheme under the age of 60 years with (4.5 millions) or without CMUC (34.1 millions) in 2008 and still alive at the end of the year. Data were derived from the French national health insurance reimbursements and short-stay hospital discharge databases. Age - and sex-adjusted hospitalization rates and relative risk significantly greater overall hospitalization rates (17.5% vs 13.2%) (males RR= 2.0, female RR 2.3) and each parasitic diseases (RR = 2.1), which include viral diseases and fevers of unknown origin (1.1/1000, RR =1.6), septicaemia (0.4/1000, RR = 2.2), HIV infection (0.7/1000, RR = 3.5), other infectious and parasitic diseases (0.7/1000, RR= 2.5) and, more precisely, measles (2.7/1000, RR = 5.0). Hospitalization for sickle cell disease (3%, RR = 4.5) were also more frequent as also for lead poisoning (0.12/1000, RR = 5.2). In this low-income population with free access to health care, hospitalizations were higher for many diseases that are targets for prevention and screening actions. This is tha case for immigrant with CMUC coverage arriving in France and when they travel to their country of origin.

[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.