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

Risk factors for COVID-19 hospitalisation after booster vaccination during the Omicron period: A French nationwide cohort study

BACKGROUND

In spite of major effectiveness, a residual risk after COVID-19 primary vaccination was identified, in particular, for vulnerable individuals of advanced age or with comorbidities. Less is known about the Omicron period in people protected by a booster dose. We aimed to identify the characteristics associated with severe COVID-19 during the Omicron period in a population that had received a booster dose in France and to compare differences with the previous periods of the pandemic.

METHODS

This study was carried out using the French national COVID-19 vaccination database (VAC-SI) coupled with the National Health Data System (SNDS). Individuals aged 12 years or over who received at least one booster dose were identified. Associations between socio-demographic and clinical characteristics and the risk of COVID-19 hospitalisation occurring at least 14 days after receiving a third dose of vaccine during the period of Omicron predominance, i.e., from 1 January 2022 to 10 November 2022, were assessed using Cox proportional hazard models adjusted for age, sex, time since booster dose and vaccination schedule. Analyses were performed overall and by sub-period of circulation of the strains BA.1, BA.2, and BA.4/BA.5, defined as periods where the main sub-variant accounted for more than 80 % of genotyped samples.

FINDINGS

In total, 35,640,387 individuals received a booster dose (mean follow-up of 291 days) and 73,989 were hospitalised for COVID-19 during the total period. Older age (aHR 20.5 95 % CI [19.6-21.5] for 90 years of age or older versus 45-54 years of age), being male (aHR 1.52 [1.50-1.55]), and social deprivation (aHR 1.33 [1.30-1.37] for the most deprived areas versus the least deprived) were associated with an increased risk of hospitalisation for COVID-19. Most of the chronic diseases considered were also positively associated with a residual risk, in particular, cystic fibrosis (aHR 9.83 [7.68-12.56]), active lung cancer (aHR 3.26 [3.06-3.47]), chronic dialysis (aHR 3.79 [3.49-4.11]), psychological and neurodegenerative diseases (more markedly than during the periods of circulation of the alpha and delta variants), and organ transplantation. The use of immunosuppressants was also associated with an increased risk (aHR 2.24 [2.14-2.35], including oral corticosteroids aHR (2.58 [2.50-2.67]).

CONCLUSION

Despite an effective booster and a generally less virulent circulating variant, a residual risk of severe COVID-19 still exists in vulnerable populations, especially those with neurological disorders.

Risk of Gastrointestinal Perforation in Patients With Rheumatic Diseases Exposed to Janus Kinase Inhibitors Versus Adalimumab: A Nationwide Cohort Study

OBJECTIVE

To compare the risk of gastrointestinal perforation (GIP), a rare but serious adverse event, in patients who a JAK inhibitor (JAKi; tofacitinib, baricitinib, upadacitinib, or filgotinib) versus adalimumab (tumor necrosis factor inhibitor) among a comprehensive real-world population of patients with rheumatic diseases.

METHODS

We conducted a nationwide population-based cohort study of the French national health data system, the exposed group that received a JAKi and the comparison group adalimumab. We included all individuals with a rheumatic disease who had their first dispensation of these treatments from July 2017 to December 2021. The primary endpoint was the occurrence of GIP (end of follow-up May 2022). Weighted hazard ratios (wHRs) were estimated with the inverse probability of treatment weighting method to account for confounding factors. Concomitant administration of systemic glucocorticoids, nonsteroidal anti-inflammatory drugs, and proton-pump inhibitors were time-varying variables.

RESULTS

The cohort included 39,758 patients: 12,335 and 27,423 in the groups that received a JAKi and adalimumab (mean age 58.2 and 47.3 years; female 76% and 58%; rheumatoid arthritis 85.3% and 27.3%, and psoriatic arthritis/axial spondyloarthritis 14.7% and 72.7%), respectively. During follow-up, 38 and 42 GIPs occurred in the groups that received a JAKi and adalimumab groups; incidence rates were 2.1 (95% confidence interval [CI] 1.5-2.8) and 1.1 (95% CI 0.8-1.5) per 1,000 person-years, respectively. Rates of GIP did not differ between the groups that received a JAKi and adalimumab: wHR 1.1 (95% CI 0.7-1.9; P = 0.65). Despite the lack of power in some subgroup analyses, results were consistent whatever the subgroup of a type of JAKi received or subgroup with a type of rheumatic disease.

CONCLUSION

In this nationwide cohort study, the rates of GIPs did not differ between groups of patients who received JAKi and adalimumab treatment. These results need to be confirmed in other observational studies.

Real-world economic burden of hepatitis C and impact of direct-acting antivirals in France: A nationwide claims data analysis

BACKGROUND AND AIMS

The economic impact of managing patients with hepatitis C virus (HCV) infection remains unknown. This study aimed to assess the economic burden of chronic HCV infection from a national health insurance perspective and the impact of direct-acting antivirals (DAAs) using nationwide real-world data.

METHODS

Patients with chronic HCV infection were identified from the French Health Insurance Claims Databases (SNDS) and matched for age and sex to the general population. Health resource utilization and reimbursements were summarized according to healthcare expenditure items from 2012 to 2021. The economic burden attributable to chronic HCV infection was evaluated over a 10-year period. Finally, the impact of DAAs was estimated using economic data derived from the SNDS.

RESULTS

A total of 145 187 patients with chronic HCV infection were identified. Among the patients eligible for DAA therapy, 81.5% had received DAA by the end of 2021. Over a 10-year period, managing patients with chronic HCV infection resulted in an additional cost of €9.71 billion (95% confidence interval [CI]: €9.66-€9.78 billion) or €9191 (95% CI: €9134-€9252) per patient per year compared to the general population. After DAA therapy, patients with chronic HCV infection had a higher economic burden than the general population, with an additional cost of €5781 (95% CI: €5540-€6028) per patient at the fifth-year post-DAA therapy.

CONCLUSIONS

A significant economic burden persists among patients with HCV infection after DAA treatment. The high proportion of patients not treated with DAA therapy supports reinforcing policies for universal access.

Prevalence of multiple sclerosis in France in 2021: Data from the French health insurance database

BACKGROUND

France is among the countries with high prevalence of multiple sclerosis (MS). The most recent estimates are from 2012 and need to be updated because MS prevalence has increased worldwide.

OBJECTIVE

To estimate MS prevalence in France on December 31, 2021 and to describe the characteristics of the French MS population using data from the French national health insurance database (SNDS).

MATERIAL AND METHODS

Persons with MS (PwMS) were identified in the SNDS database (99% of national coverage) using an algorithm with three criteria: long-term disease status, hospitalizations, and MS-specific drug reimbursements. Crude and sex- and age-stratified prevalence rates were calculated with their 95% confidence intervals as well as the standardized prevalence stratified on the region of residence.

RESULTS

In total, 134,062 PwMS were identified (71.8% of women, median age 53.0±14.8years) yielding a prevalence of 197.6 per 100,000 (95% CI [196.5-198.7]). Prevalence rates in women and men were respectively 274.9 (95% CI [273.2-276.6]) and 115.2 (95% CI [114.0-116.4]). In metropolitan France, the highest prevalence rates were observed in the northeastern regions (e.g.>230 PwMS per 100,000 in Grand Est and Hauts-de-France), and the lowest rates in the southwestern regions (∼180 PwMS per 100,000 in Nouvelle-Aquitaine and Occitanie). Overall, 32.1% of PwMS had another long-term disease and 51.8% received at least one MS-specific drug in 2021.

CONCLUSION

MS prevalence in France has increased by ∼30% in the last 10years. This increase is probably linked to population ageing, longer survival of PwMS, and the long observation period. The part attributable to a possible increase in MS risk remains to be determined with incidence studies.

Cost-effectiveness of weekly adaptive radiotherapy versus standard IMRT in head and neck cancer alongside the ARTIX trial

BACKGROUND AND PURPOSE

We performed a cost-effectiveness analysis (CEA) comparing an adaptive radiotherapy (ART) strategy, based on weekly replanning, aiming to correct the parotid gland overdose during treatment and expecting therefore to decrease xerostomia, when compared to a standard IMRT.

MATERIALS AND METHODS

We conducted the ARTIX trial, a randomized, parallel-group, multicentric study comparing a systematic weekly replanning ART to a standard IMRT. The primary endpoint was the frequency of xerostomia at 12 months, measured by stimulating salivary flow with paraffin. The CEA was designed alongside the ARTIX trial which was linked to the French national health data system (SNDS). For each patient, healthcare consumptions and costs were provided by the SNDS. The reference case analysis was based on the primary endpoint of the trial. Sensitivity and scenario analyses were performed.

RESULTS

Of the 129 patients randomly assigned between 2013 and 2018, only 2 records were not linked to the SNDS, which provides a linkage proportion of 98.4%. All of the other 127 records were linked with good to very good robustness. On the intent-to-treat population at 12 months, mean total costs per patient were €41,564 (SD 23,624) and €33,063 (SD 16,886) for ART and standard IMRT arms, respectively (p = 0.033). Incremental cost effectiveness ratio (ICER) was €162,444 per xerostomia avoided. At 24 months, ICER was €194,521 per xerostomia avoided. For both progression-free and overall survival, ART was dominated by standard IMRT.

CONCLUSION

The ART strategy was deemed to be not cost-effective compared with standard IMRT for patients with locally advanced oropharyngeal cancer.

Lower risk of hospitalisation for depression following hospitalisation for COVID-19 versus for another reason

INTRODUCTION

Although hospitalisation for COVID-19 is associated with a higher post-discharge risk of mood disorders, including major depressive disorder (MDD) and bipolar disorder (BD), this risk has not been compared to that following hospitalisation for a reason other than COVID-19.

METHODS

Using data from France's National Health Data System (SNDS) database, we compared patients hospitalised for mood disorders in the 12 months following COVID-19/another reason hospitalisation.

RESULTS

96,313 adult individuals were hospitalised for COVID-19, and 2,979,775 were hospitalised for another reason. In the 12 months post-discharge, 110,976 (3.83 %) patients were hospitalised for mood disorders. In unadjusted analyses, patients initially hospitalised for COVID-19 (versus another reason) were more likely to be subsequently hospitalised for a mood disorder (4.27 % versus 3.82 % versus, respectively, p < 0.0001). These patients were also more likely to have a history of mood disorders, especially depressive disorders (6.45 % versus 5.77 %, respectively, p < 0.0001). Women, older age, lower social deprivation, a history of mood disorders, longer initial hospitalisation (COVID-19 or other), and a higher level of clinical care during initial hospitalisation were all significantly associated with the risk of subsequent hospitalisation for MDD and BD. In contrast, after adjusting for all these factors, persons initially hospitalised for COVID-19 were less likely to be subsequently hospitalised for MDD (OR = 0.902 [0.870-0.935]; p < 0.0001). No difference between both groups was observed for BD.

LIMITATIONS

Other reasons were not separately studied.

CONCLUSIONS

After adjusting for confounding factors, initial hospitalisation for COVID-19 versus for another reason was associated with a lower risk of hospitalisation for a mood disorder.

Deleterious association between proton pump inhibitor and protein kinase inhibitor exposure and survival for patients with lung cancer: A nationwide cohort study

INTRODUCTION

Previous studies have identified an interaction between protein kinase inhibitors (PKIs) and proton pump inhibitors (PPIs) in patients with lung cancer. This type of interaction may reduce the efficacy of PKIs. However, the effect of PKI-PPI interaction on patient mortality remains controversial. This study set out to determine the impact of PKI-PPI interaction on overall survival for lung cancer patients.

MATERIALS AND METHODS

This study was conducted using data from the French National Health Care Database from January 1, 2011 to December 31, 2021. We identified patients with: (i) an age equal to or greater than 18 years; (ii) lung cancer; and (iii) at least one reimbursement for one of the following drugs: erlotinib, gefitinib, afatinib and osimertinib. Patients were followed-up between the first date of PKI reimbursement and either December 31, 2021 or if they died, the date on which death occurred. The cumulative exposure to PPI duration during PKI treatment was calculated as the ratio between the number of concomitant exposure days to PKI and PPI and the number of exposure days to PKI. A survival analysis using a Cox proportional hazards model was then performed to assess the risk of death following exposure to a PKI-PPI interaction.

RESULTS

34,048 patients received at least one reimbursement for PKIs of interest in our study: 26,133 (76.8 %) were exposed to erlotinib; 3,142 (9.2 %) to gefitinib; 1,417 (4.2 %) to afatinib; and 3,356 (9.9 %) to osimertinib. Patients with concomitant exposure to PKI-PPI interaction during 20 % or more of the PKI treatment period demonstrated an increased risk of death (HR, 1.60 [95 % CI, 1.57-1.64]) compared to other patients. When this cut-off varied from 10 % to 80 %, the estimated HR ranged from 1.46 [95 % CI, 1.43-1.50] to 2.19 [95 % CI, 2.12-2.25].

DISCUSSION/CONCLUSION

In our study, an elevated risk of death was observed in patients exposed to PKI-PPI interaction. Finally, we were able to identify a dose-dependent effect for this interaction. This deleterious effect of osimertinib and PPI was revealed for the first time in real life conditions.

A French nationwide study compared various conditions and healthcare use of individuals < 65 years with a Down's syndrome to those without

Few regular national clinical data are available for individuals with Down's syndrome (IDS) bearing in mind that they are subject to countries variations in medical termination of pregnancy and screening. Individuals < 65 in 2019 were selected in view of the low number of older IDS. Thus, 98% of 52.4 million people with correct data were included from the national health data system. IDS (35,342) were identified on the basis of the International Classification of Diseases 10th revision code (Q90). Risk ratios (RR) were calculated to compare the frequencies in 2019 between IDS and individual without Down's syndrome (IWDS) of use of health care. The prevalence of IDS was 0.07% (48% women), comorbidities were more frequent, especially in younger patients (24% < 1 year had another comorbidity, RR = 20), as was the percentage of deaths (4.6%, RR = 10). Overall, tumours were less frequent in IDS compared with IWDS (1.2%, RR = 0.7) except for certain leukaemias and testicular tumours (0.3%, RR = 4). Cardiac malformations (5.2%, RR = 52), dementia (1.2%, RR = 29), mental retardation (5%, RR = 21) and epilepsy (4%, RR = 9) were also more frequent in IDS. The most frequent hospital diagnoses for IDS were: aspiration pneumonia (0.7%, RR = 89), respiratory failure (0.4%, RR = 17), sleep apnoea (1.1%, RR = 8), cryptorchidism (0.3%, RR = 5.9), protein-energy malnutrition (0.1%, RR = 7), type 1 diabetes (0.2%, RR = 2.8) and hypothyroidism (0.1%, RR = 72). IDS were more likely to use emergency services (9%, RR = 2.4), short hospital stay (24%, RR = 1.6) or hospitalisation at home (0.6%, RR = 6). They consulted certain specialists two to three times more frequently than IWDS, for example cardiologists (17%, RR = 2.6). This study is the first detailed national study comparing IDS and non-IDS by age group. These results could help to optimize prenatal healthcare, medical and social support.

COVID-19 Hospitalization in Solid Organ Transplant Recipients on Immunosuppressive Therapy

Importance

Solid organ transplant recipients are at high risk of severe infection with SARS-CoV-2 compared with the general population. However, factors associated with COVID-19-related severity in this population are still insufficiently explored in the literature.

Objective

To examine which health conditions and immunosuppressive drugs for preventing graft rejection are associated with the risk of COVID-19-related hospitalization in solid organ transplant recipients.

Design, Setting, and Participants

Using the French National Health Data System, this cohort study assessed patients of any age who received transplants between their date of birth and entry into the cohort on February 15, 2020. The cohort was followed up between February 15, 2020, and July 31, 2022.

Exposures

Immunosuppressive drugs, including steroids, and health conditions (age, sex, and comorbidities).

Main Outcomes and Measures

The main outcome was hospitalization for COVID-19, defined by main diagnostic International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes. Factors associated with the outcome were identified with a nonconditional logistic regression. Confounding by indication was controlled using a multivariable model with adjustment for individual confounders. Each transplanted organ was examined separately.

Results

Overall, 60 456 participants (median [IQR] age, 59 [47-67] years; 63.7% male) were included in the study, of whom 41 463 (68.6%) had kidney transplants, 14 464 (23.9%) had liver transplants, 5327 (8.8%) had heart transplants, and 2823 (4.6%) had lung transplants. Among them, 12.7% of kidney transplant recipients, 6.4% of liver transplant recipients, 12.9% of heart transplant recipients, and 18.0% of lung transplant recipients were hospitalized for COVID-19. In kidney transplant recipients, steroids (adjusted odds ratio [AOR], 1.60; 95% CI, 1.49-1.73) and mycophenolic acid (AOR, 1.37; 95% CI, 1.25-1.51) were associated with a high risk of hospitalization. In liver transplant recipients, tacrolimus (AOR, 0.77; 95% CI, 0.61-0.98) was associated with a decreased risk, and steroids (AOR, 1.60; 95% CI, 1.38-1.86) and mycophenolic acid (AOR, 1.61; 95% CI, 1.37-1.90) were associated with an increased risk of hospitalizations. In heart transplant recipients, cyclosporine (AOR, 0.67; 95% CI, 0.47-0.94) was associated with a decreased risk, and steroids (AOR, 1.42; 95% CI, 1.11-1.82), mycophenolic acid (AOR, 1.29; 95% CI, 1.02-1.64), sirolimus (AOR, 2.71; 95% CI, 1.20-6.09), and everolimus (AOR, 1.24; 95% CI, 1.01-1.51) were associated with an increased risk of hospitalization. Only steroids (AOR, 1.72; 95% CI, 1.19-2.48) were associated with a high risk of COVID-19 hospitalization in lung transplant recipients.

Conclusions and Relevance

This study suggests that mycophenolic acid, sirolimus, and steroids are associated with an increased risk of COVID-19-related hospitalization in solid organ transplant recipients. These results should be considered by clinicians treating transplant recipients and may help inform epidemic-related decisions for this population in the future.

What drives health care spending in Switzerland? Findings from a decomposition by disease, health service, sex, and age

BACKGROUND

High and increasing spending dominates the public discussion on healthcare in Switzerland. However, the drivers of the spending increase are poorly understood. This study decomposes health care spending by diseases and other perspectives and estimates the contribution of single cost drivers to overall healthcare spending growth in Switzerland between 2012 and 2017.

METHODS

We decompose total healthcare spending according to National Health Accounts by 48 major diseases, injuries, and other conditions, 20 health services, 21 age groups, and sex of patients. This decomposition is based on micro-data from a multitude of data sources such as the hospital inpatient registry, health and accident insurance claims data, and population surveys. We identify the contribution of four main drivers of spending: population growth, change in population structure (age/sex distribution), changes in disease prevalence, and changes in spending per prevalent patient.

RESULTS

Mental disorders were the most expensive major disease group in both 2012 and 2017, followed by musculoskeletal disorders and neurological disorders. Total health care spending increased by 19.7% between 2012 and 2017. An increase in spending per prevalent patient was the most important spending driver (43.5% of total increase), followed by changes in population size (29.8%), in population structure (14.5%), and in disease prevalence (12.2%).

CONCLUSIONS

A large part of the recent health care spending growth in Switzerland was associated with increases in spending per patient. This may indicate an increase in the treatment intensity. Future research should show if the spending increases were cost-effective.

Cross-validation of comorbidity items in two national databases in a sample of patients with end-stage kidney disease

BACKGROUND

The use of national medico-administrative databases for epidemiological studies has increased in the last decades. In France, the Healthcare Expenditures and Conditions Mapping (HECM) algorithm has been developed to analyse and monitor the morbidity and economic burden of 58 diseases. We aimed to assess the performance of the HECM in identifying different conditions in patients with end-stage kidney disease (ESKD) using data from the REIN registry (the French National Registry for patients with ESKD).

METHODS

We included all patients over 18 years of age who started renal replacement therapy in France in 2018. Five conditions with a similar definition in both databases were included (ESKD, diabetes, human immunodeficiency virus [HIV], coronary insufficiency, and cancer). The performance of each SNDS algorithm was assessed using sensitivity, specificity, positive predictive values (PPVs), negative predictive values (NPVs), and Cohen's kappa coefficient.

RESULTS

In total 5,971 patients were included. Among them, 81% were identified as having ESKD in both databases. Diabetes was the condition with the best performance, with a sensitivity, specificity, PPV, NPV, and Kappa coefficient all over 80%. Cancer had the lowest level of agreement with a Kappa coefficient of 51% and a high specificity and high NPV (94% and 95%). The conditions for which the definition in the HECM included disease-specific medications performed better in our study.

CONCLUSION

The HECM showed good to very good concordance with the REIN database information overall, with the exception of cancer. Further validation of the HECM tool in other populations should be performed.

Work accident effect on the use of psychotropic drugs: the case of benzodiazepines

BACKGROUND

A work accident constitutes a shock to health, likely to alter mental states and affect the use of psychotropic drugs. We focus on the use of benzodiazepines, which are a class of drugs commonly used to treat anxiety and insomnia. Prolonged use can lead to dependence. Our objective is to determine the extent to which work accidents lead to benzodiazepine use and overuse (i.e. exceedance of medical guidelines).

METHOD

We use a two-step selection model (the Heckman method) based on data from the French National Health Data System (Système National des Données de Santé, SNDS). Our study sample includes all general plan members who experienced a single work accident in 2016 (and not since 2007). This sample includes 350,000 individuals in the work accident group and more than 1.1 million people randomly drawn from the population without work accidents from 2007 to 2017 (the non-work accident group).

RESULTS

The occurrence of a work accident leads to an increase in benzodiazepine use and overuse the following year. The selection model shows a clear influence of the accident on the use probability (+ 39%), but a very slight impact on the risk of overuse among users (+ 1.7%), once considered the selection effect. The effect on overuse risk is higher for more severe accidents and among women.

CONCLUSION

The increase in the risk of benzodiazepine overuse is due to an increase in the likelihood of using benzodiazepines after a work accident that leads to overuse, rather than an increase in likelihood of overuse among people who use benzodiazepines. Results call for targeting the first-time prescription to limit the risk of overuse after a work accident.

Protection of COVID-19 Vaccination Against Hospitalization During the Era of Omicron BA.4 and BA.5 Predominance: A Nationwide Case-Control Study Based on the French National Health Data System

Background

Knowing the duration of effectiveness of coronavirus disease 2019 (COVID-19) booster doses is essential to providing decision-makers with scientific arguments about the frequency of subsequent injections. We estimated the level of protection against COVID-19-related hospitalizations (Omicron BA.4-BA.5) over time after vaccination, accounting for breakthrough infections.

Methods

In this nationwide case-control study, all cases of hospitalizations for COVID-19 identified in the comprehensive French National Health Data System between June 1, 2022, and October 15, 2022, were matched with up to 10 controls by year of birth, sex, department, and an individual COVID-19 hospitalization risk score. Conditional logistic regressions were used to estimate the level of protection against COVID-19-related hospitalizations conferred by primary and booster vaccination, accounting for history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Results

A total of 38 839 cases were matched to 377 653 controls; 19.2% and 9.9% were unvaccinated, respectively, while 68.2% and 77.7% had received ≥1 booster dose. Protection provided by primary vaccination reached 45% (95% CI, 42%-47%). The incremental effectiveness of booster doses ranged from 69% (95% CI, 67%-71%; ≤2 months) to 22% (95% CI, 19%-25%; ≥6 months). Specifically, the second booster provided an additional protection compared with the first ranging from 61% (95% CI, 59%-64%; ≤2 months) to 7% (95% CI, 2%-13%; ≥4 months). Previous SARS-CoV-2 infection conferred a strong, long-lasting protection (51% ≥20 months). There was no incremental effectiveness of a second booster among individuals infected since the first booster.

Conclusions

In the era of Omicron BA.4 and BA.5 predominance, primary vaccination still conferred protection against COVID-19 hospitalization, while booster doses provided an additional time-limited protection. The second booster had no additional protection in case of infection since the first booster.

Individual and contextual risk factors for mortality in nursing home residents during the first wave of COVID-19 in France: a multilevel analysis of a nationwide cohort study

BACKGROUND

Mortality amongst nursing home (NH) residents increased by 43% during the first wave of coronavirus disease 2019 (COVID-19). We estimated the 'contextual effect' on mortality, tried to explain it by NH characteristics and identified resident- and NH-level risk factors for mortality.

METHODS

The contextual effect was measured for two cohorts of NH residents managed by the general scheme in metropolitan France (RESIDESMS data from 03/01/2020 to 05/31/2020 and 03/01/2019 to 05/31/2019) by the intraclass correlation coefficient (ICC) estimated from mixed-effects logistic regression.

RESULTS

Amongst 385,300 residents (5,339 NHs) included in 2020 (median age 89 years, 25% men), 9.1% died, versus 6.7% of 379,926 residents (5,270 NHs) in 2019. In the empty model, the ICC was 9.3% in 2020 and 1.5% in 2019. Only the geographic location partially explained the heterogeneity observed in 2020 (ICC: 6.5% after adjustment). Associations with mortality were stronger in 2020 than in 2019 for male sex and diabetes and weaker for heart disease, chronic respiratory disease and residence <6 months. Mortality was higher in 2020 (15.1%) than 2019 (6.3%) in NHs with at least one death with a mention of COVID-19 and more heterogeneous (ICC: 8.0%) than in the others (mortality: 6.7% in both years; ICC: 1.1%).

CONCLUSION

Our results suggest that the COVID-19 crisis had a heterogeneous impact on mortality in NH residents and that geographic location explain a part of the contextual effect, which appears to have had little influence on mortality in NHs not being affected by the virus.

The risk of hospitalization for psychotic disorders following hospitalization for COVID-19: a French nationwide longitudinal study

COVID-19, like other infectious diseases, may be a risk factor for psychotic disorders. We aimed to compare the proportions of hospitalizations for psychotic disorders in the 12 months following discharge from hospital for either COVID-19 or for another reason in the adult general population in France during the first wave of the pandemic. We conducted a retrospective longitudinal nationwide study using the national French administrative healthcare database. Psychotic disorders were first studied as a whole, and then chronic and acute disorders separately. The role of several adjustment factors, including sociodemographics, a history of psychotic disorder, the duration of the initial hospitalization, and the level of care received during that hospitalization, were also analyzed. Between 1 January 2020 and 30 June 2020, a total of 14,622 patients were hospitalized for psychotic disorders in the 12 months following discharge from hospital for either COVID-19 or another reason. Initial hospitalization for COVID-19 (vs. another reason) was associated with a lower rate of subsequent hospitalization for psychotic disorders (0.31% vs. 0.51%, odds ratio (OR) = 0.60, 95% confidence interval (CI) [0.53-0.67]). This was true for both chronic and acute disorders, even after adjusting for the various study variables. Importantly, a history of psychotic disorder was a major determinant of hospitalization for psychotic disorders (adjusted OR = 126.56, 95% CI [121.85-131.46]). Our results suggest that, in comparison to individuals initially hospitalized for another reason, individuals initially hospitalized for COVID-19 present a lower risk of hospitalization for first episodes of psychotic symptoms/disorders or for psychotic relapse in the 12 months following discharge. This finding contradicts the hypothesis that there is a higher risk of psychotic disorders after a severe COVID-19.

Cardiovascular Disease in Saudi Arabia: Facts and the Way Forward

Cardiovascular diseases (CVDs) remain a major health concern globally. While some risk factors for CVDs are non-modifiable, other determinants like obesity, hypertension, type-2 diabetes and dyslipidemia can be mitigated by a wide plethora of measures to control CVD morbidity and mortality. Those determinants have been on the rise in Saudi Arabia, exacerbated by sedentary lifestyle. The Saudi Vision 2030 aims to reduce CVD clinical and economic burden and to scale up vitality and longevity; in a new era of comprehensive healthcare. From a health economics standpoint, CVDs entail a burden on healthcare systems directly through expenditure and indirectly through years living with the disease, low productivity, premature morbidity and mortality. This manuscript reviews current CV health and unmet needs in Saudi Arabia, discusses G20 countries' initiatives on primary prevention: public health measures, awareness programs; and proposes national registries and digital solutions to facilitate population-specific research, improve CV surveillance and alleviate CVD burden in Saudi Arabia.

Severe SARS-CoV-2 infection as a marker of undiagnosed cancer: a population-based study

No study has yet investigated if a severe SARS-CoV-2 infection represents a marker of an undiagnosed cancer. This population-based study, using the SNDS database, identified from 02/15/2020 to 08/31/2021, 41,302 individuals hospitalized in intensive care unit due to SARS-CoV-2 (ICU-gr) and 713,670 control individuals not hospitalized for SARS-CoV-2 (C-gr). Individuals were matched according to year of birth, sex and French department. The cancer incidence was compared in the two groups during the follow-up period (index date-12/31/2021), using Cox proportional hazards models adjusted on matching variables, socioeconomic characteristics and comorbidities. In the ICU-gr, 2.2% (n = 897) was diagnosed with a cancer in the following months, compared to 1.5% (n = 10,944) in the C-gr. The ICU-gr had a 1.31 higher risk of being diagnosed with a cancer following hospital discharge compared to the C-gr (aHR 1.31, 95% CI 1.22-1.41). A global similar trend was found when competing risk of death was taken into account (aHR 1.25, 95% CI 1.16-1.34). A significant higher risk was found concerning renal (aHR 3.16, 95% CI 2.33-4.27), hematological (aHR 2.54, 95% CI 2.07-3.12), colon (aHR 1.72, 95% CI 1.34-2.21), and lung (aHR 1.70, 95% CI 1.39-2.08) cancers. This suggests that a severe SARS-CoV-2 infection may represent a marker of an undiagnosed cancer.

Potentially inappropriate medications in nursing homes and the community older adults using the French health insurance databases

PURPOSE

Potentially inappropriate medications (PIMs) have become a major issue in improving prescribing practices and reducing the risk of adverse drug events in older people. However, very few studies have compared exposition to PIMs controlling for differences in demographic and health between nursing home residents (NHRs) and community-dwelling older adults (CDOAs). This study aimed to assess the prescribing pattern of PIMs between NHRs and CDOAs.

METHODS

We conducted a cross-sectional study over three months in 2019 using the French Health Insurance databases. The study population included 274 971 NHRs and 4 893 721 CDOAs aged 75 years or over. The prevalence ratio (PR) between NHRs and CDOAs of 17 PIM indicators, based on the Beers and STOPP criteria lists, was assessed using multivariable robust Poisson regression adjusted for age, sex, diseases, and polypharmacy.

RESULTS

During the study period, 54% of NHRs and 29% of CDOAs received at least one PIM. After adjustment, the prevalence of PIMs was 33% higher among NHRs compared to CDOAs (aPR = 1.33; 95% CI [1.33-1.34]). NHRs received PIMs related to benzodiazepines (aPR = 1.43; 95% CI [1.42-1.43]), anticholinergic drugs (aPR = 1.29; 95% CI [1.27-1.31]), and at least three central nervous system-active drugs (aPR = 1.94; 95% CI [1.92-1.96]) more frequently. Prevalence of PIMs related to non-steroidal anti-inflammatory drugs (aPR = 0.50; 95% CI [0.48-0.52]) and long-acting benzodiazepines (aPR = 0.84; 95% CI [0.82-0.85]) was lower among NHRs.

CONCLUSION

The NHRs were at greater risk for PIM than CDOAs, although differences exist according to the category of PIMs. As the population is aging, it is essential to promote and evaluate interventions in NHs and the community to enhance medication optimization.

Suicidal risk associated with finasteride versus dutasteride among men treated for benign prostatic hyperplasia: nationwide cohort study

Finasteride, a 5α-reductase inhibitor used in benign prostatic hyperplasia and androgenetic alopecia, has been associated with an increased suicidal risk, whereas it is unclear whether such risk is similar to that for another 5α-reductase inhibitor, dutasteride. We aimed to assess the risk of suicidal behaviours with finasteride relative to dutasteride. A nationwide cohort study was conducted using the French National Health Data System (SNDS). Men aged 50 years or older initiating finasteride 5 mg or dutasteride 0.5 mg in France between 01-01-2012 and 30-06-2016 were included and followed until outcome (suicide death identified from death certificate or self-harm hospitalisation), treatment discontinuation or switch, death, or 31-12-2016. Self-harm by violent means or resulting in admission to an intensive care unit were also examined. Cox proportional hazards models controlled for age and psychiatric and non-psychiatric conditions by inverse probability of treatment weighting (IPTW). Analyses were stratified according to psychiatric history. The study compared 69,786 finasteride new users to 217,577 dutasteride new users (median age: 72.0 years [Q1-Q3 = 64.5-80.2] vs. 71.1 [Q1-Q3 = 65.0-79.2]). During follow-up, 18 suicide deaths (0.57/1000 person-years) and 34 self-harm hospitalisations (1.08/1000) occurred among finasteride users versus 47 deaths (0.43/1000) and 87 hospitalisations (0.79/1000) among dutasteride users. Overall, finasteride was not associated with an increased risk of any suicidal outcome (IPTW-adjusted Hazard Ratio = 1.21 [95% Confidence Interval  .87-1.67]), suicide death or self-harm hospitalisation. However, among individuals with a history of mood disorders, finasteride was associated with an increased risk of any suicidal outcome (25 versus 46 events; HR = 1.64 [95% CI 1.00-2.68]), suicide death (8 versus 10 events; HR = 2.71 [95% CI 1.07-6.91]), self-harm by violent means (6 versus 6 events; HR = 3.11 [95% CI 1.01-9.61]), and self-harm with admission to an intensive care unit (7 versus 5 events; HR = 3.97 [95% CI 1.26-12.5]). None of these risks was significantly increased among individuals without a psychiatric history. These findings do not support an increased risk of suicide with finasteride used in the treatment of benign prostatic hyperplasia. However, an increased risk cannot be excluded among men with a history of mood disorder, but this result based on a limited number of events should be interpreted with caution.

An Empirical Study on the Use of Digital Technologies to Achieve Cost-Effectiveness in Healthcare Management

Objectives: Healthcare cost reduction is one of the major challenges of the current era. This study was based on the general system theory-based view to assess the significance of sensing communication technologies and processing actuation technologies in improving healthcare quality, leading to cost reduction. Moreover, the contingent rule of healthcare supply chain management in enhancing the influence of improved quality on healthcare cost reduction was also empirically tested. Methods: The sample of the study comprised 337 middle and senior healthcare managers employed in various government and private hospitals and health institutions in Jakarta, Indonesia. The administrative departments of each hospital and health institution was visited to take their consent to conduct this survey at their clinical and non-clinical departments. The data collected was analyzed using SmartPLS ver. 4 software. Results: Results reveal a significant direct and indirect influence of sensing communication technologies and processing actuation technologies on achieving cost-effectiveness in the healthcare sector, in the presence of perceived quality improvement as a mediator. However, the strength of the associations varied and was based on highly reliable and familiar nature of sensing communication technologies compared to processing actuation technologies which were emerging and gaining popularity in recent years. Conclusion: Considering the healthcare cost as a critical factor based on limited resources in emerging economies, healthcare institutions/centers should use digital technologies to achieve cost-effectiveness for providing healthcare facilities in the industry 4.0 era.

Does Measles, Mumps, and Rubella (MMR) Vaccination Protect against COVID-19 Outcomes: A Nationwide Cohort Study

Cross-protection from previous live attenuated vaccines is proposed to explain the low impact of COVID-19 on children. This study aimed to evaluate the effect of live attenuated MMR vaccines on the risk of being hospitalized for COVID-19 in children. An exposed (MMR vaccine)-non-exposed cohort study was conducted using the nationwide French National Health Data System (SNDS). We included children born between 1 January 2009 and 31 December 2019. Exposure was defined as a claim of at least one dose of MMR vaccine since birth. Hospitalization for COVID-19 was defined using main diagnostic ICD10 codes. Non-conditional logistic regression was used to calculate the adjusted odds ratios (aORs) of the association between MMR exposure and hospitalization for COVID-19, controlling for socio-demographic and socio-economic factors, co-morbidities, and general health. In total, 6,800,542 (median age 6 IQR [3-8] years) children exposed to a MMR vaccine and 384,162 (6 [3-9] years) not exposed were followed up with for 18 months. Among them, 873 exposed to the MMR vaccine and 38 who were not exposed were hospitalized for COVID-19. In a multi-variate analysis, the exposure of children to MMR vaccination was not associated with a decreased risk of COVID-19 hospitalization versus non-exposure (aOR (95%CI) = 1.09 [0.81-1.48]). A stratified analysis by age showed an aOR = 1.03 [0.64-1.66] for children aged 1-4, an aOR = 1.38 [0.82-2.31] for those aged 5-9, and an aOR = 1.11 [0.54-2.29] for those aged 10-12. Our study suggests that the live attenuated MMR vaccine does not protect children against COVID-19 hospitalization.

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.

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.

Hospitalization for COVID-19 is associated with a higher risk of subsequent hospitalization for psychiatric disorders: A French nationwide longitudinal study comparing hospitalizations for COVID-19 and for other reasons

Introduction

Although COVID-19 has been associated with psychiatric symptoms in patients, no study to date has examined the risk of hospitalization for psychiatric disorders after hospitalization for this disease.

Objective

We aimed to compare the proportions of hospitalizations for psychiatric disorders in the 12 months following either hospitalization for COVID-19 or hospitalization for another reason in the adult general population in France during the first wave of the current pandemic.

Methods

We conducted a retrospective longitudinal nationwide study based on the national French administrative healthcare database.

Results

Among the 2,894,088 adults hospitalized, 96,313 (3.32%) were admitted for COVID-19. The proportion of patients subsequently hospitalized for a psychiatric disorder was higher for COVID-19 patients (11.09 vs. 9.24%, OR = 1.20 95%CI 1.18–1.23). Multivariable analyses provided similar results for a psychiatric disorder of any type and for psychotic and anxiety disorders (respectively, aOR = 1.06 95%CI 1.04–1.09, aOR = 1.09 95%CI 1.02–1.17, and aOR = 1.11 95%CI 1.08–1.14). Initial hospitalization for COVID-19 in intensive care units and psychiatric history were associated with a greater risk of subsequent hospitalization for any psychiatric disorder than initial hospitalization for another reason.

Discussion

Compared with hospitalizations for other reasons, hospitalizations for COVID-19 during the first wave of the pandemic in France were associated with a higher risk of hospitalization for a psychiatric disorder during the 12 months following initial discharge. This finding should encourage clinicians to increase the monitoring and assessment of psychiatric symptoms after hospital discharge for COVID-19, and to propose post-hospital care, especially for those treated in intensive care.