Évolution de la prescription des examens de biologie après la diffusion de recommandations médicales sur les dyslipidémies

BACKGROUND

Guidelines for screening and treatment of dyslipidemia were disseminated in September and October 2000 by the National Agency of Accreditation and of Evaluation in Health (ANAES) and the French Agency of Medical Safety of the Products of Health (AFSSAPS). It was confirmed that the specific biological test was the measurement of LDL Cholestérol.

OBJECTIVE

To study changes in biological test practices after diffusion of guidelines among patients on statin therapy, using Health Insurance database on reimbursement of patients living in Ile-de-France region (8,534,623 social insurance contributors).

METHODS

Two groups of patients were defined in the database from the codes for medication refunds during one month (March 2000 and March 2002). The first group named "new users" included patients starting statin therapy in March, in order to follow the biological test for screening. The second group named "long term users" included patients who had been treated by statin therapy for one year or more, in order to examine the biological follow-up of treatment. All lipid biological tests were recorded during one year, before March 2000 and March 2002. Changes in medical practices were noted as the percentage of the biological tests for "exploration of a lipidic anomaly" (EAL) with determination of LDL cholesterol.

RESULTS

For new users the percentage of patients having had at least one EAL for screening purposes increased by 13.5 (39.9% in 2000 and 53.4% en 2002). For long term users the change was + 21.1 (38.3% in 2000 and 59.4% in 2002) during follow-up.

CONCLUSION

An improvement in biological testing practices was noted after diffusion of guidelines.

Antithrombotic therapy is associated with better survival in patients with severe heart failure and left ventricular systolic dysfunction (EPICAL study)

BACKGROUND

In patients with congestive heart failure (CHF), clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality. Nevertheless so far, there is no published controlled study of long-term antithrombotic therapy in patients with CHF. The aim of this work was to identify the relationship between cardiovascular drug use, especially antithrombotic therapy, and survival of CHF patients in current clinical practice, using an observational, population-based database.

METHODS

The EPICAL study (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) has identified prospectively all patients with severe CHF in the community of Lorraine. Inclusion criteria were age 20-80 years in 1994, at least one hospitalisation for cardiac decompensation, NYHA III/IV HF, ventricular ejection fraction < or =30% or cardiothoracic index > or =60% and arterial hypotension or peripheral and/or pulmonary oedema. A total of 417 consecutive patients surviving at hospital discharge were included in the database. The average follow-up period was 5 years. Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival. Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors.

RESULTS

Duration of disease >1 year, renal failure, serum sodium > or =138 mmol/l, old age, serious comorbidity, previous decompensation, high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years. Oral anticoagulants, aspirin, lipid lowering drugs and beta-blockers use were associated with better survival. There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival.

CONCLUSION

Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF. These results together with other previously published circumstantial evidence urge for a prospective, controlled and randomised trial specifically designed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure.

[Application of medical guidelines for the prescription of statins]

BACKGROUND

The efficacy of statins to prevent coronary heart disease (CHD) is well documented. This class of lipid-lowering drugs is now widely prescribed and was demonstrated to be cost effective in high risk patients.

OBJECTIVE

To assess the appropriateness of statins use, regarding initiation and follow-up of the treatment, as compared to the guidelines elaborated in 1996 by National Agency for the Development of Medical Evaluation (ANDEM). These guidelines were based on stratification of patients according to cardiovascular risk.

METHODS

Two groups of patients living in Ile-de-France region were defined, using Health Insurance computer database, on reimbursements. The first group named "new users" included patients in whom statin therapy was initiated during March 2000. The second group named "long term users" included patients who have been treated by statin therapy for one year or more. A sample of patients were randomly selected among these two groups. Trained Health Insurance advisors analyzed in depth the patients medical history and diet. All biological results were recorded and a complete history of medical therapy was assessed for each patient. An algorithm allowed the advisor to rate for nonadherence according to French medical guidelines.

RESULTS

"New users": the random sample consisted of 460 patients, among whom 398 (87%) were free of CHD in whom the nonadherence rate was 72.4% (68.0% to 76.8%). Nonadherence concerned: LDL cholesterol level not tested (32%) and/or absence of prior fat-free diet (37%) and/or LDL cholesterol value before drug therapy was below the guidelines/threshold. "Long term users": the random sample consisted of 582 patients, among whom 381 (65%) were free of CHD. The nonadherence rate was 71.1% (66.5% to 75.7%). In addition, the nonadherence rate for patients in secondary prevention was 82.1% (79.7% to 84.6%) respectively, corresponding to: LDL cholesterol level not tested (41% and 34%); and/or no change dietary (18% and 12%); and/or unreach the LDL-C target level (24% and 45%).

CONCLUSION

This study shows that the implementation of guidelines needs to be improved in clinical practice.

[Secondary prevention of myocardial infarction in the Ile de France]

This enquiry was carried out to evaluate the measures of secondary prevention at 6 months and over of myocardial infarction in the ile de France region with respect to the recommendations of scientific societies and results of large scale therapeutic trials. A questionnaire was completed for the 1,215 patients selected from data obtained from the hospital discharge summary, interrogation and examination of the patient, and a telephone conversation with the attending physician. The data covered cardiovascular risk factors, the main clinical parameters, the results of biological tests and investigations carried out for risk stratification, plus different elements of therapeutic management. Compared with previous studies of the same type, this enquiry showed a favourable tendency towards the prescription of antithrombotic drugs and betablockers (98.3% and 82.4% of patients, respectively), and to patients with reputedly normal blood pressure values (84.7%). A positive result concerning the reduction in the number of smokers (17.4%) and the increase in lipid lowering prescriptions should be tempered by the fact that advice about stopping smoking was rarely given and that the quantitative target of LDL cholesterol was often ignored. Finally, the prescriptions of ACE inhibitors, physical exercise and cardiac rehabilitation remained well below the recommendations or recent scientific data.

[Description of type 2 diabetes mellitus in residents of Ile-de-France aged at most 70 years]

Our study of patients with type 2 diabetes mellitus residing in the Paris area (Ile-de-France) aged 70 years or younger included 1 591 patients examined by national health insurance expert physicians who also filled out a self-administrated questionnaire. Their primary care physicians also answered a questionnaire (79% participation, indicating their personal implication). We found that diabetes was most often discovered during regular check-ups. Single-drug regimens were the most widely used. Sulfamides were prescribed for 77% of the patients. Among the 912 patients who were overweight (BMI > 28 Kg/m2), 34.3% were taking sulfamides alone despite the fact that metformin is recommended as the first intention drug for these patients. Blood pressure control was not satisfactory in 30% of the patients who were treated or not for high blood pressure. This proportion rose to about 50% among treated patients alone. The patients appeared to be knowledgeable about the risk of complications, particularly ocular complications. They were aware of a certain number of messages but the results would suggest difficulty in application.