Cancer incidence and prevalence in cystic fibrosis patients with and without a lung transplant in France

Background

Cystic fibrosis (CF) care and the life expectancy of affected patients have substantially improved in recent decades, leading to an increased number of patients being diagnosed with comorbidities, including cancers. Our objective was to characterize the epidemiology of cancers between 2006 and 2017 in CF patients with and without a lung transplant.

Methods

Medical records of CF patients from 2006 to 2016 in the French CF Registry were linked to their corresponding claims data (SNDS). The annual prevalence and incidence rates of cancers were estimated from 2006 to 2017 in CF patients without lung transplant and in those with lung transplant after transplantation.

Results

Of the 7,671 patients included in the French CF Registry, 6,187 patients (80.7%) were linked to the SNDS; among them, 1,006 (16.3%) received a lung transplant. The prevalence of any cancer increased between 2006 and 2017, from 0.3 to 1.0% and from 1.3 to 6.3% in non-transplanted and transplanted patients, respectively. When compared to the general population, the incidence of cancer was significantly higher in both non-transplanted [Standardized Incidence Ratio (SIR) = 2.57, 95%CI 2.05 to 3.17] and transplanted (SIR = 19.76, 95%CI 16.45 to 23.55) patients. The median time between transplant and the first cancer was 3.9 years. Among the 211 incident cancer cases, the most frequent malignant neoplasms were skin neoplasm (48 cases), lung cancers (31 cases), gastro-intestinal (24 cases), and hematologic cancers (17 cases).

Conclusion

The overall burden of cancer in CF patients is high, particularly following lung transplantation. Therefore, specific follow-up, screening and cancer prevention for CF patients with transplants are necessary.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Differences in severe exacerbations rates and healthcare utilisation in COPD populations in the UK and France

Introduction

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality in Europe; however, it is important to understand how clinical practice patterns differ between countries and how this might relate to disease outcomes, to identify ways of improving local disease management. We aimed to describe and compare the management of patients with COPD in the UK and France between 2008 and 2017.

Methods

We used data from the Clinical Practice Research Datalink GOLD and Hospital Episode Statistics in the UK and the Echantillon Généraliste des Bénéficiaire in France to identify patients with COPD each year between 2008 and 2017. We compared patient characteristics, all-cause mortality and COPD exacerbations each year between 2008 and 2017 for patients in the UK and France separately. Health care utilisation and COPD exacerbations in 2017 were compared between France and the UK using t-tests and χ² tests.

Results

Patients with COPD were similar in gender and comorbidities in both countries. Incidence of COPD exacerbations remained stable in the UK and France between 2007 and 2017. In 2017, the proportion of all-cause and COPD-related hospitalisations was greater in the UK than in France (43.9% vs 32.8% and 8.3% vs 4.9%, respectively; p<0.001) as was the proportion of patients visiting accident and emergency (A&E) (39.8% vs 16.2%, respectively; p<0.001). In addition, the mean length of stay in hospital for COPD-related causes was shorter in the UK than in France (6.2 days (SD 8.4) vs 10.5 days (SD 9.1), respectively; p<0.001).

Discussion

Overall, UK patients were more likely to go to A&E, be hospitalised for COPD-related causes and stay in hospital for fewer days after being admitted for COPD-related reasons compared with patients in France, illustrating a difference in health-seeking behaviours and access to healthcare.

Mortality and Respiratory-Related Hospitalizations in Idiopathic Pulmonary Fibrosis Not Treated With Antifibrotics

Background: Real-world data regarding outcomes of idiopathic pulmonary fibrosis (IPF) are scarce, outside of registries. The claims data from the French National Health System (SNDS) were used to describe outcomes in patients diagnosed with IPF in 2015–2016 but who did not receive antifibrotic therapies.

Method: Patients aged <50 years were excluded, as were patients with pulmonary fibrosis other than IPF, patients who had previously received a lung transplant, and those who had received antifibrotic therapies at any time between 2010 and 2016. Patients were followed-up until their last health record, lung transplantation, initiation of antifibrotic therapies, death, or the end of the study period (31 December 2017), whichever occurred first.

Results: A total of 5,360 patients (43.2%) not treated with antifibrotic therapies were included. The mean age was 75.5 years, and 57.9% were males. In the year before inclusion, 47.3% of patients had a Charlson score ≥5. During follow-up, 41.2% of patients died. The unadjusted incidence rate was 29.9 per 100 person-years (95%CI = [28.7–31.2]), and the cumulative incidence of death at 3 years was 50.2% (95% CI = [48.3–52.1%]). In the study population, 35.3% of patients experienced an acute respiratory-related hospitalization. The unadjusted incidence rate was 32.1 per 100 person-years (95%CI = [30.6–33.5]) and the cumulative incidence of the event at 3 years was 41.5% (95% CI = [39.7–43.2%]).

Interpretation: This observational study showed that, if untreated with antifibrotics, IPF is associated with a 50% all-cause mortality at 3 years. These figures can serve as a historical control of the natural course of the disease.

Antipsychotic prescribing practices in real-life (APPREAL study): Findings from the French National Healthcare System Database (2007-2017)

BACKGROUND

Antipsychotics are used in a large variety of psychiatric and neurological disorders; investigating their use in real life is important to understand national prescribing practices, as well as to determine the levels of patient adherence.

METHODS

Using a 1/97e random sample (General Sample of Beneficiaries, EGB) of the French health insurance reimbursement database, we conducted a historical cohort study on the 2007-2017 period. The aim was to describe the sociodemographic characteristics of patients, the types of antipsychotics dispensed, the types of prescribers, the mean doses and average durations of treatment, the co-dispensed medications, and the levels of adherence to treatment. To exclude punctual uses of antipsychotics, we selected only patients with a continuous dispensing of the same antipsychotic over at least 3 months.

RESULTS

In total, 13,799 subjects (1.66% of the EGB sample) were included (56.0% females; mean age 55.8 ± 19.4 years). Risperidone (19.3%), cyamemazine (18.7%), olanzapine (11.9%), tiapride (8.8%), and haloperidol (7.5%) were the five most prescribed antipsychotics. 44.9% of prescriptions were written by general practitioners, 34.1% by hospital practitioners, and 18.4% by private-practice psychiatrists. On average, the mean dispensed doses were relatively low, but the variation range was large. Long-acting forms were used in 5.4% of the sample, and clozapine in 1.3%. 34.2% of patients received more than one antipsychotic, and almost 15% were prescribed at least three concomitant antipsychotics. Paliperidone and clozapine were associated with the highest levels of adherence, and risperidone and haloperidol with the lowest ones.

CONCLUSION

An important heterogeneity of antipsychotic prescribing practices was observed in France. The rate of use of long-acting antipsychotics was low, whereas multiple antipsychotic prescriptions were frequent.

Human papillomavirus (HPV) vaccine coverage rates (VCRs) in France: A French claims data study

BACKGROUND

The French Cancer Plan 2014-2019 had a target of 60% HPV vaccine coverage. The PAPILLON study investigated the annual age-specific vaccination initiation rates and cumulative partial and complete vaccination rates in France from 2017 to 2022. It also identified the factors associated with vaccination in different age groups and those associated with the type of completion of the vaccination scheme (partial vs full vaccination).

METHODS

For this publication, all females recorded in the French National Claims database who initiated HPV vaccination between 1 July 2007 and 31 December 2018 and were aged between 11 and 19 years at initiation were included. Annual HPV vaccination initiation rates were estimated in 11- to 14-year-old (target population) and 15- to 19-year-old females (catch-up). Cumulative vaccine coverage rates (VCRs) were estimated among those who were 15, 16, 20 and 21 years old. Partial vaccination was defined by dispensing of at least one dose of HPV vaccine by the pharmacy, while full vaccination was defined by two or three doses dispensed by a pharmacy over an 18-month period, according to current French recommendations based on the age at vaccination initiation.

RESULTS

Among the 465,629 females who initiated HPV vaccination in 2017 or 2018, the initiation rate increased from 7.7 to 11.1% in 11- to 14-year-old girls and from 4.5 to 6.5% in 15- to 19-year-old females. In 2017 and 2018, the cumulative VCRs for partial vaccination by age 15 were 28.2% and 32.8%, respectively, while by age 20, they were 41.6% and 38.8%. The cumulative VCRs for full vaccination were 15.6% and 18.6% by age 16, while they were 25.9 and 23.6% by age 20. HPV vaccination initiation and completion were strongly associated with the use of health services.

CONCLUSION

Overall, the HPV VCR substantively increased between 2017 and 2018, which is positive evidence of the resumption of vaccination. Updates in 2022 should confirm these results.

Comparative outcomes in patients receiving pirfenidone or nintedanib for idiopathic pulmonary fibrosis

Background

Real-world data regarding outcomes of idiopathic pulmonary fibrosis (IPF) are scarce, outside of registries. In France, pirfenidone and nintedanib are only reimbursed for documented IPF, with similar reimbursement criteria with respect to disease characteristics, prescription through a dedicated form, and IPF diagnosis established in multidisciplinary discussion.

Research question

The data of the comprehensive French National Health System were used to evaluate outcomes in patients newly treated with pirfenidone or nintedanib in 2015–2016.

Study design and methods

Patients aged < 50 years or who had pulmonary fibrosis secondary to an identified cause were excluded. All-cause mortality, acute respiratory-related hospitalisations and treatment discontinuations up to 31 December 2017 were compared using a Cox proportional hazards model adjusted for age, sex, year of treatment initiation, time to treatment initiation and proxies of disease severity identified during a pre-treatment period.

Results

During the study period, a treatment with pirfenidone or nintedanib was newly initiated in 804 and 509 patients, respectively. No difference was found between groups for age, sex, time to treatment initiation, Charlson comorbidity score, and number of hospitalisations or medical contacts prior to treatment initiation. As compared to pirfenidone, nintedanib was associated with a greater risk of all-cause mortality (hazard ratio [HR], 1.8; 95% confidence interval [CI] 1.3–2.6), a greater risk of acute respiratory-related hospitalisations (HR 1.3; 95% CI 1.0–1.7) and a lower risk of treatment discontinuation at 12 months (HR 0.7; 95% CI 0.6–0.9).

Interpretation

This observational study identified potential differences in outcome under newly prescribed antifibrotic drugs, deserving further explorations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01714-y.

Naxos study: risk of bleeding with oral anticoagulants in non-valvular atrial fibrillation patients in France

Background

In patients with non-valvular atrial fibrillation (NVAF), oral anticoagulants reduce the risk of stroke and systemic embolism, at the expense of an increased risk of bleeding.

Purpose

To compare the risk of bleeding and sites of bleeding according to the type of oral anticoagulant used in NVAF patients.

Methods

NAXOS is a population-based, historical cohort study including all patients aged ≥18 years with NVAF and newly initiating one of the OACs available in France between 2014 and 2016, aiming to compare safety, effectiveness, and all-cause mortality, according to the type of oral anticoagulant used. The French national health insurance reimbursement database, cross-linked with the hospitalisation database and civil status registry (SNIIRAM) was used to identify first users of oral anticoagulants and outcomes over their follow-up.

Major bleeding events were identified through main diagnoses of hospital stays, with a specific focus on bleeding site. Apixaban was used as the reference treatment.

Analyses were performed on crude data and with adjustment on propensity scores calculated separately for each of the comparators (VKAs, rivaroxaban and dabigatran).

Results

Overall, 321,501 NVAF patients were included: 87,565 (27.2%), 112,628 (35.0%), 100,063 (31.1%), and 21,245 (6.6%) initiated apixaban, VKAs, rivaroxaban, and dabigatran, respectively. The crude risks of intracranial bleeding were 0.45 [0.40–0.50], 1.23 [1.16–1.30], 0.48 [0.44–0.53], and 0.26 [0.19–0.34] per 100 patient-year, for apixaban, VKA, rivaroxaban, and dabigatran, respectively. The respective figures for gastro-intestinal bleeding were: 0.67 [0.61–0.74], 1.73 [1.64–1.81], 1.01 [0.94–1.08], 1.02 [0.89–1.17]; and those for non-intracranial and non-gastro-intestinal but other bleeding were: 0.84 [0.78–0.92], 2.22 [2.13–2.32], 1.24 [1.17–1.31] and 0.71 [0.60–0.84].

After adjustment on propensity-scores, patients initiating apixaban were at a lower risk of all major bleeding vs. VKA, rivaroxaban and dabigatran (HR=0.49 [0.46–0.52], 0.63 [0.58–0.67]) and 0.85 [0.76–0.95]). Apixaban was associated with a decreased risk of intracranial bleeding compared with VKAs (HR=0.46 [0.40–0.53]) and rivaroxaban (HR=0.80 [0.69–0.93]), and an increased risk compared with dabigatran (HR=1.53 [1.12–2.07]). The risk of gastro-intestinal bleeding was lower with apixaban than with VKAs (HR=0.57; [0.55–0.59]), rivaroxaban (HR=0.59; [0.52–0.66]), and dabigatran (HR=0.57; 0.48–0.68]). For other bleedings, apixaban was associated with a lower risk compared with VKAs (HR=0.47; [0.43–0.52]), and rivaroxaban (HR=0.59; [0.53–0.66]), and with a similar risk compared with dabigatran (HR=1.01; [0.84–1.23]).

Conclusion

In this large, real-world, population-based cohort, apixaban was associated with a lower risk of all types of bleedings requiring hospitalisation, compared with vitamin K antagonists. Differences between direct oral anticoagulants were also observed.

Results of the comparative analyses

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Bristol-Myers Squibb, Pfizer

Comparative Safety and Effectiveness of Oral Anticoagulants in Nonvalvular Atrial Fibrillation: The NAXOS Study

Supplemental Digital Content is available in the text.

Background and Purpose:

The effects of direct oral anticoagulants in nonvalvular atrial fibrillation should be assessed in actual conditions of use. France has near-universal healthcare coverage with a unified healthcare information system, allowing large population-based analyses. NAXOS (Evaluation of Apixaban in Stroke and Systemic Embolism Prevention in Patients With Nonvalvular Atrial Fibrillation) aimed to compare the safety, effectiveness, and mortality of apixaban with vitamin K antagonists (VKAs), rivaroxaban, and dabigatran, in oral anticoagulant-naive patients with nonvalvular atrial fibrillation.

Methods:

This was an observational study using French National Health System claims data and including all adults with nonvalvular atrial fibrillation who initiated oral anticoagulant between 2014 and 2016. Outcomes of interest were major bleeding events leading to hospitalization (safety), stroke and systemic thromboembolic events (effectiveness), and all-cause mortality. Four approaches were used for comparative analyses: matching on propensity score (PS; 1:n); as a sensitivity analysis, matching on high-dimensional PS; adjustment on PS; and adjustment on known confounders. For each outcome, cumulative incidence rates accounting for competing risks of death were estimated.

Results:

Overall, 321 501 patients were analyzed, of whom 35.0%, 27.2%, 31.1%, and 6.6% initiated VKAs, apixaban, rivaroxaban, and dabigatran, respectively. Apixaban was associated with a lower PS–matched risk of major bleeding compared with VKAs (hazard ratio [HR], 0.43 [95% CI, 0.40–0.46]) and rivaroxaban (HR, 0.67 [95% CI, 0.63–0.72]), but not dabigatran (HR, 0.93 [95% CI, 0.81–1.08]). Apixaban was associated with a lower risk of stroke and systemic thromboembolic event compared with VKAs (HR, 0.60 [95% CI, 0.56–0.65]), but not rivaroxaban (HR, 1.05 [95% CI, 0.97–1.15]) or dabigatran (HR, 0.93 [95% CI, 0.78–1.11]). All-cause mortality was lower with apixaban than with VKAs, but not lower than with rivaroxaban or dabigatran.

Conclusions:

Apixaban was associated with superior safety, effectiveness, and lower mortality than VKAs; with superior safety than rivaroxaban and similar safety to dabigatran; and with similar effectiveness when compared with rivaroxaban or dabigatran. These observational data suggest potentially important differences in outcomes between direct oral anticoagulants, which should be explored in randomized trials.

Impact of Therapy Persistence on Exacerbations and Resource Use in Patients Who Initiated COPD Therapy

Purpose

This study assessed therapy persistence in patients with chronic obstructive pulmonary disease (COPD) in France, and the impact of non-persistence on exacerbations and described COPD-related healthcare resource use (HRU).

Methods

Patients aged ≥45 years who received ≥1 dispensed bronchodilator per quarter over three consecutive quarters between 2007 and 2014 and initiated specific COPD therapy were selected from the Echantillon Généraliste des Bénéficiaires (EGB) database. Persistence, defined as the absence of dispensing gaps of >90 days, was measured at 12 months. Exacerbations were compared between persistent and non-persistent patients during follow-up after patient matching and adjustment for confounding factors. COPD-related HRU during follow-up was described.

Results

Among 4020 patients with COPD, 2164 initiated a specific therapy. Of these, 54.4% stopped treatment within 12 months. Persistence with all COPD therapy regimens was low, particularly for inhaled corticosteroid (ICS; 25.6%) and ICS/twice-daily long-acting beta-agonist (39.4%) regimens. Among 721 persistent patients who were matched with 721 non-persistent patients, there was no difference in the number of moderate or severe exacerbations at 12 months. However, medical procedures (for instance, pulmonary function testing and chest X-rays) were more frequently observed among persistent patients than among non-persistent patients, suggesting worse disease severity.

Conclusion

Patients receiving specific treatment(s) for COPD demonstrated low persistence for all examined therapy regimens, with no clear impact of persistence status on the frequency of exacerbations at 12 months.

P1255Comparative safety and effectiveness of standard doses of apixaban versus dabigatran, rivaroxaban, and VKAs in non-valvular atrial fibrillation patients in France: the NAXOS study

Background

Real-world data comparing all available oral anticoagulants (OAC) on a nationwide scale (i.e. in France: apixaban, rivaroxaban, dabigatran and vitamin K antagonists – VKAs) are lacking. In everyday practice, oral anticoagulants are often underdosed, which may render comparisons between agents difficult.

Purpose and methods

NAXOS is a French real-world study comparing the safety (major bleeding), effectiveness (stroke, systemic thromboembolic events (STE)) and all-cause mortality for apixaban, dabigatran, rivaroxaban, and VKAs, in adult patients with non-valvular atrial fibrillation (NVAF) initiating a given OAC between 2014 and 2016. The French national health insurance data (SNIIRAM) were used. Analyses were performed with adjustment on propensity scores. To avoid bias potentially related to underdosing, the present analysis included only patients receiving standard doses of apixaban (5mg bid), rivaroxaban (20mg od), and dabigatran (150 mg bid), or VKAs. Only OAC naïve patients were included.

Results

In the OAC-naive cohorts treated with apixaban, rivaroxaban, and dabigatran, 54,575 (62.3%), 65,208 (65.2%), and 9,000 (42.4%), respectively, had the standard dose at the index dispensation, and 112,628 patients received VKAs. After adjustment on propensity scores, apixaban 5 mg was associated with a lower risk of major bleeding, compared to VKAs (Hazard Ratio: 0.47; 95% CI: 0.43–0.51) and rivaroxaban 20mg (HR: 0.64; 0.59–0.71), but not to dabigatran 150 mg (HR: 0.97; 0.79–1.18). Apixaban was associated with a lower risk of stroke and STE, compared to VKAs (HR: 0.62; 0.56–0.69) but not to rivaroxaban (HR: 1.03; 0.92–1.16), and dabigatran (HR: 0.96; 0.76–1.21). Apixaban showed a lower risk of all-cause mortality compared to VKAs (HR: 0.44; 0.41–0.47) and rivaroxaban (HR: 0.87; 0.81–0.94) but not to dabigatran (HR: 1.10; 0.92–1.32).

Figure 1. Forest plot presenting the results of the standard dose analysis (PS adjusted).

Conclusions

The NAXOS population-based country-wide observational study shows that 42% to 65% of patients were treated with standard doses of OACs. Analyses of standard doses confirmed the superiority of apixaban compared with VKAs for the three studied outcomes and suggests better safety profile of apixaban compared to rivaroxaban but similar to dabigatran.

Acknowledgement/Funding

The Alliance Bristol-Myers Squibb/Pfizer

Dual versus triple therapy in patients hospitalized for COPD in France: a claims data study

Purposes

Following a hospitalization for COPD, dual and triple therapies were compared in terms of persistence and relations with outcomes (exacerbations, health care resource use and costs).

Methods

This was a historical observational database study. All patients aged ≥45 hospitalized for COPD between 2007 and 2015 were identified in a 1/97^th random sample of French claims data. Patients receiving dual therapy within 60 days after hospitalization were compared to patients receiving triple therapy, after propensity score matching on disease severity.

Results

Of the 3,089 patients hospitalized for COPD, 1,538 (49.8%) received either dual or triple therapy in the 2 months following inclusion, and 1,500 (48.6%) had at least 30 days of follow-up available; 846 (27.4%) received dual therapy, and 654 (21.2%) received triple therapy. After matching, the number of exacerbations was 2.4 per year in the dual vs 2.3 in the triple group (p=0.45). Among newly treated patients (n=206), persistence at 12 months was similar in the dual and triple groups (48% vs 41%, respectively, p=0.37). As compared to patients on dual therapy, more patients on triple therapy received oral corticosteroids (49.1 vs 40.4%, p=0.003) or were hospitalized for any reason (67% vs 55.8%, p=0.0001) or for COPD (35.3 vs 25.1%, p=0.0002) during follow-up. Cost of care was higher for patients on triple than for those on dual therapy (€11,877.1 vs €9,825.1, p=0.01).

Conclusion

Following hospitalizations for COPD, patients on dual and triple therapy experienced recurrent exacerbations, limited adherence to therapies and high cost of care. Patients on triple therapy appeared more severe than those on dual therapy, as reflected by exacerbations and health care resource use.