Recurrence of hypertensive disorders of pregnancy: results from a nationwide prospective cohort study (CONCEPTION)

OBJECTIVE

To assess the risk of gestational hypertension (GH) and pre-eclampsia (PE) during a second pregnancy after occurrence during a first pregnancy.

DESIGN

Prospective cohort study.

SETTING

CONCEPTION is a French nationwide cohort study that used data from the National Health Data System (SNDS) database.

METHODS

We included all women who gave birth for the first time in France in 2010-2018 and who subsequently gave birth. We identified GH and PE through hospital diagnoses and the dispensing of anti-hypertensive drugs. The incidence rate ratios (IRR) of all hypertensive disorder of pregnancy (HDP) during the second pregnancy were estimated using Poisson models adjusted for confounding.

MAIN OUTCOME MEASURES

Incidence rate ratios of HDP during the second pregnancy.

RESULTS

Of the 2 829 274 women included, 238 506 (8.4%) were diagnosed with HDP during their first pregnancy. In women with GH during their first pregnancy, 11.3% (IRR 4.5, 95% confidence interval [CI] 4.4-4.7) and 3.4% (IRR 5.0, 95% CI 4.8-5.3) developed GH and PE during their second pregnancy, respectively. In women with PE during their first pregnancy, 7.4% (IRR 2.6, 95% CI 2.5-2.7) and 14.7% (IRR 14.3, 95% CI 13.6-15.0) developed GH and PE during their second pregnancy, respectively. The more severe and earlier the PE during the first pregnancy, the stronger the likelihood of having PE during the second pregnancy. Maternal age, social deprivation, obesity, diabetes and chronic hypertension were all associated with PE recurrence.

CONCLUSION

These results can guide policymaking that focuses on improving counselling for women who wish to become pregnant more than once, by identifying those who would benefit more from tailored management of modifiable risk factors, and heightened surveillance during post-first pregnancies.

Les infarctus du myocarde pendant un an de pandémie de COVID-19 - Étude nationale française des taux d'hospitalisation, du pronostic et de la mortalité à 90 jours

Introduction

Au début de la pandémie de COVID-19, plusieurs études ont signalé une diminution des séjours hospitaliers hors COVID-19. L'objectif de cette étude était de décrire les tendances nationales des admissions pour infarctus du myocarde (IDM) à l'hôpital en 2020 et comparer les caractéristiques, le pronostic hospitalier et la mortalité à 90 jours des patients admis en 2020, à ceux des patients admis en 2017-19.

Méthodes

Tous les patients hospitalisés pour IDM en France entre 2017 et 2020 ont été inclus à partir du PMSI-MCO. Les analyses ont comparé les tendances temporelles d'admissions pour IDM, les taux de complications cardiaques hospitalières, la réadmission et la mortalité hospitalière et à 90 jours en 2020 versus 2017-19 ; puis ont été stratifiées par période d'admission, type d'IDM, sexe, âge et régions.

Résultats

En 2020, 94 747 patients ont été hospitalisés pour IDM, correspondant à une diminution de 6 % des admissions pour IDM par rapport à 2017-2019. Cette diminution était plus importante durant le premier confinement (-24 %, p<0,0001) que pendant le deuxième (-8 %, p<0,0001), et a atteint -40 % en semaine 13. Les diminutions d'hospitalisation pour IDM étaient plus élevées et ont persisté plus longtemps pour les NSTEMI, pour les personnes âgées et pour les femmes. Une augmentation des hospitalisations pour STEMI a été observée entre les confinements (+4 %, p=0,0005). Globalement et après ajustement sur l’âge, le sexe et l'effet temporel, les taux de mortalité hospitalière et dans les 90 jours qui suivaient la sortie d'hospitalisation ne différaient pas entre 2020 et 2017-2019 (IRRaj-hosp =1,03[0,98 ; 1,08], p=0,19 - IRRaj 90j-post-sortie=1,06[0,98 ; 1,13], p=0,14).

Discussion/Conclusion

En 2020, une diminution significative des hospitalisations pour IDM a été observée et était particulièrement importante au début de l'année. L'impact de la crise du COVID-19 sur les complications aiguës et le pronostic à trois mois des patients admis apparaît limité. Néanmoins, la surveillance des complications chroniques de l'IDM et de l'impact sur les personnes non hospitalisées devra être poursuivie.

Care management and 90-day mortality in patients hospitalized for myocardial infarction and COVID-19 in France

Background

Concomitant COVID-19 in patients with myocardial infarction (MI) may lead to difficulties in acute care management and may impair prognosis. To date, studies have involved a limited number of patients.

Purpose

To estimate and compare the characteristics, care management and 90-day outcomes of patients hospitalized for MI who didn’t have Covid-19, with those having concomitant hospital diagnosis of Covid-19 from the French National Health Data System, an exhaustive and nationwide database.

Methods

All patients hospitalised for MI in France between 30 December 2019 and 4 October 2020 were included. Patients with a previous hospitalization with Covid-19 were excluded (n = 135). Patients’ characteristics were compared according to Covid-19 status. 90-day mortality rates and follow-up outcomes were estimated and adjusted on age, sex and comorbidities.

Results

Among the 55,389 patients hospitalized for MI, 329 had concomitant Covid-19 (21% asymptomatic). MI patients with concomitant Covid-19 were more comorbid than patients without Covid-19. They had longer hospital stays, more admissions to resuscitation unit, underwent less percutaneous coronary intervention, and discharged more often to rehabilitation units than patients without Covid-19. The in-hospital and 90-day-out-of hospital mortality rates of MI patients with Covid-19 were 11.9% and 6.2%, respectively, compared to 3.5% and 2.8% in MI patients without Covid-19. The risk of in-hospital and out-of-hospital death remained increased after adjustment on comorbidities (OR_ajin-hosp = 3.31[2.32;4.72], OR_{ajout-of-hosp} = 1.79 [1.02;3.15]).

Conclusions

The prognosis of patients hospitalized for MI who had concomitant Covid-19 was impaired in the short term but also in the medium term. These results underline the need of an urgent protection of the population at cardiovascular risk from Covid-19, as well as a systematized and rapid management despite the pandemic context, and then a close follow-up of these patients.

One year of Covid-19: French nationwide study of hospitalisation, 90-day readmission and mortality rates from myocardial infarction

Background

Studies reported a decrease in hospital admissions for myocardial infarction (MI) in early 2020 due to Covid19 crisis, but these were restricted to the early weeks of the pandemic.

Purpose

To describe patient characteristics, in-hospital management and 90-day mortality of MI patients throughout the year 2020, in particular during periods of lockdowns.

Methods

All patients hospitalised for MI in France from 2017 to 2020 were selected from the national hospital discharge database. Incidence rate ratios were computed to analyze time trends in MI admissions and mortality rates and stratified by type of MI, sex, age, and period of admission. Characteristics and management of patients in 2020 were described and compared to 2017-19 (OR adjusted on temporality, sex, age)

Results

In 2020, 94,747 patients were hospitalized for MI corresponding to a 6% decrease in MI admissions compared to 2017-19. This decrease was more significant during the first lockdown (−24%, P < 0.0001), in particular in week 13 (−40%) than during the second lockdown (−8%). Decreases in MI admissions were more pronounced and longer for NSTEMI, older people and for women. An increase in the rate of STEMI admissions was observed between the two 2020 lockdowns (+4%, P = 0.0005). Admission to a resuscitation unit and complications rates did not differ between 2017-19 and 2020. In early 2020, there was also a decrease in 90-days readmission. In 2020, the in-hospital and 90-days-out-of hospital mortality rates were 5.5% and 3.8%, compared to 5.7% and 3.6% in reference years. Globally and after adjustment, mortality rates did not differ in 2020 vs. 2017-19 (IRR_in-hosp = 1.03[0.98;1.08], P = 0.19 - IRR_out-hosp = 1.04[0.97;1.27], P = 0.21).

Conclusions

This nationwide study showed significant decrease in MI hospitalization during 2020, in particular during the first lockdown, with a slight STEMI increase during the summer. However, these trends were not associated with more cardiac complications or mortality.

Identifying patients at risk of readmission for heart failure in the French national claim database

Background

To reduce readmissions for heart failure (HF) among HF patients, most at-risk individuals could be targeted to benefit from adapted interventions. A better understanding of HF readmission predictors could help clinicians and regulators identify patients most at-risk. We focused, in particular, on distinguishing HF severity from overall health-state severity.

Methods

We studied predictors of HF readmission available in administrative data in a nationwide cohort of patients aged 65 years or older surviving an index hospitalization for HF in 2015 (N = 70 657). To take into account the competing mortality risk, we estimated subdistribution hazard ratios (sdHRs) of HF readmission and cause-specific hazard ratios (csHRs) for HF readmission and for death without HF readmission, over a 1-year follow-up period. We then computed cumulative incidences and daily rates of HF readmission for specific risk-groups.

Results

31.8% of patients were readmitted at least once for HF, among which 27.2% (8.6% of study cohort) were readmitted 30 days after discharge. 17.6% of patients died without any HF readmission. HF severity and overall health-state severity were the strongest HF readmission predictors (sdHRs 2.66 [95% CI: 2.52-2.81] and 1.37 [1.30-1.45] respectively, when comparing extreme categories). HF severity and length of index stay were more strongly associated with the rate (csHRs) of HF readmissions, whereas overall health-state severity and age were more strongly associated with the competing rate of death without HF readmission. Risk-groups defined upon HF severity and overall health-state severity had approximately 40% of separation in HF readmission proportion (21.9% versus 60.4%).

Conclusions

Our results stress the importance of considering both HF severity and overall morbidity and of accounting for the competing mortality risk to identify patients at-risk of HF readmission. Such patients could benefit from targeted transitional or post-discharge HF care.

Key messages

Heart failure patients can be stratified into risk-groups of readmission using administrative data. Identifying at-risk patients could help clinicians and regulators to target interventions.

Outpatient health care 30 days after hospitalization for heart failure in France

Background

Recommendations for heart failure (HF) outpatient follow-up have been published. The SNDS offers the opportunity to confront them to real-life, including geographical disparities. Moreover, estimation variation has to be explored when population excludes institutionalized patients (IP) that have specific healthcare use and refund: rehabilitation (SSR), psychiatric hospitalization (psy), skilled nursing home (EHPAD) which is not usually done.The Purpose is to study outpatient healthcare use variations in France after hospitalization for HF, using SNDS data.

Methods

The first stay for HF (&gt;0days) in 2015 of patients over 18 yo covered by the general scheme (RG/SLM 88% of population) was considered. Healthcare use 30 days after was compared with (RG/SLM) or without IP (RG/SLM eIP). Regional outpatient care use rates were standardized by age and sex.

Results

Among 104 984 alive patients 30 days after HF hospitalization (RG/SLM, female 52%, mean age 79 yo), 16% stayed in SSR, 9% in cardiologic SSR, 12% in EHPAD, 0.2% in psy and 75% returning home and not institutionalized (RG/SLM eIP; n = 70367). Among all RG/SLM patients vs RG/SLM eIP (mean age 79 yo vs 78 yo), a cardiologist was seen at least once in 30 days post hospitalization 20% vs 21% (median delay 14 days IQR 7-23 vs 16 IQR 9-24), a general practitioner 69% vs 78% (8 IQR 3-16 vs 7 IQR 3-15), a nurse 58% vs 69% (3 IQR 1-9 vs 2 IQR 1-7). ACE inhibitors were reimbursed at least once for 34% vs 39%, ARBs 14% vs 17%, and diuretics 69% vs 77%. Among RG/SLM eIP patients, departmental disparities were high: cardiologist (3% to 46%), GP (59% to 93%), nurse visit (49% to 82%). Lower rates for GP were found in the center of France but with higher rates for nurse visits.

Conclusions

We recommend using RG/SLM eIP when studying outpatient healthcare use in the SNDS. Low visit rates and high delays regarding the recommendations point out the need of a multidisciplinary community health care in France.

Key messages

Low visit rates and high delays regarding the recommendations point out the need of a multidisciplinary community health care in France. We recommend using RG/SLM eIP when studying outpatient healthcare use in the SNDS.

Time trends in hospital admissions and mortality due to abdominal aortic aneurysms in France, 2002-2013

BACKGROUND

Abdominal aortic aneurysms (AAA) are serious disease with a high fatality rate but recent epidemiologic data showed a decrease of AAA mortality. Our objective was to estimate, in France, the hospitalization, inhospital mortality and mortality rates due to AAA and to analyze their trends over time.

METHODS

Hospitalization data were extracted from the hospital discharge summaries in the national database between 2002 and 2013. The analysis covered all patients hospitalized for AAA as a principal diagnosis. During the same period, all death certificates mentioning AAA as an initial cause of death were included in the study. Crude and standardized rates were calculated according to age and sex. Poisson regression was used to analyze the average annual percent change.

RESULTS

In 2013, there were 8853 patients hospitalized for AAA in France (7986 unruptured and 867 ruptured). Between 2002 and 2013, the rate of patients hospitalized for unruptured AAA decreased slightly in men (-5.0%) but increased in women (+5.2%). By contrast, the rate of patients hospitalized for ruptured AAA has decreased by >20% in men and women. The proportion of endovascular treatment of unruptured AAA rose from <10% in 2005 to 35% in women and 40% in men in 2013. In 2013, 939 deaths from AAA were recorded. Mortality for this disease declined significantly from 2002 to 2013 in men and women.

CONCLUSION

The unfavorable epidemiological trends in women and important evolution of the management of AAA call for an epidemiological surveillance of this disease.

Pulmonary embolism: Does the seasonal effect depend on age? A 12-year nationwide analysis of hospitalization and mortality

BACKGROUND

Circannual variations in the incidence and mortality of pulmonary embolism (PE) have been previously described although conflicting observations have been reported. However, the association between age and seasonal variations of incidence and mortality rates is not established. This nationwide study aimed to assess the seasonal pattern in hospitalizations and mortality for PE along with the effect of age.

METHODS

Comprehensive records from the French hospital discharge databases between 2002 and 2013 and death certificates between 2000 and 2010 were used. For each outcome and separately for each sex, monthly event counts were analyzed using quasi-Poisson models with tensor-products of regression splines, including a seasonal component and controlling for the underlying time trend, age of patients and population size changes.

RESULTS

During the period studied, 599,432 patients with PE were hospitalized and 150,404 death certificates mentioned a PE. Compared with summer months, the winter peak was associated with 25% increasing rates in hospitalizations and mortality. The rates ratio of hospitalizations between the winter peak and the summer trough increased with age. The winter excess of incidence raised from 10%, IC 95% [5-16] in 30-year-old men to 33% [31-35] in 75year-old men. In the same way, the incidences at the peak time was 13% [9-18] and 34% [31-36] higher in 30 and 75-year-old women respectively.

CONCLUSION

Based on large nationwide study, our study showed a clear seasonal pattern both on PE incidence and mortality. In addition, our data supported an association of age on the PE seasonal variations.