French Health Insurance System Research Articles

Geographic variations of multiple sclerosis in France

France is located in an area with a medium to high prevalence of multiple sclerosis, where its epidemiology is not well known. We estimated the national and regional prevalence of multiple sclerosis in France on 31 October 2004 and the incidence between 31 October 2003 and 31 October 2004 based on data from the main French health insurance system: the Caisse Nationale d'Assurance Maladie des Travailleurs Salariés. The Caisse Nationale d'Assurance Maladie des Travailleurs Salariés insures 87% of the French population. We analysed geographic variations in the prevalence and incidence of multiple sclerosis in France using the Bayesian approach. On the 31 October 2004, 49 417 people were registered with multiple sclerosis out of the 52 359 912 insured with the Caisse Nationale d'Assurance Maladie des Travailleurs Salariés. Among these, 4497 were new multiple sclerosis cases declared between 31 October 2003 and 31 October 2004. After standardization for age, total multiple sclerosis prevalence in France was 94.7 per 100,000 (94.3-95.1); 130.5 (129.8-131.2) in females and 54.8 (54.4-55.3) in males. The national incidence of multiple sclerosis between 31 October 2003 and 31 October 2004 was 7.5 per 100,000 (7.3-7.6); 10.4 (10.2-10.6) in females and 4.2 (4.0-4.3) in males. The prevalence and incidence of multiple sclerosis were higher in North-Eastern France, but there was no obvious North-South gradient. This study is the first performed among a representative population of France (87%) using the same method throughout. The Bayesian approach, which takes into account spatial heterogeneity among geographical units and spatial autocorrelation, did not confirm the existence of a prevalence gradient but only a higher prevalence of multiple sclerosis in North-Eastern France and a lower prevalence of multiple sclerosis in the Paris area and on the Mediterranean coast.

How reimbursement databases can be used to support drug utilisation studies: example using the main French national health insurance system database

Reimbursement databases are potentially invaluable tools to develop and conduct pharmacoepidemiological studies on drug use. However, two types of factors that may influence the performance of a database can be distinguished: firstly, factors related to the constitution of the database, and secondly, factors related to the data. For the latter, we think that two are important: the presence of the drug in the database and the capacity to capture real-life use, both of which are influenced by the marketing status (e.g., OTC) and whether reimbursement is possible. To illustrate and discuss to what extent reimbursement databases are relevant tools to conduct drug utilization studies with regard to the data on drugs. In order to illustrate the reliability of data in reimbursement databases, data from the main French national health insurance database (55 million individuals) were compared to national drug sales in France (units) during the same year. Depending on the ATC class, the capture in the database of drugs actually sold ranged from 32 to 81%. Capture of classes of drugs in the database may be explained by the specific characteristics of the French health insurance system (reimbursable drugs, OTC market share). These characteristics influence the studies that can be performed both in terms of the topic but also the methodology. This problem probably exists for the other reimbursement databases used worldwide. Studies should be designed according to the strengths and weaknesses of reimbursement databases that were not originally developed for pharmacoepidemiology.

Medical and non‐medical direct costs of chronic low back pain in patients consulting primary care physicians in France

A retrospective, observational, cohort study in primary care. To determine the total direct medical and non-medical cost of chronic low back pain (LBP) in France and its associated factors. Chronic LBP affects 5-10% of the population its burden in France is unknown. Ninety-eight randomly selected general practitioners included 796 adult patients with chronic LBP between October 2001 and December 2002. Direct costs due to physician visits, investigations, medications, hospitalizations, and other medical and non-medical resource use were collected for the 6 months prior to study visit. Costs both reimbursed and not by the French health insurance system were considered. Quality of life (QoL) and disease severity were measured using Short Form (SF)-8 and Roland-Morris disability questionnaire (RMDQ), respectively. Costs were updated to represent 2007 prices. Men represented 50.6% of the 796 patients, mean age was 53 +/- 11.3 years, and the duration of LBP was more than 1 year in 80.9% of patients. The total mean cost per patient over six months was 715.6 euro (95% CI: 644.2-797.8). Of these costs, 22.9% related to care provided by physiotherapists and allied specialists, 19.5% to medications, 17.4% to hospitalizations, 9.6% to investigations, and 12.5% to physician fees. In multivariate analysis, the factors associated with the cost of chronic LBP were disease severity (RMDQ score) and age of the patients. LBP is a disease that is both common and costly.

Référentiel de bon usage et Thésaurus national de cancérologie digestive : analyse des écarts à l’hôpital Tenon

The financial orders of French health insurance system for anticancer treatment are guided by the National recommendations of "Good Use" of anticancer treatment (law article dated August 25, 2005 for the good use of anticancer outside the classic financial hospitals). This law of "Good Use" is based on the recommendations of référentiels de bon usage (RBU). RBU include drugs with labelling or protocoles thérapeutiques temporaires (PTT). If the prescriptions do not conform with RBU, it will be considered as not confirmed and the prescriptor has to explain clearly his point of view in the medical file supported by national and international references and publications and also that of the experts' opinions. The objective of this study, made in 2007 in Tenon Hospital, Paris, was to evaluate the percentage of the prescriptions conform with RBU and the analysis of the other different prescriptions in regards to Thésaurus national de cancérologie digestive (TNCD). We found out that 25% of the anticancer prescriptions for digestive tumours in Tenon hospital are not known by the law of "Good Use". Half of these percentages were clearly recommended via the TNCD. The other half of these non-conform prescriptions were realized in an advanced disease in which there were no clear recommendations or references and there were no other choice. The TNCD validation by the National Cancer Institute can reduce the prescriptions, which are considered as non-conform. In the other hand, for the uncertain prescriptions (non-conform), the decision must be systematically discussed in multidisciplinary stuff with detailed argumentations and clear written explications in the medical file.

Prise en charge thérapeutique des patients diabétiques en France : Apport de la Banque Nationale de Pharmacovigilance

The aim of this study was to investigate the use of the French Pharmacovigilance Database to estimate characteristics of drug utilization in specific diseases. We identified diabetic patients from the French Pharmacovigilance Database between 2002 and 2005. In this population, we studied demographic characteristics, and the patterns of drug use, particularly hypoglycemiant drug use and other drug exposure. In order to validate this approach, we compared our data to a population of patients with diabetes identified from the French Health Insurance System claims database in one French area. The estimation of prevalence of diabetes was very close in the sources: 2.7% in the French Pharmacovigilance Database and 3.2% in the French Health Insurance System claims database. We found similar results as well for demographic characteristics as for hypoglycemiant drug use and other drug exposure. These results suggest that the French Pharmacovigilance Database may be used to investigate drug utilization patterns.

Is the intersection syndrome is an occupational disease?

The intersection syndrome, described since the 19th century, is an uncommon disorder associated with the abductor pollicis longus and extensor pollicis brevis bellies (first dorsal compartment) rubbing against the extensor carpi radialis longus and brevis tendons (second dorsal compartment). Overuse occurred in occupational setting was barely described although it could lead to compensation by the French health insurance system. We reported a case of an intersection syndrome in a 58-year-old man who recently became a supermarket cashier. This job involved repeated extension and flexion of the wrist. The disorders arose after a minimal traumatism. Since it is recognized as an occupational disease, compensated ending of the activity causing the disorder could have been obtained.

Triptan use and risk of cardiovascular events: a nested-case-control study from the French health system database

The use of triptans (5-HT agonists) in the treatment of migraine is associated with a potential increasing risk of cardiovascular events and raises the question of the relationship between overuse and the occurrence of ischemic events. The aim of this study was to examine the association between the intensity of triptan use and occurrence of an cardiac event. Using the reimbursed drug prescription database of the National French Health Insurance System in the Midi-Pyrenees area, we identified subjects receiving at least one triptan in the second semester of 2002. From this population, we selected new users and retrieved all reimbursed care data up to 31 December 2003. We estimated the patterns of triptan exposure by calculating the number of defined daily doses (DDD) received per 30-day period. Another reimbursed health care database was used to identify as cases of cardiac outcomes those patients receiving care for the management of a possible heart ischemic event. Each case was randomly matched on age and gender with four controls free of any cardiovascular event before the index date. A conditional logistic regression was performed to assess the relationship between cardiac outcomes and exposure to triptans in the 30 days before the index date. The cohort of new users of triptans included 8625 subjects, 4414 (51.18%) of whom received only one dispensation for triptans during the follow-up period (median duration: 427 days). For the remaining subjects, the peak of triptans delivery was </=8 DDD for 14.68% of the cohort, between 9 and 14 DDD for 22.17%, between 15 and 29 for 10.04% and >/=30 DDD for 1.92%. Fifty-seven users (0.66%) presented a cardiac history and 1388 patients (16.09%) had cardiovascular risk factors. We identified 155 incident cases of cardiac outcomes during the follow-up and compared these to 620 matched controls. Cases were older and presented more frequently with cardiac history or cardiovascular risk factors than the other users of triptans. The distribution exposure to triptans did not significantly differ between cases and controls with an odds ratio for an exposure </=8 DDD in the last 30 days of 0.74 [95% CI (0.31-1.77)] and that for an exposure >8 DDD equal to 1.14 [95% CI (0.58-2.27)]. The proportion of patients showing an overuse of triptans (more than 15 DDD for 30 days) reached 12% in this cohort of new users of triptans. However, we did not find any relationship between the overuse of triptans and cardiac outcomes. This study also shows that some patients with cardiovascular risk factors are actually treated by triptans. These patients are more likely to present a cardiac outcome potentially related to an ischemic event after the introduction of triptan.

Anxiolytics, hypnotics, and antidepressants dispensed to adolescents in a French region in 2002

This study proposes to complete declarative studies by describing the prescriptions of anxiolytics, hypnotics, and antidepressants dispensed to adolescents in a French region in 2002. This cross-sectional study analyzes all the hypnotic, anxiolytic, and antidepressant prescriptions (ATC codes beginning with N05B, N05C, and N06A, respectively) sent by adolescents (aged 13-17 years) to the French Health Insurance system of the study region for reimbursement during one year (2002). It was performed in a southern France area with 120,908 adolescents covered by this insurance scheme. Adverse drug reactions (ADRs) recorded in the Pharmacovigilance database were also studied. Three thousand two hundred and eighty-six adolescents (2.7% of adolescent population) had at least one prescription of the studied drugs. This prevalence increased with age and female sex, leading to a maximum of 6.3% for the 17-year-old girls. Two thousand four hundred and thirty-one of adolescents were dispensed anxiolytics, 935 antidepressants, and 548 hypnotics. The most dispensed drugs were zolpidem, zopiclone, and niaprazine for hypnotics; hydroxyzine, etifoxine, and bromazepam for anxiolytics; and paroxetine, sertraline, and fluoxetine for antidepressants. Zolpidem, hydroxyzine, and paroxetine accounted, respectively, for 82.9%, 57.1%, and 59.8% of the prescriptions. 75.5% of hypnotics users had only one prescription, 77.4% for anxiolytics, and 57.4% for antidepressants. Three ADRs were reported. This study confirms the large use of psychotropics in French adolescents and the influence of age and sex. Also, the results underline treatment for most adolescents is short, which may be beneficial for hypnotics and anxiolytics but not for antidepressants.

Profil des utilisateurs d’anti-inflammatoires non stéroïdiens

AbstractPatterns of Non Steroidal Anti-Inflammatory Drug Use in Ambulatory Care. The aim of this study was to discuss the patterns of non steroidal anti-inflammatory drug (NSAID) use in general population. We identified NSAID’s users from the French Health Insurance System claims database covering more of the population in the Midi-Pyrenees area (southwest of France), if they have received at least one NSAID in June 2003. We discussed this population according to the NSAID used, to their demographic characteristics and to other drugs delivered in the period. Oui’ study shows different patterns of use according to each NSAID. For example, users of ibuprofen or tiaprofenic acid were younger and less frequently exposed to “gastroprotective” drugs, users of coxibs were older and more frequently exposed to drugs increasing the risk of bleeding. This study confirms the wide use of NSAIDs and describes their target population. It underlines the interest of Health Insurance System Database for better knowledge of drug use in ambulatory care in France

Financial cost of osteoarthritis in France: The “COART” France study

Objective. – Osteoarthritis is the most common musculoskeletal disease, with about 9–10 million patients in France including 4.6 million with symptoms. The objective of the COART France study is to evaluate the cost of osteoarthritis in France from the societal point of view and to compare the results to those obtained in 1993 using the same methodology. Materials and methods. – The cost of osteoarthritis was evaluated using the macroeconomic approach. Direct costs were estimated from healthcare resource use (physician visits, drug prescriptions, and hospital admissions) and indirect costs from doctor-prescribed sick-leave durations. Results. – Direct costs of osteoarthritis in 2002 exceeded 1.6 billion Euros, contributing about 1.7% of expenses of the French health insurance system, which covers all residents of France regardless of employment or documentation status. Hospital admissions were the greatest single contributor to direct costs, with more than 800 million Euros. Osteoarthritis led to 13 million physician visits, during which 570 million Euros worth of medications were prescribed. The 156% increase in direct medical costs compared to 1993 was chiefly related to an increase in the number of patients (+54%); the cost increase per patient was only 2.5% per year. Conclusion. – Despite the large increase in the number of treated patients and the development of new costly medications, the rise in the cost of managing osteoarthritis seems well contained. The aging of the population, development of new technologies, and increasing patient expectations will probably govern the future economic impact of osteoarthritis, which remains a major public health burden.

Impact of medical practices on the costs of management of rheumatoid arthritis by anti-TNFα biological therapy in France

When the anti-TNFα drugs first came onto the market, their high price was the subject of much debate. Moreover, we must add the costs associated with their administration to the purchase price. Variations in medical practices may be the source of substantial variations in these costs. Objective. – To compare the costs involved with the use of infliximab and etanercept in the treatment of rheumatoid arthritis (RA) and to study the impact of variations in medical practices on them. Methods. – A pragmatic cost minimization analysis was conducted from the payer's perspective to compare the costs of administration, that is, the direct medical costs, of the first two available anti-TNFα agents: infliximab and etanercept. Records of 60 patients from three university hospital rheumatology departments were reviewed retrospectively for a 52-week period. This analysis considered the following costs: purchase costs for the drugs and for any co-prescribed disease-modifying drugs, inpatient or outpatient administration, medical follow-up and the transportation costs associated with treatment that were reimbursed by the French health insurance system. Costs that did not differ between the two products were excluded (work-up for inclusion, etc.). Results. – Data were collected for 58 patients, 30 treated with infliximab and 28 with etanercept. Patients' mean age was 52 years; 81% were women. RA had first developed on average 15 years earlier; the disease was positive for rheumatoid factors in 68% of cases and erosive in 93%. The total average annual cost of administration did not differ for infliximab and etanercept: 19,469 and 19,619 €, respectively ( P = 0.56). The mean costs of administration nonetheless varied considerably between the three hospital centers: from 16,566 to 24,313 € for infliximab ( P < 0.0001) and from 16,069 to 24,383 € for etanercept ( P < 0.0001). Conclusion. – The financial burden of biological treatments for RA is strongly influenced by the substantial heterogeneity in medical practices.

Les trompe-l'œil de la « gouvernance » de l'assurance maladie

<titre>Trompes-l&#8217;&#339;il in the &#8220;Governance&#8221; of Health Insurance French-German Contrasts </titre> The authors judge the relevance of the term governance &#8212; now the accepted term for the transformation of the regulation mode of the health insurance system &#8212; in relation to two basic issues&#160;: the horizontal relationships between state and non-state actors, and the importance given to negotiation between multiple actors. These two aspects of the system are then discussed in the framework of an analysis of the recent reforms in the French health insurance system. Finally, a comparison with Germany shows the limits of a governance unable to question the validity of the two essential elements constituting the identity of the French health system&#160;: the patient&#8216;s freedom and the freedom of liberal practitioners (doctors practising outside the state healthcare system).

Souffrance psychosociale et antécédents biographiques traumatiques des fumeurs: Enquête auprès de consultants d’un Centre de prévention sanitaire et sociale

The relationship between smoking and various socio-demographic or socio-economic factors, as well as the interactions between depressive mood and smoking are already known. However, the respective contribution of psychological factors and stressful life antecedents during childhood and adolescence warrants further specification.2315 consecutive subjects, aged 16 to 59, consulting for a free work-up in a preventive health centre, supported by the National French Health insurance system, were invited to fill out a series of questionnaires: the GHQ-28 and the LOT, respectively measuring psychosocial distress and dispositional optimism, as well as a questionnaire on socio-demographic, socio-economic and biographical data.78.1% complete records could be analysed: the "smokers" group (n = 870, 48.1%) declared a current tobacco consumption of at least one cigarette/day. This group was characterized by a predominance of male subjects, older age, modest educational level, low income level and responded to socio-economic criteria of precariousness more frequently (p < 0.001, except for age: p = 0.006). Smoking was also associated with higher levels of psychosocial distress, as assessed by GHQ-28, especially for the depressive mood and anxiety items of the questionnaire (p < 0.001), and with lower levels of dispositional optimism (p < 0.01). As regards biographical data, smokers were characterized by a way of life marked by financial problems, reduced social contacts, and a higher frequency, before the age of 18, of divorce or separation of the parents (p = 0.002), frequent parental quarrels (p < 0.001) or separation from the parents (p < 0.001). The presence of a depressive mood at GHQ-28 as well as frequent parental quarrels remained independent risk factors for smoking in multiple logistic regression (odds ratio respectively equal to 1.61 and 1.34), after adjustment on gender, educational level and the notion of socio-economic precariousness.These results highlight the complementary role of socio-economic, psychological factors and certain stressful life antecedents among the determinants of smoking and should be taken into account for tailoring smoking cessation programs.

Utilisation d’une matrice emplois-exposition pour l’identification des expositions professionnelles à l’amiante

According to a recent French legislation (1995), retired people who have been exposed to an occupational carcinogen can benefit from a specific post-occupational medical follow-up program, supported by the "Caisse Primaire d'Assurance-Maladie" (CPAM), the French health insurance system. However, only very few people presently take access to this social measure. The ESPACES project developed and evaluated a procedure to identify retirees who have been exposed to asbestos during their career, and to inform them about the post-occupational medical follow-up program. This pilot study was performed within the health centers ("Centres d'examens de santé" (CES)) of the health insurance system in a random sample of men who have retired from the six main French administrative divisions between 1994 to 1996. A probability of exposure to asbestos was attributed through a job exposure matrix. Subjects were interviewed in the CES to validate their exposure data. Retired subjects with confirmed exposure to asbestos were referred to their CPAM, to apply for the medical follow-up. The whole process was evaluated through a comparison with control CPAMs, and simulations were performed to assess its sensitivity and specificity, as well as the total number of persons in France who could potentially benefit. Among the 737 persons classified as exposed by the matrix who came to the CES, the exposure was confirmed for 53.8%, and 143 benefited from the medical follow-up, 17 times more than in a sample of control CPAMs. Based on an annual number of about 250,000 new retirees, simulations showed that a low detection threshold, taking into account the probability and duration of exposure, would yield approximately 25,000 persons coming to the CES, more 6,000 of them benefiting from the follow-up. The proposed detection threshold would allow for a feasible and ethically acceptable generalization, due to the optimization of the false negative and false positive rate.

Prospective randomized study comparing the medicoeconomic benefits of Hylan GF-20 vs. conventional treatment in knee osteoarthritis

Objectives. – In a previous study, we determined the costs over 6 months to the French public health insurance system of Hylan GF-20 (Synvisc ®) in 66 patients with knee osteoarthritis. Here, we compared the medicoeconomic benefits over 9 months in 506 patients given Hylan GF-20 or conventional treatment for knee osteoarthritis. Patients and methods. – This prospective randomized study was conducted from October 1998 to February 2000. Clinical status was evaluated using the Lequesne index, the WOMAC index, and the SF12 quality-of-life questionnaire. Medical and sick leave costs to the public health insurance system were determined. Results. – Effectiveness criteria were evaluable in all 506 patients. Significant clinical improvements were noted from the first month to the end of the 9-month study period in the Synvisc ® group. A mean 2-point difference in the Lequesne index area-under-the-curve was found in favor of Synvisc ® ( P < 0.0001). Mean medical and sick leave costs per patient over 9 months were €829.10 in the Synvisc ® group and €829.40 in the conventional treatment group. Conclusion. – This study carried out over 9 months in a large population confirms that Synvisc ® viscosupplementation is more effective than conventional treatment, at no additional cost. It takes a step toward answering the request of international experts for medicoeconomic data on viscosupplementation for osteoarthritis.

Étude prospective randomisée comparant le bénéfice médico-économique de Synvisc ® à celui des traitements usuels chez des patients souffrant de gonarthrose

Objectives. – In a previous study, we determined the costs over 6 months to the French public health insurance system of Hylan GF-20 (Synvisc ®) in 66 patients with knee osteoarthritis. Here, we compared the medico-economic benefits over 9 months in 506 patients given Hylan GF-20 or conventional treatment for knee osteoarthritis. Patients and methods. – This prospective randomized study was conducted from October 1998 to February 2000. Clinical status was evaluated using the Lequesne index, the Womac index, and the SF12 quality-of-life questionnaire. Medical and sick leave costs to the public health insurance system were determined. Results. – Effectiveness criteria were evaluable in all 506 patients. Significant clinical improvements were noted from the first month to the end of the 9-month study period in the Synvisc ® group. A mean 2-point difference in the Lequesne index area-under-the-curve was found in favor of Synvisc ® ( p < 0.0001). Mean medical and sick leave costs per patient over 9 months were 829.10 € in the Synvisc ® group and 829.50 € in the conventional treatment group. Conclusion. – This study done over 9 months in a large population confirms that Synvisc ® viscosupplementation is more effective than conventional treatment, at no additional cost. It takes a step toward answering the request of international experts for medico-economic data on viscosupplementation for osteoarthritis.

Liberalisation Through the State. Why is the French Health Insurance System Becoming so British?

The French Health Insurance system has experienced major changes in the 1990’.. The 1996 reform is rather paradoxical because it is a mix of liberalisation (through the introduction of competition mechanisms) and strengthening of the State. This mix of State improvement (mainly illustrated by the limitation of health insurance expenses by fixed budgets) and liberalisation (illustrated by the promotion of competition mechanisms) is not a French peculiarity: it is more the sign of a convergence trend for all European health care systems. This is why there is a blurring of the differences with the British health care system. Financial constraints, changes in policy networks (which were partly the side-effects of previous cost containment policies) and political mobilisation explain these reforms in the French case

Dépenses de santé : l'hypothèse d'aléa moral

Health Expenditures : the Moral Hazard Assumption by Pierre- Yves Geoffard The analysis of many proposals to reform the French health insurance system, and in particular those focusing on co-payment schemes, is heavily dependent on delicate empirical measures of the elasticity of demand for health care. This paper offers a critical survey of the empirical literature on the moral hazard assumption, according to which more extensive health insurance coverage would lead to more spending. The paper begins by recalling that the Rand Health Insurance Study, a major study conducted in the United States in the 1970s, unambiguously concluded that the price elasticity of demand for medical care was negative, especially for ambulatory care. The paper then stresses the limitations of more recent studies undertaken on French data - limitations which are either inherent to the data or due to the econometric methods employed. In addition, evaluating the redistributive aspects of co-payments and their impact on access to care would require more accurate measures of cross price-income elasticity. Despite all these uncertainties, the lessons drawn from the existing empirical studies suggest that the current French co-payment scheme (the ticket modérateur system) is very far from being fair and efficient.

Shock treatment for French health insurance system

Shock treatment for French health insurance system