Main Health Insurance Scheme Research Articles

General practitioners may improve cervical screening equality in France

BackgroundVulnerable social groups have greater difficulty in accessing care and a lower quality of care. Health systems focused on primary care appear to be more effective, efficient and equitable. However, difficulties in accessing primary care are persisting. We focused on primary care screening for cervical cancer through Cervico-Uterine Smear (CUS), which has been shown to be effective in reducing disease incidence and mortality. In this study, we aimed to investigate the characteristics of women who undergo CUS according to the category of health professionals (general practitioners or gynaecologists) performing CUS and to analyse potential differences in access to care in terms of socioeconomic and geographical characteristics.MethodsThis was a retrospective observational study based on data from the main health insurance schemes in France, allowing analysis of health care consumption according to socioeconomic levels and proximity to health care services. We included women aged 25 to 64 years in 2012 for whom CUS would be a relevant procedure (695,694). The sociodemographic and territorial indicators were age, geographical area deprivation, and the availability of gynaecological care. The analysis was performed using multinomial logistic regression.ResultsA total of 202,271 (29%) patients underwent CUS; of whom 68% underwent CUS administered by gynaecologists and 28% were administered by general practitioners (GPs). However, inequalities in CUS screening rates were observed, with a decrease in the number of CUSs performed with increased age, a rural location, deprivation, and sparse health care provisions. Deprived people seemed less penalised by GPs.ConclusionsInvolvement of General Practitioners may improve cervical screening equality in France. The organisation of health systems around primary care may allow a better access to care and to account for the specific needs of deprived populations.

Real-World Heart Failure Burden in Thai Patients.

Heart failure (HF) is one of the leading causes of hospitalization worldwide. In Thailand, data on HF burden remains limited. This study aimed to describe comprehensive evidence detailing the HF prevalence, hospital admission rates, in-hospital mortality, and overall mortality rates at the hospital level. All eligible adult patients' medical records from 2018 and 2019 were analyzed retrospectively at five hospitals in different regions. The patients were diagnosed with HF, as indicated by the International Classification of Diseases (ICD)-10 code I50. Descriptive statistics were used to examine the hospital burden as well as patients' clinical and outcome data. A total of 7384 patients with HF were identified from five tertiary hospitals. Around half of the patients were male. The mean age was 67years, and the main health insurance scheme was the Universal Coverage Scheme. The prevalence of HF was 0.1% in 2018 and 0.2% in 2019. Heart failure with preserved ejection fraction (HFpEF) was the most common type of HF in both visits, followed by heart failure with reduced ejection fraction (HFrEF) and heart failure with mildly reduced ejection fraction (HFmrEF). The proportion of HF hospitalizations was 1.2% in 2018 and 1.5% in 2019. The proportion of HF rehospitalizations versus hospitalizations in patients with HF was 22.7% in 2018 and 23.9% in 2019. The risk of rehospitalization was highest at 180days after hospital discharge (87.8%). Among the patients with HF, the proportion of all-cause mortality was 9.1% in 2018 and 8.0% in 2019. Most of the deaths occurred within 30days after hospitalization. Our study demonstrated that the burden of HF in terms of hospitalization and in-hospital mortality was notably high when compared to similar studies conducted in Thailand and other countries.

Adults at risk of pneumococcal disease in France

BackgroundImmunocompromised patients and those with certain underlying medical conditions are at risk of pneumococcal disease, but in France their vaccine coverage is largely unknown. We aimed to assess the number of adult patients eligible for pneumococcal vaccination in France. MethodsWe conducted an annual cross-sectional study based on retrospective data from the French National Health Data System. Over 2014–2018, we included all adults continuously affiliated to the General health insurance scheme (covering 76% of the population), at risk of pneumococcal disease. Patients were identified with published or newly developed algorithms using diagnoses and reimbursements for hospital stays, medical procedures, and specific treatments, laboratory tests, or medical devices. ResultsOn January 1, 2018, we identified 4,045,021 at-risk patients (11% increase since 2014). Mean age was 66.1years (55.1% were aged≥65), 51% were men, and 18% had at least two conditions. Of these, 3,634,594 had a chronic medical condition (including 2,617,921 patients treated for diabetes, 616,003 for chronic respiratory disease, 424,223 for heart failure, and 285,214 for chronic liver disease) and 570,035 were immunocompromised (of these, 191,527 were treated with immunosuppressive drugs or biotherapy, 152,255 with chemotherapy for cancer, and 100,604 for HIV). ConclusionThese published or newly developed algorithms — which can be used to address other public health issues — identified more than 4 million adults eligible for pneumococcal vaccination in the main health insurance scheme (10% of the studied adult population). This is a first step towards ensuring patients get vaccinated as part of their chronic condition management.

Infertility Treatment in France, 2008-2017: A Challenge of Growing Treatment Needs at Older Ages.

Objectives. To measure trends in infertility treatment use between 2008 and 2017 in France using data from the national health insurance system.Methods. Between 2008 and 2017, we observed a representative national sample of nearly 1% of all women aged 20 to 49 years who were affiliated with the main health insurance scheme in France (more than 100 000 women observed each year). We exhaustively recorded all health care reimbursed to these women.Results. Among women aged 20 to 49 years, 1.25% were treated for infertility each year. Logistic regression analysis showed a significant interaction between age and year of treatment use (P < .001). Over the decade, infertility treatment use increased by 23.9% among women aged 34 years or older, whereas among women younger than 34 years there was a nonsignificant variation.Conclusions. Women aged 34 years or older were increasingly treated for infertility between 2008 and 2017.Public Health Implications. Treatment efficiency decreases strongly with a woman's age, presenting a challenge for medical infertility care.

Development and validation of the two morbidity indices for health-state severity adjustment, using data from the French National Health Insurance Information

Introduction Morbidity indices are commonly used for adjustment or stratification on health-state severity, for research purposes and to inform policy-makers. The performance of morbidity indices is enhanced when multiple data sources are combined to identify conditions included as predictors and when indices are used for the same outcome and in similar settings as for which they were developed. Most existing indices use a single data source to identify conditions and have been developed to predict a single outcome or subsequently adapted to heterogeneous settings. The French National Health Insurance Information System (“Systeme National des Donnees de Sante, SNDS”) provides individual expenditure and morbidity information for each beneficiary of the main health insurance scheme, representing over 57 million individuals (87% of the French population). Morbidity is measured through a set of standard algorithms combining ICD-10 diagnoses and pharmacy data to identify specific conditions. We used SNDS data to develop and validate two outcome-specific morbidity indices: the Mortality-Related Morbidity Index (MRMI) predictive of all-cause mortality and the Expenditure-Related Morbidity Index (ERMI) predictive of healthcare expenditure. Methods A cohort including all beneficiaries of the main French health insurance scheme aged 65 years or older on December 31, 2013 (N = 7,672,111) was randomly split into a development population for index elaboration and a validation population for predictive performance assessment. Age, gender and selected lists of conditions were used as predictors for 2-year mortality and 2-year healthcare expenditure in separate models. Predictors were selected according to face validity of their identifying algorithm, correlation analysis within disease categories, univariate association with each outcome and outcome-specific considerations: number of events for mortality prediction and variance explained for expenditure prediction. To derive a weighted index from the adjusted regression coefficients, we applied a scoring rule where each additional point reflected risk associated with a 5-years age increase. We conducted two series of sensitivity analyses to test the stability of the weights when accounting for effect modification due to age and gender or to associations of conditions. Overall performance and calibration of the MRMI and ERMI were measured and compared to various versions of the Charlson index (CCI). For the MRMI, we assessed discrimination using the concordance statistic (c-statistic, equivalent to the area under the receiver operating characteristic curve). For the ERMI, we measured the percentage of total expenditure variance explained by the index. Calibration was assessed, for both indices, by comparing predictions with observations among individuals with the same index value. Results The MRMI included 16 conditions weighted 1 to 3. Adjusted odds ratios [95% confidence interval] ranged from 1.34 [1.31–1.37] for depression, 1.36 [1.32–1.39] for Rheumatic or connective tissue diseases, to 3.79 [3.62–3.97] for end-stage renal disease, 4.09 [4.04–4.15] for cancer. The MRMI was more discriminant than the age-adjusted CCI (c-statistic: 0.8252 [95% CI: 0.8244–0.8260] vs. 0.7999 [0.7991–0.8008]) and better calibrated. Age and gender alone (c-statistic: 0.7613 [0.7604–0.7623]) were more discriminant than indices that did not include age (original CCI and cost-adapted CCI). The ERMI included 19 conditions weighted 2 to 16, explained more variance than the cost-adapted CCI (21.8% vs. 13.0%) and was better calibrated. Sensitivity analyses showed that the estimates and resulting weights were stable for both indices. Conclusions The MRMI and ERMI indices are performant tools to account for health-state severity according to outcomes under study. They also document the differential adjusted effect of conditions on different outcomes.

Estimating the prevalence of depression associated with healthcare use in France using administrative databases

BackgroundQuantitative indicators are needed in order to define priorities, plan policies and evaluate public health interventions in mental health. The aim of this study was to assess the contribution of a large and exhaustive French national administrative database to study and monitor treated depression by comparing the prevalence and characteristics of the population using significant healthcare resources for depression as identified by different estimation methods and sources and to discuss the advantages and drawbacks of these methods.MethodsThis study included the French population covered by the main health insurance scheme in 2012 (Régime général, 86% of the insured French population). Data were extracted from the French health insurance claim database (SNIIRAM), which contains information on all reimbursements, including treatments and hospital stays in France. The following distinct sources of the SNIIRAM were used to select persons with depression: diagnoses of long-term or costly conditions, data from national hospital claims and data concerning all national health insurance reimbursements for drugs.ResultsIn 2012, we included 58,753,200 individuals covered by the main health insurance scheme; 271,275 individuals had full coverage for depression; 179,470 individuals had been admitted to a psychiatric hospital and 66,595 individuals admitted to a general hospital with a diagnosis of depression during a 2-year timeframe and 144,670 individuals had more than three reimbursements for antidepressants during the study year (with a history of hospitalisation for depression during the past 5 years). Only 16% of individuals were selected by more than one source.ConclusionsWe propose an algorithm that includes persons recently hospitalised for depression, or with a history of hospitalisation for depression and still taking antidepressants, or with full coverage for depression as a specific long-term or costly condition, yielding a prevalence estimate of 0.93% or 544,105 individuals. Changes in the case selection methodology have major consequences on the frequency count and characteristics of the selected population, and consequently on the conclusions that can be drawn from the data, emphasizing the importance of defining the characteristics of the target population before the study in order to produce relevant results.

Erratum to: Mortality and treatment costs of hospitalized chronic kidney disease patients between the three major health insurance schemes in Thailand.

Thailand has reformed its healthcare to ensure fairness and universality. Previous reports comparing the fairness among the 3 main healthcare schemes, including the Universal Coverage Scheme (UCS), the Civil Servant Medical Benefit Scheme (CSMBS) and the Social Health Insurance (SHI) have been published. They focused mainly on provision of medication for cancers and human immunodeficiency virus infection. Since chronic kidney disease (CKD) patients have a high rate of hospitalization and high risk of death, they also require special care and need more than access to medicine. We, therefore, performed a 1-year, nationwide, evaluation on the clinical outcomes (i.e., mortality rates and complication rates) and treatment costs for hospitalized CKD patients across the 3 main health insurance schemes. All adult in-patient CKD medical expense forms in fiscal 2010 were analyzed. The outcomes focused on were clinical outcomes, access to special care and equipment (especially dialysis), and expenses on CKD patients. Factors influencing mortality rates were evaluated by multiple logistic regression. There were 128,338 CKD patients, accounting for 236,439 admissions. The CSMBS group was older on average, had the most severe co-morbidities, and had the highest hospital charges, while the UCS group had the highest rate of complications. The mortality rates differed among the 3 insurance schemes; the crude odds ratio (OR) for mortality was highest in the CSMBS scheme. After adjustment for biological, economic, and geographic variables, the UCS group had the highest risk of in-hospital death (OR 1.13;95% confidence interval (CI) 1.07–1.20; p < 0.001) while the SHI group had lowest mortality (OR 0.87; 95% CI 0.76–0.99; p = 0.038). The circumscribed healthcare benefits and limited access to specialists and dialysis care in the UCS may account for less favorable comparison with the CSMBS and SHI groups. Significant differences are observed in mortality rates among CKD patients from among the 3 main healthcare schemes. Improvements in equity of care might minimize the differences.

Assessment of emergency medical service of three schemes under the concept “medical emergency care for everybody everywhere”

Background Thailand has three main health insurance schemes: Universal Coverage Scheme (UCS), Social Security Scheme (SSS) and Civil Servant Medical Benefit Scheme (CSMBS). Health benefits of these schemes are different, which could lead to inequity in access to care and quality of care. Medical emergency care was the first healthcare programme that was implemented towards harmonization of the three schemes. This programme was implemented since April 1, 2012. Since then, all emergency care patients were expected to be treated under the same rules without being rejected by all private hospitals. The payment mechanism used fee schedule of CSMBS for outpatient service and diagnosis related group (DRG) for inpatient service with a single base rate of 10,500 Baht per adjusted relative weight including medical instruments and drugs. The aim of the study was to assess the policy outcomes of the Emergency Medical Service focusing on private hospitals.

Trends in use of antipsychotics in elderly patients with dementia: Impact of national safety warnings

Based on evidence of an increased risk of death, drug agencies issued safety warnings about the use of second generation antipsychotics (SGAs) in the elderly with dementia. The French agency issued a warning in 2004. which was extended to all antipsychotics in 2008. Little is known about the impact of these warnings on use. We conducted a quasi-experimental study (interrupted time-series) in France, for 2003–2011, including subjects aged ≥65 with dementia and subjects aged ≥65 without dementia in the EGB database (1/97th representative random sample of claims from the main Health Insurance scheme). Outcomes were monthly rates of use of antipsychotics (by class and agent) and of five comparison drug classes (antidepressants, benzodiazepines, dermatologicals, antidiabetics, antiasthmatics). Trends were analyzed by joinpoint regression, impact of warnings by linear segmented regression. In patients with dementia (n=7169), there was a 40% reduction in antipsychotic use from 14.2% in 2003 to 10.2% in 2011. The reduction began before 2004 and was unaffected by the warnings. Use of first generation antipsychotics declined over the period, while use of SGAs increased and leveled off from 2007. Use of the five comparison drug classes increased on the period. In subjects without dementia (n=91,942), rates of overall antipsychotic use decreased from 2.3% in 2003 to 1.8% in 2011 with no effect of the warnings. Meanwhile, use of SGAs continuously increased from 0.37% to 0.64%. Antipsychotic use decreased in the elderly between 2003 and 2011, especially in dementia. The timing of the decrease, however, did not coincide with safety warnings.

Assessment of prescription practices for serological tests for viral hepatitis B and C in the Greater Parisian area in 2002

The aim of this study was to ascertain the reasons for the prescription of serological tests for viral hepatitis B (HBV) and C (HCV) in the Greater Parisian area, and to assess standards of prescription with respect to current guidelines. The population studied comprised patients affiliated to the three main health insurance schemes in the Greater Parisian area, for whom at least one serological test for HBV or HCV was reimbursed on May 14th or 15th, 2002. Data was collected from prescribing and laboratory heads. The sample consisted of 1 046 prescription orders for HBV and/or HCV tests. The mean age of patients was 39 years, and 68% were females. The main medical indications declared by the prescribing physicians were: screening for HBV or HCV (40%), tests for pregnant women (19%), suspected hepatitis B or C (13%), pre- and post-vaccination tests for HBV (7%), medically assisted procreation (6%), follow-up of diagnosed chronic hepatitis (4%). Assessment of the standards of prescription orders showed a lack of compliance with guidelines for 71% of HBV tests, and 56% of HCV tests. The implementation of guidelines for the prescription of serological tests for HBV and HCV needs to be improved in clinical practice.