Characterization of antipsychotic utilization before clozapine initiation for individuals with schizophrenia: an innovative visualization of trajectories using French National Health Insurance data

Abstract Aims Despite recommendations to initiate clozapine after two unsuccessful trials of antipsychotics, clozapine is underprescribed and initiated too late. The aim of this study was to describe different antipsychotic treatment sequences in the 36 months before the initiation of clozapine and to characterize clusters of treatment trajectories. Methods Using the French National Health Insurance database, a historical cohort study of the population in an area in western France was performed. The data from all new users of clozapine with a diagnosis of schizophrenia or schizoaffective disorder in the period of 2017–2018 were evaluated. All outpatient reimbursements for antipsychotics during the 36 months before clozapine initiation were analysed. Successive reimbursements for identical treatments were grouped into treatment trials (TTs), and different trajectories were clustered using a state sequence analysis. Results The results showed 1191 TTs for 287 individuals. The mean number of TTs per individual was 3.2. Risperidone, aripiprazole and haloperidol were the main treatments delivered. The frequencies of antipsychotics used differed between monotherapies and combination therapies. A three-cluster typology was identified: one cluster (n = 133) of ‘less treated’ younger individuals with fewer TTs and shorter TT durations; a second cluster (n = 53) of ‘more treated’ individuals with higher numbers of TTs and combinations of antipsychotics; and a third cluster (n = 103) of ‘treatment-stable’ older individuals with longer TT durations. Conclusions The results indicate that the median number of TTs during the 36 months before clozapine prescription was higher than the two recommended. The different trajectories were associated with individual characteristics and treatment differences, suggesting that additional studies of clinical parameters are needed to understand barriers to clozapine prescription

Le parcours de soins coordonnés (vécu et perspectives des médecins généralistes de Loire-Atlantique)

Le parcours de soins coordonnés à été institué par la loi du 13 août 2004. Ce dispositif vise à inciter les patients âgés de plus de 16 ans à ne plus consulter directement un spécialiste en libre accès, mais à s'adresser en premier recours à leur médecin traitant qui éventuellement les dirigera, si il le juge nécessaire, vers le spécialiste adapté. Les incitations sont d'ordre financières, le non respect du parcours de soins entrainant une baisse des remboursements par la sécurité sociale des consultations des assurés depuis le premier janvier 2006. Par cette réforme, l'assurance maladie entend également améliorer la coordination et la qualité des soins, tout en en facilitant l'accès, en respectant le libre choix du patient, en assurant une perspective d'avenir aux médecins libéraux et la notion de maîtrise médicalisée de l'évolution des dépenses de santé. Six ans après sa mise en place, alors qu'une nouvelle convention médicale vient d'être signée en Juillet 2011 réaffirmant le rôle central du médecin traitant dans la prise en charge des patients, nous avons souhaité nous intéresser à la manière dont les médecins généralistes vivaient cette réforme au quotidien, par le biais d'une enquête qualitative réalisée auprès de médecins généralistes de Loire-Atlantique. Il ressort de cette enquête une impression pour les praticiens d'une formalisation d'un mode de fonctionnement préexistant avant sa mise en place. Il semble cependant avoir eu un impact positif sur la coordination des soins, et dans une moindre mesure sur leur qualité. Il ne semble par contre pas avoir eu d'impact évident sur les dépenses de santé, contrairement à l'idée reçue de nombreux patients qu'il avait été institué dans cet unique but, et ne semble pas non plus avoir eu de conséquences sur le sentiment de revalorisation des médecins généralistes. Concernant la nouvelle convention de juillet 2011, même si certains saluent une alternative au paiement à l'acte, les praticiens sont nombreux à douter de l'efficacité de celle-ci en termes d'amélioration de la qualité des soins, et insistent sur la nécessité d'une concertation entre les différents acteurs du système de santé dans la démarche de qualité.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF

Réactivité et communication des décisions de pharmacovigilance des autorités de santé vers les professionnels de santé : exemples du pergolide et du célécoxib

Objectifs : Évaluer l'impact des communications des autorités de santé sur les pratiques médicales à travers deux exemples : célécoxib et prise en compte de la nouvelle contre-indication concernant les risques cardio-vasculaires ; pergolide et prise en compte du risque de valvulopathie cardiaque. Matériel et méthodes : Suivi dans la base de données de l'assurance maladie des Pays de Loire du nombre de patients à risque cardiovasculaire recevant du célécoxib et de la surveillance cardiologique chez les patients exposés au pergolide. Résultats : Pour le célécoxib, après communication des autorités de santé, on observe une diminution majeure (71,9 %) du nombre de patients à risque exposés et pour le pergolide on observe une diminution de 14 % des patients qui n'ont aucun suivi cardiologique (183 patients au lieu de 222 parmi les 277 patients traités pendant au moins 6 mois). Conclusions : L'information concernant le célécoxib a été complètement suivie contrairement à celle concernant le pergolide. La différence semble se situer dans la médiatisation

Influence of Socioeconomic Status on Antipsychotic Prescriptions among Youth in France

International audienceRecent studies analysing the trends in antipsychotic (AP) prescriptions for children and adolescents have raised concerns regarding the influence of socioeconomic status. Previous findings have also shown variable prescription rates for first-generation (FG) and second-generation (SG) APs. Method Our objectives were to assess the proportion of patients from low-income families receiving APs and the most commonly prescribed APs in France. We conducted a descriptive analysis of AP drugs dispensed during a 1-year period (July 1, 2013–June 30, 2014) in a northwestern region of France with 941,857 subjects less than 18 years old. All data were extracted from an exhaustive, individual and anonymous social security database. We obtained each subject’s socioeconomic status (by identifying their affiliation with a specific social security program) and also collected sociodemographic data, drug type, prescribing and dispensing dates and amount, and prescriber type (e.g., hospital physician, general practitioner, psychiatrist, paediatrician). Results There were two main novel findings. First, we found that the proportion of patients with AP prescriptions was nearly ten times higher in low-income families than in the general population: 35.9% of CMU-C patients compared to 3.7% in all of Pays de la Loire (X 2 = 7875.1, p < 0.001). Additionally, we found a higher rate of FGAP than SGAP prescriptions (65% vs. 57%). Conclusions Our study suggests two types of AP misuse that could provide interesting targets for public healthcare interventions. First, our results strongly suggest an over-representation of patients from low-income families. Low-income families primarily resided in areas with low physician density and appeared to receive drugs to treat their conditions more frequently than other individuals. This increased prescription rate is a public health issue, potentially requiring political action. Second, the use of FGAPs did not adhere to the latest recommendations for drug use in this population, and this discrepancy should be addressed with informational campaigns targeted to medical practitioners

Did the new French pay-for-performance system modify benzodiazepine prescribing practices?

International audienceBACKGROUND: French general practitioners (GPs) were enrolled in a new payment system in January 2012. As part of a national agreement with the French National Ministry of Health, GPs were asked to decrease the proportion of patients who continued their benzodiazepine treatment 12 weeks after its initiation and to decrease the proportion of patients older than 65 who were prescribed long half-life benzodiazepines. In return, GPs could expect an extra payment of up to 490 euros per year. This study reports the evolution of the corresponding prescribing practices of French GPs during that period regarding patients who were prescribed a benzodiazepine for the first time. METHODS: The national healthcare system's administrative database was used to report the longitudinal follow-up of two historical cohorts of French patients from the Pays de la Loire area. STUDY PATIENTS: The "2011" and "2012" cohorts included all patients who initiated benzodiazepine regimens from April 1 to June 30 in 2011 and 2012, respectively.The primary outcomes were the proportion of those study patients who continued benzodiazepine treatment after 12 weeks and the proportion of study patients >65 years who were prescribed long half-life benzodiazepines.Analyses were performed using a multi-level regression. RESULTS: In total, 41,436 and 42,042 patients initiated benzodiazepine treatment in 2011 and 2012, respectively. A total of 18.97% of patients continued treatment for more than 12 weeks in 2012, compared with 18.18% in 2011. In all, 27.43% and 28.06% of patients >65 years continued treatment beyond 12 weeks in 2011 and 2012, respectively. The proportion of patients >65 years who were prescribed long half-life benzodiazepines decreased from 53.5% to 48.8% (p 65 years who were prescribed short half-life benzodiazepines were more likely to continue treatment after 12 weeks (p < 0.005). CONCLUSIONS: Despite the pay-for-performance strategy, the number of short half-life benzodiazepine prescriptions increased between 2011 and 2012, and the number of long half-life benzodiazepine initiations remained unchanged. Reducing the proportion of long half-life benzodiazepine prescriptions might be counterproductive because prescribing short half-life benzodiazepines was associated with higher rates of continuation beyond the recommended duration

Influence of socioeconomic status on antipsychotic prescriptions among youth in France

Background: Recent studies analysing the trends in antipsychotic (AP) prescriptions for children and adolescents have raised concerns regarding the influence of socioeconomic status. Previous findings have also shown variable prescription rates for first-generation (FG) and second-generation (SG) APs.Method: Our objectives were to assess the proportion of patients from low-income families receiving APs and the most commonly prescribed APs in France. We conducted a descriptive analysis of AP drugs dispensed during a 1-year period (July 1, 2013-June 30, 2014) in a northwestern region of France with 941,857 subjects less than 18 years old. All data were extracted from an exhaustive, individual and anonymous social security database. We obtained each subject's socioeconomic status (by identifying their affiliation with a specific social security program) and also collected sociodemographic data, drug type, prescribing and dispensing dates and amount, and prescriber type (e.g., hospital physician, general practitioner, psychiatrist, paediatrician).Results: There were two main novel findings. First, we found that the proportion of patients with AP prescriptions was nearly ten times higher in low-income families than in the general population: 35.9% of CMU-C patients compared to 3.7% in all of Pays de la Loire (X-2 = 7875.1, p < 0.001). Additionally, we found a higher rate of FGAP than SGAP prescriptions (65% vs. 57%).Conclusions: Our study suggests two types of AP misuse that could provide interesting targets for public healthcare interventions.First, our results strongly suggest an over-representation of patients from low-income families. Low-income families primarily resided in areas with low physician density and appeared to receive drugs to treat their conditions more frequently than other individuals. This increased prescription rate is a public health issue, potentially requiring political action. Second, the use of FGAPs did not adhere to the latest recommendations for drug use in this population, and this discrepancy should be addressed with informational campaigns targeted to medical practitioners

Interaction between CYP2D6 Inhibitor Antidepressants and Codeine: Is This Relevant?

International audienceINTRODUCTION: Co-occurring pain impairs depression's prognosis. Selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) are first-line pharmacotherapies for depression and inhibit many cytochrome 2D6 enzymes. Codeine is a first-line treatment for pain and needs to be metabolized into morphine by cytochrome 2D6 to exert its analgesic effect. Concomitant prescription of both pharmacotherapies leads to inadequate analgesia. Areas covered: We performed a systematic review of the literature to amalgamate the current knowledge regarding the clinical effect of this association and quantified its prevalence in clinical practice in the French Pays de la Loire area using a retrospective observational cohort study design. Expert opinion: The literature review highlighted that antidepressants with moderate-to-strong inhibition of CYP2D6 should be avoided in patients receiving codeine. However, 0.44% of the 12,296 sampled patients received concomitant codeine and CYP2D6 inhibitor between January 2015 and June 2015. Switching drugs in both painful and depressive patients depends on the pain and depression subtypes. Promising drugs that both show an effect on pain and depression are currently being studied but are not usable in clinical practice. Until then, tailored communication reinforcement toward health-care professionals is needed to prevent these problematic occurrences of concomitant prescription administration