Utilisation en France du baclofène dans l’alcoolodépendance de 2007 à 2013 : étude à partir du SNIIRAM et du PMSI

Objectif. Quantifier et décrire pour la période 2007-2013 la population débutant en France un traitement de baclofène pour alcoolodépendance. Méthodes. Utilisation du système national d’information inter-régimes de l’Assurance maladie (SNIIRAM) et du programme de médicalisation des systèmes d’information (PMSI) pour identifier la population débutant un traitement de baclofène, déterminer par algorithme le motif de prescription, définir les caractéristiques des patients et de leur traitement. Résultats. Environ 200 000 personnes ont débuté un traitement de baclofène entre 2007 et 2013, dont 52,0 % pour alcoolodépendance. En 2013, ces personnes étaient majoritairement des hommes (62,3 %), avaient en moyenne 50,1 ans, 58,9 % avaient eu un primoprescripteur généraliste, 48,8 % étaient encore sous traitement 6 mois après leur instauration et parmi eux la moitié consommaient quotidiennement au moins 57,0 mg de baclofène. Conclusion. L’utilisation du baclofène pour une alcoolodépendance a fortement augmenté depuis 2008, avec en 2013 plus de 34 000 nouveaux utilisateurs et plus de 9 000 primoprescripteurs généralistes

The Best Use of the Charlson Comorbidity Index With Electronic Health Care Database to Predict Mortality

International audienceBACKGROUND:The most used score to measure comorbidity is the Charlson index. Its application to a health care administrative database including International Classification of Diseases, 10th edition (ICD-10) codes, medical procedures, and medication required studying its properties on survival. Our objectives were to adapt the Charlson comorbidity index to the French National Health Insurance database to predict 1-year mortality of discharged patients and to compare discrimination and calibration of different versions of the Charlson index.METHODS:Our cohort included all adults discharged from a hospital stay in France in 2010 registered in the French National Health Insurance general scheme. The pathologies of the Charlson index were identified through ICD-10 codes of discharge diagnoses and long-term disease, specific medical procedures, and reimbursement of specific medications in the past 12 months before inclusion.RESULTS:We included 6,602,641 subjects at the date of their first discharge from medical, surgical, or obstetrical department in 2010. One-year survival was 94.88%, decreasing from 98.41% for Charlson index of 0-71.64% for Charlson index of ≥5. With a discrimination of 0.91 and an appropriate calibration curve, we retained the crude Cox model including the age-adjusted Charlson index as a 4-level score.CONCLUSIONS:Our study is the first to adapt the Charlson index to a large health care database including >6 million of inpatients. When mortality is the outcome, we recommended using the age-adjusted Charlson index as 4-level score to take into account comorbidities

Use of Fibrates Monotherapy in People with Diabetes and High Cardiovascular Risk in Primary Care: A French Nationwide Cohort Study Based on National Administrative Databases

<div><p>Background and Aim</p><p>According to guidelines, diabetic patients with high cardiovascular risk should receive a statin. Despite this consensus, fibrate monotherapy is commonly used in this population. We assessed the frequency and clinical consequences of the use of fibrates for primary prevention in patients with diabetes and high cardiovascular risk.</p><p>Design</p><p>Retrospective cohort study based on nationwide data from the medical and administrative databases of French national health insurance systems (07/01/08-12/31/09) with a follow-up of up to 30 months.</p><p>Methods</p><p>Lipid-lowering drug-naive diabetic patients initiating fibrate or statin monotherapy were identified. Patients at high cardiovascular risk were then selected: patients with a diagnosis of diabetes and hypertension, and >50 (men) or 60 (women), but with no history of cardiovascular events. The composite endpoint comprised myocardial infarction, stroke, amputation, or death.</p><p>Results</p><p>Of the 31,652 patients enrolled, 4,058 (12.8%) received a fibrate. Age- and gender-adjusted annual event rates were 2.42% (fibrates) and 2.21% (statins). The proportionality assumption required for the Cox model was not met for the fibrate/statin variable. A multivariate model including all predictors was therefore calculated by dividing data into two time periods, allowing Hazard Ratios to be calculated before (HR_<540) and after 540 days (HR_>540) of follow-up. Multivariate analyses showed that fibrates were associated with an increased risk for the endpoint after 540 days: HR_<540 = 0.95 (95% CI: 0.78–1.16) and HR_>540 = 1.73 (1.28–2.32).</p><p>Conclusion</p><p>Fibrate monotherapy is commonly prescribed in diabetic patients with high cardiovascular risk and is associated with poorer outcomes compared to statin therapy.</p></div

Predictors of the combined outcome in age- and gender-adjusted Cox models.

<p>Abbreviations: HR, hazard ratio; CI, confidence interval. P-values were calculated using the Cox-proportional hazard model.</p><p>Predictors of the combined outcome in age- and gender-adjusted Cox models.</p

A. Study scheme. B. Flow chart of patients with diabetes and high cardiovascular risk in primary care initiating fibrate or statin monotherapy.

<p>A. Study scheme. B. Flow chart of patients with diabetes and high cardiovascular risk in primary care initiating fibrate or statin monotherapy.</p

Final Cox models with a cut-off time at 540 days.

<p>Abbreviations: HR, hazard ratio; CI, confidence interval. P-values were calculated using the Cox-proportional hazard model.</p><p>Final Cox models with a cut-off time at 540 days.</p

Survival curves for death and cardiovascular events in patients treated with statin or fibrate monotherapy.

<p>Survival curves for death and cardiovascular events in patients treated with statin or fibrate monotherapy.</p