Julien Bezin

The national healthcare system claims databases in France, SNIIRAM and EGB: Powerful tools for pharmacoepidemiology

The French health care system is based on universal coverage by one of several health care insurance plans. The SNIIRAM database merges anonymous information of reimbursed claims from all these plans, linked to the national hospital‐discharge summaries database system (PMSI) and the national death registry. It now covers 98.8% of the French population, over 66 million persons, from birth (or immigration) to death (or emigration), making it possibly the worlds largest continuous homogeneous claims database. The database includes demographic data; health care encounters such as physician or paramedical visits, medicines, medical devices, and lab tests (without results); chronic medical conditions (ICD10 codes); hospitalisations with ICD10 codes for primary, linked and associated diagnoses, date and duration, procedures, diagnostic‐related groups, and cost coding; date but currently not cause of death. The power of the database is correlatively great, and its representativeness is near perfect, since it essentially includes the whole countrys population. The main difficulty in using the database, beyond its sheer size and complexity, is the administrative process necessary to access it. Recent legislative advances are making this easier.

Choice of ICD-10 codes for the identification of acute coronary syndrome in the French hospitalization database

The objective of this study was to evaluate the performance of the ICD‐10 (International Classification of Diseases and Related Health Problems, 10th Edition) coding in the French hospitalization database (PMSI) to identify acute coronary syndrome (ACS) occurrence. Eligible hospitalizations were those that occurred at the Bordeaux teaching hospitals between 1 January 2011 and 31 December 2011 and had one of the ICD‐10 codes related to ischaemic heart diseases (I20 to I25, excluding I23 and I25.2). Among these, 100 hospitalizations were randomly selected; for each case, the ACS diagnosis was confirmed/excluded after medical file examination by an independent events validation committee and the performance of codes, and combinations of codes, to identify ACS was evaluated by calculating the positive predictive value (PPV). Of the individual codes, I20.0, I21 and I24 had the highest PPV; 100.0% for I24 (95%CI [15.8–100.0]); 90.0% for I21 (95%CI [76.3–97.2]); and 66.7% for I20.0 (95%CI [38.4–88.2]). The combination of I20.0 or I24 codes was able to identify 12 of the 56 validated ACS cases with a PPV of 70.6% (95%CI [44.0–89.7]), the combination of I21 or I24 identified 38 cases with a PPV of 90.5% (95%CI [77.4–97.3]), the combination of I20.0 or I21 identified 46 cases with a PPV of 83.6% (95%CI [71.2–92.2]), and the combination of I20.0, I21 or I24 identified 48 cases with a PPV of 84.2% (95%CI [72.1–92.5]). The combination of I20.0, I21 or I24 codes had the best performance to identify occurrence of ACS in the French hospitalization database.

Comparative effectiveness of recommended versus less intensive drug combinations in secondary prevention of acute coronary syndrome

The secondary prevention treatment for acute coronary syndrome (ACS) is based on the combined use of drugs from four therapeutic classes (beta‐blockers, antiplatelet agents, statins, and angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers). The objective of this study was to compare the long‐term effectiveness of the recommended therapeutic combination with those of incomplete combinations in secondary prevention of ACS.

Pharmacological treatments of cardiovascular diseases: Evidence from real-life studies

The management of chronic cardiovascular diseases has evolved greatly in the last decades. Over the last thirty years, the management of acute coronary syndrome has improved, leading to an important lowering of the mortality in the acute phase of the event. Consequently, the optimal management of the secondary prevention of acute coronary syndrome has greatly evolved. Moreover, the increased number of pharmacological alternatives for patients affected by chronic heart failure and by non-valvular atrial fibrillation reserves a number of challenges for their correct management. Moreover, these diseases are without any reasonable doubt the largest contributor to global mortality in the present and will continue to be it in the future. The aim of this study was to provide the most updated information of the real-life drug use and their effectiveness. This review was performed to assess the potential knowledge gaps in the treatments of these diseases and to indicate potential perspective of pharmaco-epidemiological research in this area.

Persistence to 5-year hormonal breast cancer therapy: a French national population-based study.

Background:Non-persistence to oral hormonal therapy (HT) in breast cancer (BC) is an emerging health issue, and estimations vary according to the population selected and/or the statistical method applied. This study aimed to estimate non-persistence over 5 years to HT in an unselected sample of women with BC using a French national population-based database and accounting for competing risks.Methods:A retrospective cohort of 600 women initiating a HT between 2006 and 2007 was constituted using a representative sample of the French national healthcare insurance system database. The Cumulative Incidence Function method was used to estimate the probability of first treatment discontinuation of at least 90 days accounting for competing risk of death from any cause over the theoretical 5-year period of treatment.Results:Thirty one percent of patients who initiated a HT were identified as non-persistent at the fifth year of follow-up. Patients who switched to another HT (HR 3.10, 95% CI (2.20; 4.36)) or had metastatic BC (HR 3.07, 95% CI (1.73; 5.46)) were more likely to be non-persistent. Women who initiated aromatase inhibitors as compared with tamoxifen (HR 0.62, 95% CI (0.46; 0.83)), had administrative registration for BC (HR 0.21, 95% CI (0.13; 0.32)), or had received an adjuvant chemotherapy (HR 0.65, 95% CI (0.48; 0.89)) were less likely to discontinue.Conclusions:The estimate of long-term non-persistence in an unselected sample of women treated in France by oral hormonal therapy is substantial, even accounting for competing risks.

Medications Recommended for Secondary Prevention After First Acute Coronary Syndrome: Effectiveness of Treatment Combinations in a Real-Life Setting

Long‐term effectiveness of evidence‐based cardiovascular medications (EBCMs) indicated after acute coronary syndrome (ACS) needs to be assessed considering the combination effects for these drugs recommended in association. Using a nationwide database, we conducted a cohort study to evaluate the effectiveness of all possible incomplete EBCMs‐based combinations as compared to that associating the four recommended EBCMs over up to 5 years of follow‐up. Among the 31,668 patients included, 22.9% had ACS recurrence or died during follow‐up. The risks associated with the use of 3‐EBCM based combinations were 1.46 (95% confidence interval: 1.33–1.60) for the combinations without statins, 1.30 (1.17–1.43) for the combinations without angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, 1.11 (0.98–1.25) for the combinations without antiplatelet agents, and 0.99 (0.89–1.10) for the combination without beta‐blockers. These findings question the interest of maintaining long‐term treatment with beta‐blockers in addition to the other EBCMs for post‐ACS secondary prevention.

Risk of Serious Trauma with Glucose-Lowering Drugs in Older Persons: A Nested Case-Control Study: Risk of trauma with glucose-lowering drugs

To assess the risk of hospitalization for trauma associated with use of hypoglycemic glucose‐lowering drugs (GLDs) in individuals aged 65 and older.

Use of Lipid‐Lowering Drugs and the Risk of Cataract: A Population‐Based Nested Case‐Control Study

Eye lens membrane cells require high cholesterol concentrations that might be counteracted by lipid‐lowering drugs. Using a nationwide database, we conducted a nested case‐control study to evaluate the risk of cataract development associated with the use of lipid‐lowering drugs. Patients aged 45 years and over with first cataract surgery in 2014 (cases) and up to four controls matched on age, gender, diabetes, hypothyroidism, glucocorticoid use, cardiovascular risk, and area of residence were included in the study. Among the 2,811 cases and 11,106 matched controls included, analyses showed a significantly increased risk of cataract surgery for a cumulative exposure to fibrates exceeding 5 years (adjusted odds ratio (aOR) 1.58; 95% confidence interval (CI): 1.17–2.15), unlike cumulative exposure to statins, whatever the dose or duration of treatment (aORs from 1.00–1.08, none being significant). This study highlighted an increased risk of cataract surgery with prolonged use of fibrates but not of statins.