S. Fosse

Trends in the quality of care for elderly people with type 2 diabetes: The need for improvements in safety and quality (the 2001 and 2007 ENTRED Surveys)

AIM This study aimed to characterize the sociodemographic data, health status, quality of care and 6-year trends in elderly people with type 2 diabetes. METHODS This study used two French cross-sectional representative surveys of adults of all ages with all types of diabetes (Entred 2001 and 2007), which combined medical claims, and patient and medical provider questionnaires. The 2007 data in patients with type 2 diabetes aged 65 years or over (n=1766) were described and compared with the 2001 data (n=1801). RESULTS Since 2001, obesity has increased (35% in 2007; +7 points since 2001) while written nutritional advice was less often provided (59%; -6 points). Mean HbA(1c) (7.1%; -0.2%), blood pressure (135/76 mmHg; -4/-3 mmHg) and LDL cholesterol (1.04 g/L; -0.21 g/L) declined, while the use of medication increased: at least two OHAs, 34% (+4 points); OHA(s) and insulin combined, 10% (+4 points); antihypertensive treatment, 83% (+4 points); and statins 48% (+26 points). Severe hypoglycaemia remained frequent (10% had an event at least once a year). The overall prevalence of complications increased. Renal complications were not monitored carefully enough (missing value for albuminuria: 42%; -4.5 points), and 46% of those with a glomerular filtration rate less than 60 mL/min/1.73 m² were taking metformin. CONCLUSION Elderly people with type 2 diabetes are receiving better quality of care and have better control of cardiovascular risk factors than before. However, improvement is still required, in particular by performing better screening for complications. In this patient population, it is important to carefully monitor the risks for hypoglycaemia, hypotension, malnutrition and contraindications related to renal function.

Self-monitoring of blood glucose in people with type 1 and type 2 diabetes living in France: The Entred study 2001

OBJECTIVE To describe the practice of self-monitoring blood glucose (SMBG) testing and to determine factors linked to SMBG in people with diabetes living in France. METHODS The 2001 Entred study, a French national survey of people being treated for diabetes, is based on a representative sample of 10,000 adults who claimed reimbursement for oral hypoglycaemic agents and/or insulin in October to December 2001 and who were randomly extracted from the database of the major National Health Insurance System. A questionnaire was mailed to all these people and was returned by 36% of them, who were then classified into three groups: type 1 diabetes (T1D, N=235); type 2 diabetes treated with insulin (iT2D, N=635); and type 2 diabetes treated with oral hypoglycaemic agents (oT2D, N=2689). Factors associated with SMBG were analyzed using logistic regression models with a step-by-step forward approach. RESULTS HbA(1c) was greater than or equal to 8% in 42% of people with T1D, 48% of those with iT2D and 21% of those with oTD2. Almost all of those treated with insulin performed SMBG. The frequency of self-monitoring was higher in T1D than in iT2D. In T1D, 58% of people reported they took at least three tests a day, as recommended in guidelines, which was more frequent in those who knew what HbA(1c) meant and in women. In iT2D, 74% reported that they took at least two tests a day, as recommended, and it was more frequent in those who knew what HbA(1c) meant, who reported at least one severe hypoglycaemic episode in 2001 and who received dietary advice from their practitioner. In oT2D, 38% reported using SMBG (six tests a week on average), even though no official recommendation had been provided for these patients. SMBG was also more frequent in patients being treated with multiple oral hypoglycaemic agents, in those who benefited from a waiver of co-payment due to a chronic disease and in those, who had visited a diabetes specialist in 2001, reported they knew what HbA(1c) meant, received dietary advice and reported at least one severe hypoglycaemic episode in 2001 and/or a history of diabetes complications. CONCLUSION In France, as per the official recommendations, almost all people on insulin treatment use a SMBG device while, overall, their glucose control remains poor. More than one-third of those with oT2D regularly perform SMBG. In only 3% of people, the regular use of SMBG does not appear to be related to any special needs or events (such as insulin treatment, occurrence of severe hypoglycaemia or chronic complications).

Le diabète de type 2 en France : épidémiologie, évolution de la qualité de la prise en charge, poids social et économique. Entred 2007

Between 2001 and 2007, treatments for type 2 diabetes have increased and therapeutic choices have improved. However glycemic control remains insufficient. Cardiovascular risk control has widely increased. Statins, hypertensive and antithrombotic treatments are more often prescribed. Blood pressure and LDL cholesterol levels have decreased whatever age. However, progress remains possible, especially regarding blood pressure control. Obesity has increased between 2001 and 2007 to reach 41% whereas the frequency of dietetic visits has decreased. Insulin therapy (more than obesity) determines the frequency of dietetic visits: dietetic care happens too late. Important improvements of the quality of follow-up are observed. However, fundus exams and more specifically albuminuria measurement remain insufficiently performed and their progression is too slow, as well as the podiatric examination. Only 10% of people with type 2 diabetes have an endocrinology visit, which has been stable between 2001 and 2007. Information expectations of people with type 2 diabetes are strong, especially for diet. Education demand is lower but more important for people who have already benefited. This improvement of medical care leads to an increase in the cost of reimbursements. The consequences of diabetes, more than the disease itself, alter the quality of life.

P1 Impact du niveau socio-économique et du pays de naissance sur l’état de santé et le recours aux soins des personnes diabétiques de type 2, Entred 2007

Introduction L’impact du niveau socio-economique et du pays de naissance sur l’etat de sante et le recours aux soins des personnes diabetiques de type 2 en France metropolitaine a ete etudie a partir d’Entred 2007. Materiels et Methodes 8 926 adultes ont ete tires au sort dans les bases de l’Assurance maladie et leur consommation medicale a ete extraite ; 4 277 personnes (3 894 diabetiques de type 2) ont repondu a un auto-questionnaire ; 2 485 medecins a un questionnaire medical. Resultats Apres ajustement sur sexe, âge, anciennete du diabete, traitement antidiabetique, les personnes a plus bas revenus etaient moins souvent suivies par un endocrinologue liberal (OR = 0,7) mais plus nombreuses a consulter frequemment leur medecin generaliste (=12 consultations/an, OR = 2,3) que celles a plus hauts revenus. Elles n’etaient pas plus souvent hospitalisees (OR = 1,0). Elles etaient plus souvent sous ALD (88 %, OR = 1,5). Elles etaient aussi nombreuses a beneficier d’au moins 3 dosages d’HbA1c (OR = 0,9) mais moins nombreuses a beneficier d’un dosage de microalbuminurie (OR = 0,7), d’un fond d’œil (OR = 0,4) ou d’un test au monofilament (OR = 0,7). Elles avaient plus frequemment declare une complication macrovasculaire (OR = 1,4) et podologique (OR = 1,6) et souffraient plus souvent d’une insuffisance renale chronique (OR = 1,7). Les personnes nees au Maghreb declaraient plus souvent une complication ophtalmologique que celles nees en France (OR = 1,6) mais moins souvent avoir beneficie d’un fond d’œil (OR = 0,7). Des resultats similaires ont ete retrouves avec d’autres marqueurs du niveau socio-economique. Conclusion Les personnes diabetiques de bas niveau socio-economique beneficient moins souvent du depistage des complications, malgre une ALD et un recours au medecin generaliste plus frequents, ainsi qu’une prevalence plus elevee de ces complications. Toutefois, les plus precaires n’ont probablement pas participe, d’autres ont pu beneficier de soins non traces par l’Assurance maladie (consultations hospitalieres, centres d’examen de sante…), et le niveau socio-economique peut avoir influence la declaration des patients mais pas des medecins.

Feasibility of screening for silent myocardial ischaemia according to the ALFEDIAM–SFC 2004 Guidelines in a population of diabetic patients

BACKGROUND Screening tests have to meet a number of criteria, including feasibility. The aim of this study was to estimate the proportion of the French diabetic population that is eligible for screening for silent myocardial ischaemia (SMI), and to evaluate the feasibility of such screening in the Franche-Comté region. METHODS Data were taken from the Echantillon National Témoin Représentatif de la Population Diabétique (ENTRED, a Representative National Sample of the Diabetic Population 2001 study), which was based on questionnaires filled out by 3646 diabetic patients. All screening tests carried out in the region of Franche-Comté in eastern France in 2003 were recorded (n=19,216). RESULTS The guidelines issued by the ALFEDIAM-SFC in 2004 were applied to the ENTRED population and identified 645 diabetic patients (17%) as eligible for SMI screening. When applied to the region of Franche-Comté, the recommendations would have required screening 7480 diabetic patients over a period of 3years, involving 1246 exercise stress tests and 1246 myocardial perfusion or stress echocardiography studies annually. However, more than 14,653 exercise stress, 4248 myocardial perfusion and 315 stress echocardiography tests were carried out in the region in 2003 among diabetic and non-diabetic patients, thus largely covering the screening requirements. On the other hand, ENTRED 2001 data also showed that 60% of patients who reported existing coronary disease would not have met screening criteria. CONCLUSION The number of examinations carried out in the region of Franche-Comté greatly exceeded the number of patients required for screening. However, practical feasibility is not the only criterion needed to guarantee the quality of a large-scale screening programme. Our results raise the question of the relevance of the current screening selection criteria.

O97 Évolution du taux d’incidence des amputations de membre inférieur chez les personnes diabétiques, et devenir à 3 ans des personnes diabétiques amputées, selon les données du PMSI

Introduction Alors que l’amputation d’un membre inferieur (AMI) est une complication grave et couteuse du diabete, le devenir des personnes diabetiques amputees a ete peu etudie en France. L’objectif de cette analyse est d’estimer l’evolution du taux d’AMI de 2004 a 2007 et d’etudier le devenir a 3 ans des personnes diabetiques amputees d’un membre inferieur en 2004 a partir des donnees du PMSI. Materiels et Methodes Les actes d’AMI ont ete extraits de la base PMSI moyens et courts sejours de 2004 a 2007 de metropole. Le diagnostic de diabete a ete etabli lorsqu’au moins un sejour hospitalier (pour amputation ou autre) reportait un diagnostic de diabete durant la periode 2004–2007. Le suivi a 3 ans a ete effectue sur l’ensemble des 8 002 personnes amputees en 2004 dont le numero d’anonymat etait correct. Resultats En 2004 et 2007, respectivement 10 265 et 11 442 actes d’AMI ont ete enregistres, chez respectivement 8 470 et 9 236 personnes diabetiques. Le taux d’incidence brut de l’AMI est reste stable, autour de 375 / 100 000 personnes diabetiques. Il s’agissait en 2004 d’amputation d’orteil (44 %), de pied (19 %), de jambe (19 %) et de cuisse (18 %). Durant cette meme annee, 12 % des personnes diabetiques amputees sont decedees a l’hopital et 18 % ont ete re-amputees. Apres 3 ans de suivi, le taux cumule de deces hospitalier etait de 23 % et le taux cumule de re-amputation de 35 %, soit un taux cumule de deces hospitalier ou de re-amputation de 50 % et une duree d’hospitalisation cumulee mediane de 54 jours. Conclusion Il est probable que l’augmentation du nombre d’actes d’AMI soit le reflet de l’augmentation de la prevalence du diabete, car l’incidence des AMI est restee stable entre 2004 et 2007. Le taux de deces hospitalier ou de re-amputation a 3 ans est extremement eleve, temoignant de la gravite de cette complication du diabete. Ce taux est neanmoins sous-estime car il ne comprend pas les deces survenus au domicile (non disponibles) ni ceux survenus en soins de suite et de readaptation (lesquels seront recherches par analyse du PMSI correspondant).

P4 Les complications rénales du diabète : dépistage, prise en charge médicale et tendances 2001–2007, selon les études Entred

Introduction Cette analyse vise a estimer la prevalence, le depistage et la prise en charge medicale des complications renales du diabete de type 2 en France metropolitaine en 2007, ainsi que leurs determinants et evolutions de 2001 a 2007. Patients et Methodes Pour Entred 2007, un tirage au sort a selectionne 8 926 personnes diabetiques remboursees d’au moins 3 antidiabetiques au cours des 12 derniers mois. Des questionnaires patient (n = 3 894 diabetiques de type 2) et medecin (n = 2 232) ont ete recueillis. Les analyses ont ete ponderees sur plan de sondage et non-reponse aux questionnaires. Les determinants d’une prise en charge appropriee ont ete analyses par regression logistique. En les restreignant a des populations comparables, les donnees 2007 (n = 1 941) ont ete comparees a celle d’Entred 2001 (n = 1 553). Resultats Le debit de filtration glomerulaire etait inferieur a 60 ml/min/1,73 m2 chez 19 % des diabetiques de type 2 (âge moyen 69 ans), et 16 % avaient une albuminurie anormale. La prevalence de la maladie renale chronique etait estimee au moins a 29 % (femmes 32 % ; hommes 26 %) et les stades 1, 2, 3, 4 et 5 a respectivement 3 %, 6 %, 18 %, 1 % et 0 % (34 % normaux et 38 % manquants). Plus de deux tiers (68 %) des personnes avec maladie renale chronique beneficiaient d’un traitement par IEC/ARA II (+ 16 points depuis 2001). Un tiers (34 %) disposait d’un suivi medical adequat (dosage de microalbuminurie, +5 points ; creatinemie, +4 points ; et 3 dosages d’HbA1c annuels, +11 points). Les facteurs lies a l’existence d’un traitement par IEC/ARA etaient l’âge = 65 ans, le surpoids ou obesite, une pression arterielle elevee, la pratique d’un dosage annuel d’albuminurie ou de creatinemie. Les facteurs lies au suivi medical adequat etaient la prise en charge a 100 % pour affection de longue duree, au moins 12 consultations en medecine generale, un suivi effectue par un medecin specialiste ou âge de 50 ans au plus. Conclusion Bien que des ameliorations soient survenues depuis 2001, le depistage, le suivi et le traitement des complications renales du diabete restent insuffisants et les complications renales frequentes.