V. Sciortino

Social inequalities in new antidepressant treatment: a study at the individual and neighborhood levels.

PURPOSE To determine whether social inequalities in new antidepressant treatment exist at the individual and/or neighborhood level; and their relation to access to prescribers and/or processes of care (treatment initiation and duration). METHODS We followed 316,412 inhabitants of Marseilles (aged 18-64 years) covered by the National Health Insurance Fund for 2.5 years. We analyzed new treatments (≥1 purchase of antidepressants and none in the 6 months before the first one), and new long treatments (≥4 within 6 months after the first purchase). We tested their associations with high individual disadvantage and census block deprivation in a multivariate, multilevel logistic model adjusted for consultations with general practitioners and psychiatrists to control for access to care. RESULTS High individual disadvantage was not associated with the probability of new treatments, but it was with lower odds of receiving new long treatments. Residing in deprived census blocks was associated with lower odds of receiving treatment for both dependent variables. CONCLUSIONS Our results suggest that social inequalities at the individual and neighborhood levels in new antidepressant treatment occur in access to specialty care and in treatment initiation and affect its duration. Further research is warranted to improve our understanding of their mechanisms.

Membership in a diabetes-care network and adherence to clinical practice guidelines for treating type 2 diabetes among general practitioners: A four-year follow-up

OBJECTIVES To assess whether private general practitioners (GPs) belonging to a diabetes-care network adhered more closely to clinical practice guidelines for diabetes care than GPs not in such a network, for all their patients with type 2 diabetes treated with medication (patients with diabetes), regardless of whether they received care through a network (that is, whether a halo effect occurred). RESEARCH DESIGN AND MEASURES The study, based on health insurance reimbursement databases in southeastern France, included 468 GPs in two networks and 468 non-network GPs in the same geographical area, matched one-to-one by propensity scores. We followed up their patients with diabetes (n=22,808) from 2008 through 2011, conducting multivariate time-to-event analyses (Cox models) that took the matching design into account to evaluate time from inclusion until performance of the given number of each of six recommended examinations/tests. RESULTS GPs belonging to a diabetes-care network adhered more closely to clinical practice guidelines but our result were slightly pronounced. Hazard ratios (HR) were significantly higher for patients of network GPs for the implementation of 3 HbA1C assays (HRa=1.13; [95%CI=1.10-1.16]), or 1 microalbuminuria assay (1.4 [1.35-1.45]); they were lower for LDL-cholesterol assays (1.04 [1.01-1.07]) and ophthalmological checkups (1.07 [1.04-1.10]), and not significant for creatinemia or cardiac monitoring. CONCLUSIONS Network GPs had better diabetes monitoring practices for all their patients with diabetes than the other GPs, especially for the most diabetes-specific tests. Further research is needed in other settings to confirm the existence of this halo effect.

Membership in a Diabetes Care Network Improves General Practitioners’ Practices for HbA1c and Microalbuminuria Monitoring: A Cohort Study Among Patients With Type 2 Diabetes

To prevent complications of diabetes, clinical practice guidelines recommend specific frequencies of several checkups. Following these guidelines can decrease all-cause mortality and cardiovascular morbidity (1). France, like other countries, has sought to improve diabetes management, specifically by establishing diabetes care networks (DCNs) that coordinate care, provide continuing medical education for health care professionals, and educate network patients. Nonetheless, less than 5% of all patients with type 2 diabetes participate in these networks. Our aim was to study whether general practitioners (GPs) belonging to a DCN adhered more closely to guidelines for diabetes monitoring than GPs not belonging to a DCN for all their patients with type 2 diabetes and not only those in a DCN. Analyses focused on orders for two diabetes-specific examinations: HbA1c and microalbuminuria testing. Using health insurance reimbursement databases in southeastern France, we included 468 GPs in two networks …

Feedback and lessons from the prescription of rimonabant, a drug to be used under strict guidelines, in southeastern France, March 2007 through June 2008

BACKGROUND To provide feedback on the initial market authorization of rimonabant, a drug to be used under strict guidelines, we conducted a study with information from the National health insurance reimbursements database for southeastern France. The aims of this study were to: (1) describe the characteristics of subjects who have had one rimonabant prescription reimbursed; (2) study the frequency of prescriptions that did not comply with reimbursement criteria; (3) study the frequency of prescriptions for patients simultaneously treated with antidepressants; and (4) analyse the factors associated with both types of prescription (patient and prescriber characteristics). METHODS Using the database of drug reimbursements maintained by the southeastern France general health insurance fund, we studied the characteristics of outpatients with at least one reimbursement for rimonabant, compared them to the rest of the population, and analysed compliance with the indications, contraindications, and regulations for rimonabant prescription with multivariate logistic regressions. RESULTS A total of 10,510 beneficiaries (0.28%) had at least one rimonabant reimbursement. Among them, 55.7% were treated for diabetes. For at least 62.4% of rimonabant beneficiaries, the reimbursement regulations were not respected: this was significantly more frequent among women less than 57 years old, subjects with no chronic diseases, and when the prescriber was not an endocrinologist; 11.4% of rimonabant beneficiaries also received an antidepressant treatment. CONCLUSION Despite the specific status of rimonabant regarding its reimbursement modalities, these results suggest that some prescribers get around reimbursement instructions and that a significant percentage of prescriptions did not respect an important contraindication. Tools to follow up the prescriptions of new drugs with strict guidelines for use should be developed and physicians should be better informed and trained regarding specific prescription regulations.