Summary
Background
The frequencies of treatment for cardiovascular risk factors are poorly documented in large populations, particularly according to the presence or absence of cardiovascular disease (CVD).
Aims
To assess frequencies of reimbursements for antihypertensive, lipid-lowering and antidiabetic medications in France among national health insurance beneficiaries in 2010 and their associations according to age, sex, French regions, level deprivation and the presence of certain CVD.
Methods
Treatment frequencies were calculated among the beneficiaries (58 million people) on the basis of reimbursements for three specific categories of medicinal products in 2010. The presence of CVD was defined by a diagnosis associated with chronic disease status and hospital stays in 2010.
Results
Among people aged greater or equal to 20 years, treatment frequencies were 22% (men 20% vs. women 23%) for antihypertensives, 15% (14% vs. 16%) for lipid-lowering agents and 6% (6% vs. 5%) for antidiabetic medications. These frequencies were, respectively, 33%, 23% and 8% in patients aged greater or equal to 40 years and 55%, 38% and 14% in patients aged greater or equal to 60 years. The frequency of at least one treatment for at least one of the three risk factors was 41% in patients aged greater or equal to 40 years and 66% in patients aged greater or equal to 60 years. Among patients aged greater or equal to 20 years, 22% were treated for at least one risk factor in the absence of CVD and 3% were treated for at least one risk factor in the presence of CVD. Regional differences were observed, with higher frequencies of antihypertensive and antidiabetic use in the North, North-East and Overseas regions. Treatment frequencies increased with level of deprivation, especially for antidiabetics.
Conclusion
This national study more clearly defines treatment frequencies and the populations and regions with the highest treatment frequencies.
Résumé
Contexte
Les fréquences de traitements des facteurs de risque cardiovasculaire sont peu connues dans de larges populations, particulièrement selon la présence ou non d’une maladie cardiovasculaire (MCV).
Objectifs
Décrire les fréquences nationales et régionales des traitements anti-hypertenseurs, antidiabétiques et hypolipémiants et de leurs associations en France parmi les assurés du régime général de l’assurance maladie selon l’âge, le sexe, la région, le niveau de défavorisation et la présence de certaines MCV.
Méthodes
Ces fréquences ont été calculées parmi ces assurés (58 millions), sur la base de trois remboursements de médicaments spécifiques en 2010. L’existence d’une MCV a été définie par les diagnostics des affections de longue durée et des séjours hospitaliers en 2010.
Résultats
Chez les personnes de 20 ans et plus, la fréquence d’un traitement anti-hypertenseur était de 22 % (hommes 20 %, femmes 23 %), d’un hypolipémiant de 15 % (14 % vs 16 %) et d’un antidiabétique de 6 % (6 % vs 5 %). Après 40 ans, elles étaient de 33 %, 23 % et 8 % et après 60 ans de 55 %, 38 % et 14 %. La fréquence d’au moins un traitement pour au moins un des trois facteurs était de 41 % pour ceux de 40 ans et plus et de 66 % pour ceux de 60 ans et plus. Parmi les personnes de 20 ans et plus, 22 % avaient au moins un facteur de risque traité et pas de MCV, et 3 % au moins un facteur traité et une MCV. Des fréquences plus élevées de l’utilisation d’anti-hypertenseurs et d’antidiabétiques étaient constatées dans les régions Nord, Nord-Est et Outremer. Les fréquences des traitements augmentaient avec le niveau de défavorisation, surtout pour les antidiabétiques.
Conclusions
Cette étude nationale permet de mieux connaître les fréquences des traitements des facteurs de risque cardiovasculaire et d’appréhender les populations et régions où elles sont plus élevées.
Background
Cardiovascular diseases (CVD) are a leading cause of healthcare consumption, disability and mortality in industrialized countries. Although the number of people affected by CVD is increasing, standardized morbidity and mortality are declining as a result, among other factors, of improved early management of recognized diseases by aggressive treatment, but also improved treatment of cardiovascular risk factors .
Compared with other European countries, in 2008, France had the lowest standardized mortality rate for ischaemic heart disease and the second lowest standardized mortality rate for stroke among patients aged 45–74 years, for both men and women . These data are confirmed by morbidity data, as the three French MONICA registries reported a significant mean 19% decrease in rates of myocardial infarction and coronary mortality between 2000–2003 and 2004–2007 for both sexes, and the Dijon registry reported a stable incidence of stroke between 1985 and 2004 with a more advanced age of onset . The standardized national hospitalization rate for myocardial infarction decreased by 17% between 2002 and 2008. This reduction was more marked among those aged greater or equal to 65 years (–22%). Before the age of 65 years, hospitalization rate decreased for men (–10%), but increased for women (+7%) . The annual hospitalization rate for stroke decreased by 3% overall, but increased by 11% before the age of 65 years . Surveillance of the levels of primary prevention of CVD and their impact in these populations therefore remains a priority, including in the youngest.
The prevalence rates, treatment and control of cardiovascular risk factors are usually measured by repeated cross-sectional studies in samples from the general population, generally based on self-reported medication consumption or measurement with (or without) clinical examination and laboratory tests . However, subgroup analyses are usually difficult due to the small sample sizes. Hypertension, diabetes and hyperlipidaemia are cardiovascular risk factors accessible to drug treatments, the use of which has been poorly studied in national administrative databases.
The present study was designed to assess national and regional frequencies of reimbursements for antihypertensive, lipid-lowering and antidiabetic medications in France among national health insurance beneficiaries in 2010 and their associations according to age, sex, French regions, level deprivation and the presence of certain CVD.
Methods
In 2010, the Régime Général de l’Assurance Maladie (French national health insurance general scheme) covered about 58 million people living in France, i.e. almost 90% of the French population and almost 75% of the population after the exclusion of local mutualist sections. The Système National d’Information Inter-Régimes de l’Assurance Maladie (SNIIRAM; French national interscheme health insurance information system) comprises an individual and anonymous database, which comprehensively records all healthcare consumption, ambulatory care or outpatient visits, reimbursed by national health insurance, with historical data limited to a period of 3 years plus the current year . Other information is also available, such as the town of residence, 100% reimbursement of care for certain chronic diseases (Affections de Longue Durée [ALD]), based on the opinion of the national health insurance general scheme consultant physician. All this information can be linked to data collected in healthcare institutions by the Programme de Médicalisation des Systèmes d’Information (PMSI; medicalized information systems programme) using the unique anonymous patient identifier generated from the Numéro d’Inscription au Répertoire des personnes physiques (social security number). Diagnoses are coded in PMSI according to the International Classification of Diseases, 10th edition (ICD-10), which is also used to code diseases corresponding to ALD.
The study population comprised national health insurance general scheme beneficiaries for whom at least one healthcare reimbursement in 2010 was recorded in SNIIRAM. This criterion was justified by the fact that survival and date of death are only available for general scheme beneficiaries (about 75% of the population) and not for the beneficiaries of other schemes managed by local mutualist sections in SNIIRAM. As the survival status was not available for all patients, the selection of beneficiaries in whom at least one healthcare reimbursement in 2010 was recorded therefore ensures that all beneficiaries of the general scheme, including local mutualist sections, were alive in 2010. Some beneficiaries could not be included due to the absence of reimbursement in the SNIIRAM database, because their treatments were financed directly by the institution (for example medical and social welfare institutions) and were therefore not reimbursed individually, or because they had no reimbursement whatsoever during the index year.
The presence of CVD was estimated by the presence of an ALD with a specific ICD-10 CVD code before or during 2010 and/or the presence of a short-stay hospitalization in 2010 with CVD ICD-10 codes in any position (main, associated or related diagnosis). Selected CVD were coronary heart disease and myocardial infarction (I20 to I25), stroke (I61 to I66, I69, G45) and peripheral artery disease (I70.2), grouped under the term CVD. National health insurance beneficiaries with other CVD codes not included above were excluded to eliminate people with CVD not known to be highly associated with the cardiovascular risk factors studied.
The presence of a treatment for one of the defined risk factors was estimated by the presence of three or more reimbursements recorded in the database in 2010 (or two prescriptions in the case of large packaging) for at least one indicated medicinal product. Medicinal products were identified in the SNIIRAM by ATC class (Anatomical Therapeutic Chemical Classification System) and the corresponding Code Identifiant de Présentation (CIP; presentation identification code). Medicinal products indicated for diabetes corresponded to ATC class A10 (drugs used in diabetes). Indicated antihypertensive medications were those for which the Marketing Authorization specified an indication in the treatment of hypertension (i.e. class C02, antihypertensive; C03, diuretics; C07, beta blocking agents; C08, calcium channel blockers; and C09, agents acting on the renin-angiotensin system). Class C10 was used to identify treatments for hyperlipidaemia.
For each of the three risk factors considered, treatment frequencies of one or several risk factors and their associations by age, sex and region and according to the presence or absence of CVD were calculated on the basis of the populations of beneficiaries with any healthcare consumption reported during 2010. Some age groups were combined (≥ 20 years; ≥ 40 years; ≥ 60 years; 18–74 years) to allow national or international comparisons. Regional frequencies were standardized according to sex and age of the population of the general scheme beneficiaries of the Répertoire National Inter-régimes des bénéficiaires de l’Assurance Maladie (RNIAM; national interscheme directory of national health insurance beneficiaries) on 1st January 2011. The cost analysis was based on the amount of annual reimbursement for each treatment according to the refunded amount of each drug studied. Spearman’s test was used to identify regional correlations between standardized treatment frequencies and standardized regional hospitalization rates for stroke, ischaemic heart disease and heart failure in 2008 for the overall population. Treatment frequencies were studied according to a geographic deprivation score expressed in quintiles, established on a scale based on the place of residence according to four factors: mean household income; percentage of high school graduates among the inhabitants aged greater or equal to 15 years; percentage of manual workers in the working population; and unemployment rate . Treatment frequencies were also studied according to the degree of urbanicity of the French county defined by counties in which no residence is separated from the next by more than 200 m. For these two analyses, people living in French Overseas departments were excluded due to a lack of place of residence codification. Statistical analyses were performed with SAS Enterprise Guide 4.1 software (SAS Institute, Inc., Cary, NC, USA).
Results
Treatment frequencies for all general scheme beneficiaries included in 2010 were 16% (men, 15%; women, 17%) for antihypertensive drugs, 11% (men, 12%; women, 11%) for lipid-lowering agents and 4% (men, 5%; women, 4%) for antidiabetic drugs ( Table 1 ). Treatment frequencies were 33%, 23% and 8%, respectively, for patients aged greater or equal to 40 years and 55%, 38% and 14%, respectively, for those aged greater or equal to 60 years. Peak frequencies were observed in those aged 75–79 years for lipid-lowering agent treatments (47%) and antidiabetics (17%) and in the group aged 85–89 years for antihypertensives (75%), in both men and women.
| Age (years) | n b | Hypertension | Hyperlipidaemia | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Men (%) ( n = 4.1) b | Women (%) ( n = 5.3) b | Ratio (W/M) | Total (%) ( n = 9.4) b | Men (%) ( n = 3.2) b | Women (%) ( n = 3.2) b | Ratio (W/M) | Total (%) ( n = 6.4) b | ||
| 0–4 | 3.7 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | ||
| 5–9 | 3.7 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | ||
| 10–14 | 3.6 | 0.1 | 0.1 | 1.0 | 0.1 | 0.0 | 0.0 | 0.0 | |
| 15–19 | 3.5 | 0.2 | 0.2 | 1.0 | 0.2 | 0.0 | 0.1 | 0.1 | |
| 20–24 | 3.5 | 0.4 | 0.6 | 1.5 | 0.5 | 0.1 | 0.2 | 2.0 | 0.1 |
| 25–29 | 3.8 | 0.7 | 1.0 | 1.4 | 0.9 | 0.3 | 0.3 | 1.0 | 0.3 |
| 30–34 | 3.9 | 1.4 | 1.7 | 1.2 | 1.5 | 0.7 | 0.4 | 0.6 | 0.6 |
| 35–39 | 4.2 | 2.8 | 3.3 | 1.2 | 3.0 | 1.9 | 1.0 | 0.5 | 1.4 |
| 40–44 | 4.1 | 5.7 | 6.4 | 1.1 | 6.0 | 4.7 | 2.2 | 0.5 | 3.4 |
| 45–49 | 4.1 | 10.9 | 11.4 | 1.0 | 11.2 | 9.3 | 4.6 | 0.5 | 6.9 |
| 50–54 | 3.8 | 19.5 | 18.9 | 1.0 | 19.2 | 16.8 | 9.5 | 0.6 | 12.9 |
| 55–59 | 3.6 | 30.5 | 27.4 | 0.9 | 28.8 | 25.9 | 17.4 | 0.7 | 21.3 |
| 60–64 | 3.5 | 41.3 | 36.3 | 0.9 | 38.7 | 34.4 | 26.5 | 0.8 | 30.2 |
| 65–69 | 2.3 | 50.0 | 46.2 | 0.9 | 48.0 | 40.8 | 34.7 | 0.9 | 37.5 |
| 70–74 | 2.0 | 57.9 | 55.9 | 1.0 | 56.8 | 45.2 | 41.3 | 0.9 | 43.1 |
| 75–79 | 1.8 | 66.0 | 65.3 | 1.0 | 65.6 | 48.3 | 45.5 | 0.9 | 46.6 |
| 80–84 | 1.4 | 71.9 | 71.9 | 1.0 | 71.9 | 47.4 | 43.1 | 0.9 | 44.6 |
| 85–89 | 0.8 | 74.8 | 75.1 | 1.0 | 75.0 | 39.3 | 33.6 | 0.9 | 35.3 |
| ≥ 90 | 0.4 | 70.8 | 72.4 | 1.0 | 72.1 | 23.6 | 18.2 | 0.8 | 19.4 |
| ≥ 20 | 43.3 | 20.5 | 22.7 | 1.1 | 21.7 | 15.8 | 13.8 | 0.9 | 14.8 |
| ≥ 40 | 27.9 | 31.9 | 33.7 | 1.1 | 32.9 | 24.8 | 20.8 | 0.8 | 22.6 |
| ≥ 60 | 12.2 | 54.5 | 54.6 | 1.0 | 54.6 | 40.8 | 35.4 | 0.9 | 37.7 |
| 18–74 | 38.9 | 16.3 | 16.2 | 1.0 | 16.3 | 13.4 | 10.3 | 0.8 | 11.8 |
| Total | 57.9 | 15.0 | 17.4 | 1.2 | 16.3 | 11.6 | 10.6 | 0.9 | 11.1 |
| Age (years) | Diabetes | |||
|---|---|---|---|---|
| Men (%) ( n = 1.3) b | Women (%) ( n = 1.2) b | Ratio (W/M) | Total (%) ( n = 2.5) b | |
| 0–4 | 0.0 | 0.0 | 0.0 | |
| 5–9 | 0.1 | 0.1 | 1.0 | 0.1 |
| 10–14 | 0.2 | 0.2 | 1.0 | 0.2 |
| 15–19 | 0.2 | 0.2 | 1.0 | 0.2 |
| 20–24 | 0.3 | 0.3 | 1.0 | 0.3 |
| 25–29 | 0.4 | 0.4 | 1.0 | 0.4 |
| 30–34 | 0.5 | 0.6 | 1.2 | 0.5 |
| 35–39 | 0.8 | 0.8 | 1.0 | 0.8 |
| 40–44 | 1.6 | 1.4 | 0.9 | 1.5 |
| 45–49 | 3.1 | 2.4 | 0.8 | 2.7 |
| 50–54 | 5.8 | 4.2 | 0.7 | 4.9 |
| 55–59 | 9.7 | 6.5 | 0.7 | 8.0 |
| 60–64 | 13.7 | 8.6 | 0.6 | 11.0 |
| 65–69 | 17.1 | 11.2 | 0.7 | 14.0 |
| 70–74 | 18.6 | 13.0 | 0.7 | 15.5 |
| 75–79 | 20.0 | 14.6 | 0.7 | 16.8 |
| 80–84 | 19.1 | 14.1 | 0.7 | 15.9 |
| 85–89 | 15.8 | 11.6 | 0.7 | 12.8 |
| ≥ 90 | 11.0 | 8.2 | 0.7 | 8.9 |
| ≥ 20 | 6.3 | 4.9 | 0.8 | 5.6 |
| ≥ 40 | 9.7 | 7.2 | 0.7 | 8.4 |
| ≥ 60 | 16.7 | 11.6 | 0.7 | 13.7 |
| 18–74 | 5.3 | 3.8 | 0.7 | 4.5 |
| Total | 4.6 | 3.8 | 0.8 | 4.2 |
a A patient treated for hypertension and diabetes is counted in hypertension, diabetes and hypertension–diabetes.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
