Two-year prognosis and cardiovascular disease prevention after acute coronary syndrome; the role of cardiac rehabilitation: a French nationwide study.

AIMS: To evaluate the impact of cardiac rehabilitation (CR) on optimization of secondary prevention treatments for acute coronary syndrome (ACS), medication persistence, medical follow-up, rehospitalisation, and all-cause mortality. METHODS: The national health insurance database was used to identify all patients hospitalised for ACS in France in 2019 and those among them who received CR. Patients' characteristics and outcomes were described and compared between CR and non-CR patients. Poisson regression models were used to identify the impact of CR after adjusting for confounders. A Cox model was fitted to identify the variables related to mortality after adjustment for medication persistence and cardiologic follow-up. RESULTS: In 2019, 22% of 134,846 patients hospitalised for ACS in France received CR within six months of their discharge. After one year, only 60% of patients who did not receive CR were still taking BASI drugs (combination of Beta blockers, Antiplatelets agents, Statins and RAAS Inhibitors). This rate and the medical follow-up rate were higher in patients who received CR. Two years after the ACS event, patients who received CR had better medical follow-up and lower mortality risk, after adjusting for cofounding variables (adjusted HR all-cause mortality = 0.65 [0.61-0.69]). After adjustment for the dispensing of cardiovascular drugs and cardiologic follow-up, the independent effect of CR was not as strong but remained significant (HR = 0.90 [95%CI: 0.84-0.95]). CONCLUSION: Patients who received CR after hospitalisation for ACS had a better prognosis. Optimization of efficient secondary prevention strategies, improved medication persistence, and enhanced cardiologic follow-up seemed to play a major role.

In our nationwide study of all patients hospitalized for acute coronary syndrome in 2019 (n = 134,846), 22% were admitted in cardiac rehabilitation after their hospitalisation. The admission in cardiac rehabilitation unit increased patients medication persistence, increased the chance to initiate a tobacco replacement therapy in smokers, reduced rehospitalisation risk and the recurrence of acute coronary syndrome. In addition the risk of death was reduced in the two years following the hospitalization. Health benefits associated with an admission in cardiac rehabilitation following an acute coronary syndrome are significant focusing recurrence and mortality. The correction of cardiovascular risk factors, the improvement of medication persistence and a more frequent cardiologic follow-up play a major role in these health benefits.These results should help to encourage increased referral for and patient participation in cardiac rehabilitation programs, whose rate is still very low in many countries, including France. Finally, decreasing hospital capacity means that new rehabilitation modalities need to be considered, including supervised home-based CR and tele-rehabilitation.

Infection and Pediatric Arterial Ischemic Stroke Presumably Related to Focal Cerebral Arteriopathy: Data From the COVID-19 Pandemic.

BACKGROUND: Infection may trigger pediatric arterial ischemic stroke (PAIS), notably when related to focal cerebral arteriopathy. Community- and individual-level nonpharmaceutical interventions during the COVID-19 pandemic resulted in a major decrease in pediatric viral infections. We explored the consequences on the incidence of PAIS. METHODS: Using national public health databases, we identified children hospitalized between 2015 and 2022 with PAIS. Using an age proxy (29 days to 7 years) and excluding patients with cardiac and hematologic conditions, we focused on children with PAIS presumably related to focal cerebral arteriopathy or with no definite cause. Considering the delay between infection and PAIS occurrence, we compared a prepandemic reference period, a period with nonpharmaceutical interventions, and a post-nonpharmaceutical intervention period. RESULTS: Interrupted time-series analyses of the monthly incidence of PAIS in this group showed a significant decrease in the nonpharmaceutical intervention period compared with the prepandemic period: -33.5% (95% CI, -55.2%, -1.3%); P=0.043. CONCLUSIONS: These data support the association between infection and PAIS presumably related to focal cerebral arteriopathy.

Temporal trends in admission for cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021: Persistent sex, age and social disparities.

BACKGROUND: Cardiac rehabilitation after an acute coronary syndrome is recommended to decrease patient morbidity and mortality and to improve quality of life. AIMS: To describe time trends in the rates of patients undergoing cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021, and to identify possible disparities. METHODS: All patients hospitalized for acute coronary syndrome in France between January 2009 and June 2021 were identified from the national health insurance database. Cardiac rehabilitation attendance was identified within 6 months of acute coronary syndrome hospital discharge. Age-standardized cardiac rehabilitation rates were computed and stratified for sex and acute coronary syndrome subtypes (ST-segment elevation and non-ST-segment elevation). Patient characteristics and outcomes were described and compared. Factors independently associated with cardiac rehabilitation attendance were identified. RESULTS: In 2019, among 134,846 patients with an acute coronary syndrome, 22.3% underwent cardiac rehabilitation within 6 months of acute coronary syndrome hospital discharge. The mean age of patients receiving cardiac rehabilitation was 62 years. The median delay between acute coronary syndrome hospitalization and cardiac rehabilitation was 32 days, with about 60% receiving outpatient cardiac rehabilitation. Factors significantly associated with higher cardiac rehabilitation rates were male sex, younger age (35-64 years), least socially disadvantaged group, ST-segment elevation, percutaneous coronary intervention and coronary artery bypass graft. Between 2009 and 2019, cardiac rehabilitation rates increased by 40% from 15.9% to 22.3%. Despite greater upward trends in women, their cardiac rehabilitation rate was significantly lower than that for men (14.8% vs. 25.8%). In 2020, cardiac rehabilitation attendance dropped because of the coronavirus disease 2019 pandemic. CONCLUSIONS: Despite the health benefits of cardiac rehabilitation, current cardiac rehabilitation attendance after acute coronary syndrome remains insufficient in France, particularly among the elderly, women and socially disadvantaged people.

One-year emergency department visits for children < 18 years of age, associated factors and frequency of primary general practitioner or pediatrician visits before: a French observational study (2018-19).

BACKGROUND: This study was designed to identify factors associated with at least one emergency department (ED) visit and those associated without consultation by a general practitioner or paediatrician (GPP) before ED visit. Levels of annual consumption of healthcare services as a function of the number of ED visit were reported. METHODS: This retrospective study focused on children < 18 years of age living in mainland France and followed for one-year after their birth or birthday in 2018. Children were selected from the national health data system, which includes data on healthcare reimbursements, long-term chronic diseases (LTD) eligible for 100% reimbursement, and individual complementary universal insurance (CMUc) status granted to households with a low annual income. Adjusted odds ratios (OR) were estimated using multivariate logistic regression. RESULTS: There were 13.211 million children included (94.2% of children; girls 48.8%). At least one annual ED visit was found for 24% (1: 16%, 2: 5%, 3 or more: 3%) and 14% of visits led to hospitalization. Factors significantly associated with at least one ED visit were being a girl (47.1%; OR = 0.92), age < 1 year (9.1%; OR = 2.85), CMUc (22.7%, OR = 1.45), an ED in the commune of residence (33.3%, OR = 1.15), type 1 diabetes (0.25%; OR = 2.4), epilepsy (0.28%; OR = 2.1), and asthma (0.39%; OR = 2.0). At least one annual short stay hospitalisation (SSH) was found for 8.8% children of which 3.4% after an ED visit. A GPP visit the three days before or the day of the ED visit was found for 19% of children (< 1 year: 29%, 14-17 years: 13%). It was 30% when the ED was followed by SSH and 17% when not. Significant factors associated with the absence of a GPP visit were being a girl (OR = 0.9), age (1 year OR = 1.4, 14-17 years OR = 3.5), presence of an ED in the commune of residence (OR = 1.12), epilepsy LTD (OR = 1.1). CONCLUSION: The low level of visits to GPP prior to a visit to the ED and the associated factors are the elements to be taken into account for appropriate policies to limit ED overcrowding. The same applies to factors associated with a visit to the ED, in order to limit daily variations.

Nationwide time trends in patients hospitalized for acute coronary syndrome: a worrying generational and social effect among women.

AIMS: To estimate the time trends in the annual incidence of patients hospitalized for acute coronary syndrome (ACS) in France from 2009 to 2021 and to analyse the current sex and social differences in ACS, management, and prognosis. METHODS AND RESULTS: All patients hospitalized for ACS in France were selected from the comprehensive National Health Insurance database. Age-standardized rates were computed overall and according to age group (over or under 65 years), sex, proxy of socioeconomic status, and ACS subtype [ST-segment elevation (STSE) and non-ST-segment elevation]. Patient characteristics and outcomes were described for patients hospitalized in 2019. Differences in management (coronarography, revascularization), and prognosis were analysed by sex, adjusting for cofonders. In 2019, 143,670 patients were hospitalized for ACS, including 53,227 STSE-ACS (mean age = 68.8 years; 32% women). Higher standardized incidence rates among the most socially deprived people were observed. Women were less likely to receive coronarography and revascularization but had a higher excess in-hospital mortality. In 2019, the age-standardized rate for hospitalized ACS patients reached 210 per 100 000 person-year. Between 2009 and 2019, these rates decreased by 11.4% (men: -11.2%; women: -14.0%). Differences in trends of age-standardized incidence rate have been observed according to sex, age, and social status. Middle aged women (45-64 years) showing more unfavourable trends than in other age classes or in men. In addition, among women the temporal trends were more unfavourable as social deprivation increased. CONCLUSION: Despite encouraging overall trends in patients hospitalized for ACS rates, the increasing trends observed among middle-aged women, especially socially deprived women, is worrying. Targeted cardiovascular prevention and close surveillance of this population should be encouraged.

The burden of acute coronary syndrome remains important in France. Moreover, there are significant social and sex disparities in the epidemiology of this disease, especially in the 45- to 64-year-old generation. The rate of coronary angiography, revascularization, cardiac complications, and inhospital mortality differed between men and women, regardless of age, comorbidities, and social status.

Effect of comorbidities on healthcare expenditures for patients on kidney replacement therapy considering the treatment modality and duration in a French cohort.

End-stage kidney disease (ESKD) is associated with a substantial economic burden. In France, the cost of care for such patients represents 2.5% of the total French healthcare expenditures but serves less than 1% of the population. These patients' healthcare expenditures are high because of the specialized and complex treatment needed as well as the presence of multiple comorbidities. This study aims to describe and assess the effect of comorbidities on healthcare expenditures (direct medical cost and non-medical costs including transportation and compensatory allowances) for patients with ESKD in France while considering the modality and duration of renal replacement therapy (RRT). This study included adults who started RRT for the first time between 2012 and 2014 in France and were followed for 5 years. Generalized linear models were built to predict mean monthly cost (MMC) by integrating first the time duration in the cohort, then patient characteristics and finally the duration of use of each treatment modalities. Comorbidities with the highest effect on MMC were inability to walk (+ 1435€), active cancer (+ 593€), HIV positivity (+ 507€) and diabetes (+ 396€). These effects vary according to age or treatment modalities. This study confirms the importance of considering patient characteristics, comorbidities and type of RRT when assessing healthcare expenditures for patients with ESKD.

A French nationwide study compared various conditions and healthcare use of individuals < 65 years with a Down's syndrome to those without.

Few regular national clinical data are available for individuals with Down's syndrome (IDS) bearing in mind that they are subject to countries variations in medical termination of pregnancy and screening. Individuals < 65 in 2019 were selected in view of the low number of older IDS. Thus, 98% of 52.4 million people with correct data were included from the national health data system. IDS (35,342) were identified on the basis of the International Classification of Diseases 10th revision code (Q90). Risk ratios (RR) were calculated to compare the frequencies in 2019 between IDS and individual without Down's syndrome (IWDS) of use of health care. The prevalence of IDS was 0.07% (48% women), comorbidities were more frequent, especially in younger patients (24% < 1 year had another comorbidity, RR = 20), as was the percentage of deaths (4.6%, RR = 10). Overall, tumours were less frequent in IDS compared with IWDS (1.2%, RR = 0.7) except for certain leukaemias and testicular tumours (0.3%, RR = 4). Cardiac malformations (5.2%, RR = 52), dementia (1.2%, RR = 29), mental retardation (5%, RR = 21) and epilepsy (4%, RR = 9) were also more frequent in IDS. The most frequent hospital diagnoses for IDS were: aspiration pneumonia (0.7%, RR = 89), respiratory failure (0.4%, RR = 17), sleep apnoea (1.1%, RR = 8), cryptorchidism (0.3%, RR = 5.9), protein-energy malnutrition (0.1%, RR = 7), type 1 diabetes (0.2%, RR = 2.8) and hypothyroidism (0.1%, RR = 72). IDS were more likely to use emergency services (9%, RR = 2.4), short hospital stay (24%, RR = 1.6) or hospitalisation at home (0.6%, RR = 6). They consulted certain specialists two to three times more frequently than IWDS, for example cardiologists (17%, RR = 2.6). This study is the first detailed national study comparing IDS and non-IDS by age group. These results could help to optimize prenatal healthcare, medical and social support.

Cross-validation of comorbidity items in two national databases in a sample of patients with end-stage kidney disease.

BACKGROUND: The use of national medico-administrative databases for epidemiological studies has increased in the last decades. In France, the Healthcare Expenditures and Conditions Mapping (HECM) algorithm has been developed to analyse and monitor the morbidity and economic burden of 58 diseases. We aimed to assess the performance of the HECM in identifying different conditions in patients with end-stage kidney disease (ESKD) using data from the REIN registry (the French National Registry for patients with ESKD). METHODS: We included all patients over 18 years of age who started renal replacement therapy in France in 2018. Five conditions with a similar definition in both databases were included (ESKD, diabetes, human immunodeficiency virus [HIV], coronary insufficiency, and cancer). The performance of each SNDS algorithm was assessed using sensitivity, specificity, positive predictive values (PPVs), negative predictive values (NPVs), and Cohen's kappa coefficient. RESULTS: In total 5,971 patients were included. Among them, 81% were identified as having ESKD in both databases. Diabetes was the condition with the best performance, with a sensitivity, specificity, PPV, NPV, and Kappa coefficient all over 80%. Cancer had the lowest level of agreement with a Kappa coefficient of 51% and a high specificity and high NPV (94% and 95%). The conditions for which the definition in the HECM included disease-specific medications performed better in our study. CONCLUSION: The HECM showed good to very good concordance with the REIN database information overall, with the exception of cancer. Further validation of the HECM tool in other populations should be performed.

REIN: a tool at the service of health authorities / REIN : un outil au service des administrations sanitaires

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of its link with health authorities, the following key messages were retained. One of the purposes of REIN is to contribute to a better understanding about patient management and its evolution, and thus to be called upon to develop health strategies aimed at improving the prevention and treatment of chronic renal failure. Indeed, the planning of the supply and the evaluation of the treatment are important issues for the public health decision-makers who must have the relevant indicators and tools to help them in their decision-making and follow-up processes. REIN is clearly identified as a source of information by institutional partners, as is shown by the various requests made by the Regional health agencies (ARS), the French National Authority for Health (HAS) and the General Directorate for Healthcare Services (DGOS), as well as other health authorities. It allows estimating the needs of the population within the framework of decree nos. 2002-1197 and 2002-1198 of September 2002 relating to the treatment of chronic renal failure by renal dialysis. The recent possibility of probabilistic matching of REIN data with the data from the National Healthcare Data System (SNDS) for a pseudonymised individual allows for more detailed studies on the different care pathways, as well as evaluating the impact of the different actions or experiments that are set up, with the help of detailed clinical information from the REIN and, among other things, the expenses reimbursed by the Health Insurance.

À l'occasion des 20 ans du REIN (Réseau Epidémiologie et Information en Néphrologie), un travail de synthèse sur les apports du registre a été mené. Sur la question de ses liens avec les administrations sanitaires, les messages clés suivants ont été retenus. Une des finalités de REIN est de contribuer à mieux connaître la prise en charge des patients et de ses évolutions et ainsi être sollicité pour l'élaboration de stratégies sanitaires visant à améliorer la prévention et la prise en charge de l'insuffisance rénale chronique. En effet, la planification de l'offre et l'évaluation de la prise en charge sont des enjeux importants pour les décideurs en santé publique qui doivent disposer d'indicateurs et d'outils pertinents pour les aider dans leur décision avec leur suivi. REIN est clairement identifié comme source d'information par les partenaires institutionnels comme en témoignent les diverses sollicitations faites par les agences régionales de santé (ARS), la Haute Autorité de santé (HAS) ou la Direction générale de l'offre de soins (DGOS) mais également d'autres administrations sanitaires. Il permet d'estimer les besoins de la population dans le cadre des décrets nos 2002-1197 et 2002-1198 septembre 2002 relatifs au traitement de l'insuffisance rénale chronique par la pratique de l'épuration extrarénale. La récente possibilité d'appariement probabiliste des données de REIN aux données du Système national des données de santé (SNDS) pour un même individu pseudonymisé permet des études plus fines sur les différents parcours de soins, mais aussi d'évaluer l'impact des différentes actions ou expérimentations mises en place, avec l'aide des informations cliniques détaillées du REIN et, entre autres, les dépenses remboursées par l'Assurance maladie.

Factors associated with hospital admission and 30-day readmission for children less than 18 years of age in 2018 in France: a one-year nationwide observational study.

BACKGROUND: Nationwide data for children for short-stay hospitalisation (SSH) and associated factors are scarce. This retrospective study of children in France < 18 years of age followed after their birth or birthday in 2018 focused on at least one annual SSH, stay < 1 night or ≥ 1 night, or 30-day readmission ≥ 1 night. METHODS: Children were selected from the national health data system (SNDS), which includes data on long-term chronic disease (LTD) status with full reimbursement and complementary universal coverage based on low household income (CMUC). Uni and multivariate quasi-Poisson regression were applied for each outcome. RESULTS: Among 13.211 million children (94.4% population, 51.2% boys), CMUC was identified for 17.5% and at least one LTD for 4% (0-<1 year: 1.5%; 14-<18 year: 5.2%). The most frequent LTDs were pervasive developmental diseases (0.53%), asthma (0.24%), epilepsy (0.17%), and type 1 diabetes (0.15%). At least one SSH was found for 8.8%: SSH < 1 night (4.9%), SSH ≥ 1 night (4.5%), readmission (0.4%). Children with at least one SSH were younger (median 6 vs. 9 years) and more often had CMUC (21%), a LTD (12%), an emergency department (ED) visit (56%), or various primary healthcare visits than all children. Those with a SSH ≥1 night vs. < 1 night were older (median: 9 vs. 4 years). They had the same frequency of LTD (13.4%) but more often an ED visit (78% vs. 42%). Children with readmissions were younger (median 3 years). They had the highest levels of CMUC (29.3%), LTD (34%), EDs in their municipality (35% vs. 29% for the whole population) and ED visits (87%). In adjusted analysis, each outcome was significantly less frequent among girls than boys and more frequent for children with CMUC. LTDs with the largest association with SSH < 1 night were cystic fibrosis, sickle cell diseases (SCD), diabetes type 1, those with SSH ≥1 night type 1 diabetes epilepsy and SCD, and those for readmissions lymphoid leukaemia, malignant neoplasm of the brain, and SCD. Among all SSH admissions of children < 10 years, 25.8% were potentially preventable. CONCLUSION: Higher SSH and readmission rates were found for children with certain LTD living in low-income households, suggesting the need or increase of specific policy actions and research.

Social deprivation and the use of healthcare services over one year by children less than 18 years of age in 2018: A French nationwide observational study.

This study aimed to describe the health status of children and how social deprivation affects their use of healthcare services and mortality. Children living in mainland France were selected from the national health data system (SNDS) on their date of birth or birthday in 2018 (< 18 years) and followed for one year. Information included data on healthcare reimbursements, long-term chronic diseases (LTDs) eligible for 100% reimbursement, geographic deprivation index (FDep) by quintile (Q5 most disadvantaged), and individual complementary universal insurance (CMUc) status, granted to households with an annual income below the French poverty level. The number of children who had at least one annual visit or hospital admission was compared using the ratio of geographic deprivation (rQ5/Q1) and CMUc (rCMUc/Not) after gender and age-standardization. Over 13 million children were included; 17.5% had CMUc, with an increase across quintiles (rQ5/Q1 = 3.5) and 4.0% a LTD (rQ5/Q1 = 1.44). The 10 most frequent LTDs (6 psychiatric) were more common as the deprivation increased. Visits to general practitioners (GPs) were similar (≈84%) for each FDep quintile and the density of GPs similar. The density decreased with increasing deprivation for specialists and visits: paediatricians (rQ5/Q1 = 0.46) and psychiatrists (rQ5/Q1 = 0.26). Dentist visits also decreased (rQ5/Q1 = 0.86) and deprived children were more often hospitalised for dental caries (rQ5/Q1 = 2.17, 2.1% vs 0.7%). Emergency department (ED) visits increased with deprivation (rCMUc/Not = 1.35, 30% vs 22%) but 50% of CMUc children lived in a municipality with an ED vs. 25% without. Approximately 9% of children were admitted for a short stay and 4.5% for a stay > 1 night (rQ5/Q1 = 1.44). Psychiatric hospitalization was more frequent for children with CMUc (rCMUc/Not = 3.5, 0.7% vs 0.2%). Higher mortality was observed for deprived children < 18 years (rQ5/Q1 = 1.59). Our results show a lower use of pediatricians, other specialists, and dentists among deprived children that may be due, in part, to an insufficient supply of care in their area of residence. These results have been used to recommend optimization and specifically adapted individual or area-wide policies on the use of healthcare services, their density, and activities.

Recurrent high grade glioma surgery with carmustine wafers implantation: a long-term nationwide retrospective study.

PURPOSE: Widespread use of carmustine wafers (CW) to treat high-grade gliomas (HGG) has been limited by uncertainties about its efficacy. To assess the outcome of patients after recurrent HGG surgery with CW implantation and, search for associated factors. METHODS: We processed the French medico-administrative national database between 2008 and 2019 to retrieve ad hoc cases. Survival methods were implemented. RESULTS: 559 patients who had CW implantation after recurrent HGG resection at 41 different institutions between 2008 and 2019 were identified. 35.6% were female and, median age at HGG resection with CW implantation was 58.1 years, IQR [50-65.4]. 520 patients (93%) had died at data collection with a median age at death of 59.7 years, IQR [51.6-67.1]. Median overall survival (OS) was 1.1 years, 95%CI[0.97-1.2], id est 13.2 months. Median age at death was 59.7 years, IQR [51.6-67.1]. OS at 1, 2 and 5 years was 52.1%, 95%CI[48.1-56.4], 24.6%, 95%CI[21.3-28.5] & 8%, 95%CI[5.9-10.7] respectively. In the adjusted regression, bevacizumab given before CW implantation, (HR = 1.98, 95%CI[1.49-2.63], p < 0.001), a longer delay between the first and the second HGG surgery (HR = 1, 95%CI[1-1], p < 0.001), RT given before and after CW implantation (HR = 0.59, 95%CI[0.39-0.87], p = 0.009) and TMZ given before and after CW implantation (HR = 0.81, 95%CI[0.66-0.98], p = 0.034) remained significantly associated with a longer survival. CONCLUSION: OS of patients with recurrent HGG that underwent surgery with CW implantation is better in case of prolonged delay between the two resections and, for the patients who had RT and TMZ before and after CW implantation.

Benefits of Cardiac Rehabilitation in Cardio-Renal Patients With Heart Failure With Reduced Ejection Fraction.

PURPOSE: Chronic kidney disease (CKD) is common in heart failure (HF). Chronic kidney disease often worsens the prognosis and impairs the management of patients with HF. Chronic kidney disease is frequently accompanied by sarcopenia, which limits the benefits of cardiac rehabilitation (CR). The aim of this study was to evaluate the impact of CR on cardiorespiratory fitness in HF patients with reduced ejection fraction (HFrEF) according to the CKD stage. METHODS: We conducted a retrospective study including 567 consecutive patients with HFrEF, who underwent a 4-wk CR program, and who were evaluated by cardiorespiratory exercise test before and after the program. Patients were stratified according to their estimated glomerular filtration rate (eGFR). We performed multivariate analysis looking for factors associated with an improvement of 10% in peak oxygen uptake (V˙ o2peak ). RESULTS: Thirty-eight percent of patients had eGFR <60 mL/min/1.73m². With decreasing eGFR, we observed deterioration in V˙ o2peak , first ventilatory threshold (VT1) and workload and an increase in brain natriuretic peptide levels at baseline. After CR, there was an improvement in V˙ O2peak (15.3 vs 17.8 mL/kg/min, P < .001), VT1 (10.5 vs 12.4 mL/kg/min, P < .001), workload (77 vs 94 W, P < .001), and brain natriuretic peptide (688 vs 488 pg/mL, P < .001). These improvements were statistically significant for all stages of CKD. In a multivariate analysis predicting factors associated with V˙ o2peak improvement, renal function did not interfere with results. CONCLUSIONS: Cardiac rehabilitation is beneficial in patients with HFrEF with CKD regardless of CKD stage. The presence of CKD should not prevent the prescription of CR in patients with HFrEF.

Newly Diagnosed High-Grade Glioma Surgery with Carmustine Wafers Implantation. A Long-Term Nationwide Retrospective Study.

BACKGROUND: Widespread use of carmustine wafers (CWs) to treat high-grade gliomas (HGG) has been limited by uncertainties about their efficacy. We sought to assess the outcome of patients after newly diagnosed HGG surgery with CW implantation and search for associated factors. METHODS: We processed the French medico-administrative national database between 2008 and 2019 to retrieve ad hoc cases. Survival methods were implemented. RESULTS: In total, 1608 patients who had CW implantation after HGG resection at 42 different institutions between 2008 and 2019 were identified; 36.7% were female and, median age at HGG resection with CW implantation was 61.5 years, interquartile range (IQR) [52.9-69.1]. A total of 1460 patients (90.8%) had died at data collection at a median age at death of 63.5 years, IQR [55.3-71.2]. Median overall survival (OS) was 1.42 years, 95% confidence interval [CI] 1.35-1.49, i.e., 16.8 months. Median age at death was 63.5 years, IQR [55.3-71.2]. OS at 1, 2, and, 5 years was 67.4%, 95% CI 65.1-69.7; 33.1%, 95% CI 30.9-35.5; and 10.7%, 95% CI 9.2-12.4, respectively. In the adjusted regression, sex (hazard ratio [HR] 0.82, 95% CI 0.74-0.92, P < 0.001), age at HGG surgery with CW implantation (HR 1.02, 95% CI 1.02-1.03, P < 0.001), adjuvant radiotherapy (HR 0.78, 95% CI 0.7-0.86, P < 0.001), chemotherapy by temozolomide (HR 0.7, 95% CI 0.63-0.79, P < 0.001), and redo surgery for HGG recurrence (HR 0.81, 95% CI 0.69-0.94, P = 0.005) remained significantly associated with the outcome. CONCLUSIONS: OS of patients with newly diagnosed HGG who underwent surgery with CW implantation is better in young patients, those of the female sex, and for those who complete concomitant chemoradiotherapy. Redo surgery for HGG recurrence also was associated with prolonged survival.

Using filled prescription sequences to rank antidepressants: A nationwide replication study.

Ranking antidepressants according to their acceptability (i.e., a combination of both efficacy and tolerability) in the general population may help choosing the best first-line medication. This study aimed to replicate the results of a proof-of-concept study ranking anti-depressants according to the proportion of filled prescription sequences consistent with a continuation of the first treatment versus those consistent with a change. We used a nationwide cohort from the French national health data system (SNDS) to support the use of this method as a widely available tool to rank antidepressant treatments in real life settings. About 1.2 million people were identified as new antidepressant users in the SNDS in 2011. The outcome was clinical acceptability as measured by the continuation/failure ratio over the six-month period following the introduction of the first-line treatment. Continuation was defined as at least two refills of the same treatment. Failure was defined as a psychiatric hospitalization, death or at least one filled prescription of another antidepressant, an antipsychotic medication, or a mood-stabilizer. Adjusted Odds Ratios (aOR) and 95% Confidence Interval (CI) were computed through multivariable binary logistic regressions. We ranked antidepressant medications according to clinical acceptability. Escitalopram again was the most acceptable option, and the five following antidepressants were the same as in the replication sample of the proof-of-concept study, in order Fluoxetine, Paroxetine, Sertraline, Citalopram and Venlafaxine with aOR (95% CI) for continuation ranging from 0.79 (0.77-0.81) to 0.66 (0.64-0.67). The present study provides evidence that filled prescription sequences is a widely available, robust and reproductible tool to rank antidepressant treatments in real life settings.

Relative survival after meningioma surgery. A French nationwide population-based cohort study.

BACKGROUND: Survival after meningioma surgery is often reported with inadequate allowance for competing causes of death. METHODS: We processed the Système National des Données de Santé, the French administrative medical database to retrieve appropriate patients' case of surgically treated meningiomas. The Pohar Perme relative survival (RS) method was implement. RESULTS: A total of 28,778 patients were identified between 2007 and 2017 of which 75% were female. Median age at surgery 59 years. Cranial convexity was the most common (24.7%) location and, benign meningioma represented 91.5% of all meningioma. Median follow-up was 3.5 years interquartile range [3.4-3.5]. At data collection, 2,232 patients were dead. The five-year survival relative to the expected survival of an age- and gender-matched French standard population was 96.2% 95% confidence interval (CI)[95.7-96.8]. Meningioma absolute excess risk of death was 973/100,000 person-years 95%CI[887-1068] (p< .001). The related standardised mortality ratio was 1.8 95%CI[1.7-1.9] (p< .001). In the adjusted model, male gender (hazard ratio [HR] =1.39, 95%CI[1.27-1.54], p< .001), age at surgery (HR=0.97, 95%CI[0.97-0.97], p < .001), type 2 neurofibromatosis (HR=2.95, 95%CI[1.95-4.46], p < .001), comorbidities HR=1.39, 95%CI[1.36-1.42], p < .001), location (HR=0.8, 95%CI[0.67-0.95], p= .0111), pre-operative embolization, (HR=1.3, 95%CI[1.08-1.56], p= .00507), cerebro-spinal fluid shunt, (HR=2.48, 95%CI[2.04-3.01], p < .001), atypical (HR=1.3, 95%CI [1.09-1.54], p= .00307) or malignant histology (HR=1.86, 95%CI[1.56-2.22], p< .001), redo surgery (HR=1.19, 95%CI[1.04-1.36], p= .0122) and radiotherapy (HR=1.43, 95%CI[1.26-1.62], p < .001) were established as independent predictors of RS. CONCLUSION: This unique study highlights the excess mortality associated with meningioma disease. Many factors such as gender, age, location, histopathological grading, redo surgery influence the RS.

Acceptability of Second-Line Antidepressant Medications Using Filled Prescription Sequences in a Nationwide Cohort Study.

Background: Although about half of patients do not respond to a first-line antidepressant medication, there is no consensus on the best second-line option. The aim of this nationwide population-based study was to rank antidepressants according to their relative acceptability (ie, efficacy and tolerability) using filled prescription sequences after failure of first treatment.Methods: About 1.2 million people were identified as new antidepressant users in the French national health data system in 2011. The inclusion criterion was having at least 2 filled prescriptions of a second-line treatment after a filled prescription of a first-line treatment, resulting in 63,726 participants. The outcome was clinical acceptability as measured by the continuation/change ratio for second-line treatment. Continuation sequence was defined as at least 2 refills of the same treatment. Change sequence was defined as at least 1 filled prescription of another antidepressant. Adjusted odds ratios (aORs) were computed through multivariable binary logistic regressions.Results: Intraclass switch had a better acceptability than interclass switch (aOR [95% CI]: 1.23 [1.20-1.28]). According to the first-line treatment, intraclass switch remained more acceptable for selective serotonin reuptake inhibitors only (1.37 [1.31-1.42]). For α2 blockers and tricyclic agents, combination antidepressant therapy was the most acceptable second-line option (1.59 [1.27-2.01] and 2.53 [1.53-4.04], respectively), whereas for serotonin-norepinephrine reuptake inhibitors there was no significant difference between the strategies. For other antidepressants, intraclass switch had lower acceptability than interclass switch (0.70 [0.51-0.95]).Conclusions: Administrative claim databases may help with ranking acceptability of second-line treatments in real world settings and complement randomized controlled trials in informing clinicians about the most acceptable second-line options according to the first-line treatment.

Outcomes associated with antidepressant treatment according to the number of prescriptions and treatment changes: 5-year follow-up of a nation-wide cohort study.

Background: Naturalistic studies regarding clinical outcomes associated with antidepressant treatment duration have yielded conflicting results, possibly because they did not consider the occurrence of treatment changes. This nation-wide population-based study examined the association between the number of filled prescriptions and treatment changes and long-term psychiatric outcomes after antidepressant treatment initiation. Methods: Based on the French national health insurance database, 842,175 adults who initiated an antidepressant treatment in 2011 were included. Cox proportional-hazard multi-adjusted regression models examined the association between the number of filled prescriptions and the occurrence of treatment changes 12 months after initiation and four outcomes during a 5-year follow-up: psychiatric hospitalizations, suicide attempts, sick leaves for a psychiatric diagnosis, new episodes of antidepressant treatment. Results: During a mean follow-up of 4.5 years, the incidence rates of the four above-mentioned outcomes were 13.49, 2.47, 4.57, and 92.76 per 1,000 person-years, respectively. The number of filled prescriptions was associated with each outcome (adjusted HRs [95% CI] for one additional prescription ranging from 1.01 [1.00-1.02] to 1.10 [1.09-1.11]), as was the occurrence of at least one treatment change vs. none (adjusted HRs [95% CI] ranging from 1.18 [1.16-1.21] to 1.57 [1.79-1.65]). Furthermore, the adjusted HRs [95% CI] of the number of filled prescriptions were greater in patients with (vs. without) a treatment change for psychiatric hospitalizations (1.12 [1.11-1.14] vs. 1.09 [1.08-1.10], p for interaction = 0.002) and suicide attempts (1.12 [1.09-1.15] vs. 1.06 [1.04-1.08], p for interaction = 0.006). Limitations: Lack of clinical data about the disorders warranting the prescriptions or their severity. Conclusion: Considering treatment changes is critical when using administrative claims database to examine the long-term psychiatric outcomes of antidepressant treatments in real-life settings.

Underuse of primary healthcare in France during the COVID-19 epidemic in 2020 according to individual characteristics: a national observational study.

BACKGROUND: The organization of healthcare systems changed significantly during the COVID-19 pandemic. The impact on the use of primary care during various key periods in 2020 has been little studied. METHODS: Using individual data from the national health database, we compared the numbers of people with at least one consultation, deaths, the total number of consultations for the population of mainland France (64.3 million) and the mean number of consultations per person (differentiating between teleconsultations and consultations in person) between 2019 and 2020. We performed analyses by week, by lockdown period (March 17 to May 10, and October 30 to December 14 [less strict]), and for the entire year. Analyses were stratified for age, sex, deprivation index, epidemic level, and disease. RESULTS: During the first lockdown, 26% of the population consulted a general practitioner (GP) at least once (-34% relative to 2019), 7.4% consulted a nurse (-28%), 1.6% a physiotherapist (-80%), and 5% a dentist (-95%). For specialists, consultations were down 82% for ophthalmologists and 37% for psychiatrists. The deficit was smaller for specialties making significant use of teleconsultations. During the second lockdown, the number of consultations was close to that in 2019, except for GPs (-7%), pediatricians (-8%), and nurses (+ 39%). Nurses had already seen a smaller increase in weekly consultations during the summer, following their authorization to perform COVID-19 screening tests. The decrease in the annual number of consultations was largest for dentists (-17%), physiotherapists (-14%), and many specialists (approximately 10%). The mean number of consultations per person was slightly lower for the various specialties, particularly for nurses (15.1 vs. 18.6). The decrease in the number of consultations was largest for children and adolescents (GPs: -10%, dentists: -13%). A smaller decrease was observed for patients with chronic diseases and with increasing age. There were 9% excess deaths, mostly in individuals over 60 years of age. CONCLUSIONS: There was a marked decrease in primary care consultations in France, especially during the first lockdown, despite strong teleconsultation activity, with differences according to age and healthcare profession. The impact of this decrease in care on morbidity and mortality merits further investigation.