Background
Lifelong medical follow‐up is mandatory after bariatric surgery. The aim of this study was to assess the 5‐year follow‐up after bariatric surgery in a nationwide cohort of patients.
...Methods
All adult obese patients who had undergone primary bariatric surgery in 2009 in France were included. Data were extracted from the French national health insurance database. Medical follow‐up (medical visits, micronutrient supplementation and blood tests) during the first 5 years after bariatric surgery was assessed, and compared with national and international guidelines.
Results
Some 16 620 patients were included in the study. The percentage of patients with at least one reimbursement for micronutrient supplements decreased between the first and fifth years for iron (from 27.7 to 24.5 per cent; P < 0.001) and calcium (from 14·4 to 7·7 per cent; P < 0·001), but increased for vitamin D (from 33·1 to 34·7 per cent; P < 0·001). The percentage of patients with one or more visits to a surgeon decreased between the first and fifth years, from 87·1 to 29·6 per cent (P < 0·001); similar decreases were observed for visits to a nutritionist/endocrinologist (from 22·8 to 12·4 per cent; P < 0·001) or general practitioner (from 92·6 to 83·4 per cent; P < 0·001). The mean number of visits to a general practitioner was 7·0 and 6·1 in the first and the fifth years respectively. In multivariable analyses, male sex, younger age, absence of type 2 diabetes and poor 1‐year follow‐up were predictors of poor 5‐year follow‐up.
Conclusion
Despite clear national and international guidelines, long‐term follow‐up after bariatric surgery is poor, especially for young men with poor early follow‐up.
Poor follow‐up despite international guidelines
Background
Few studies have assessed changes in antihypertensive and lipid‐lowering therapy after bariatric surgery. The aim of this study was to assess the 6‐year rates of continuation, ...discontinuation or initiation of antihypertensive and lipid‐lowering therapy after bariatric surgery compared with those in a matched control group of obese patients.
Methods
This nationwide observational population‐based cohort study used data extracted from the French national health insurance database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009 were matched with control patients. Mixed‐effect logistic regression models were used to analyse factors that influenced discontinuation or initiation of treatment over a 6‐year interval.
Results
In 2009, 8199 patients underwent primary gastric bypass (55·2 per cent) or sleeve gastrectomy (44·8 per cent). After 6 years, the proportion of patients receiving antihypertensive and lipid‐lowering therapy had decreased more in the bariatric group than in the control group (antihypertensives: –40·7 versus –11·7 per cent respectively; lipid‐lowering therapy: –53·6 versus –20·2 per cent; both P < 0·001). Gastric bypass was the main predictive factor for discontinuation of therapy for hypertension (odds ratio (OR) 9·07, 95 per cent c.i. 7·72 to 10·65) and hyperlipidaemia (OR 11·91, 9·65 to 14·71). The proportion of patients not receiving treatment at baseline who were subsequently started on medication was lower after bariatric surgery than in controls for hypertension (5·6 versus 15·8 per cent respectively; P < 0·001) and hyperlipidaemia (2·2 versus 9·1 per cent; P < 0·001). Gastric bypass was the main protective factor for antihypertensives (OR 0·22, 0·18 to 0·26) and lipid‐lowering medication (OR 0·12, 0·09 to 0·15).
Conclusion
Bariatric surgery is associated with a good discontinuation of antihypertensive and lipid‐lowering therapy, with gastric bypass being more effective than sleeve gastrectomy.
Drugs often stopped
To describe the association between socio-economic position, health status and quality of diabetes care in people with Type 2 diabetes in France, where people may receive full healthcare coverage for ...chronic disease.
Data from a national cross-sectional survey performed in people pharmacologically treated for diabetes were used. They combined data from medical claims, hospital discharge, questionnaires for patients (n = 3894 with Type 2 diabetes) and their physicians (n = 2485). Socio-economic position was assessed using educational level (low, intermediate, high) and ability to make ends meet (financial difficulties vs. financially comfortable).
People with diabetes reporting financial difficulties were more likely to be smokers (adjusted odds ratio 1.4; 95% CI 1.1-1.6) and obese (adjusted odds ratio 1.3; 95% CI 1.2-1.6) and to have poorer glycaemic control (HbA1c > 64 mmol/mol (8%); adjusted odds ratio 1.4; 95% CI 1.1-1.8), than those who were financially comfortable. They were more likely to have their diabetes diagnosed because of complications (adjusted odds ratio 1.6; 95% CI 1.3-2.0). They were also more likely to have coronary and podiatric complications (adjusted odds ratios 1.3; 95% CI 1.1-1.6 and 1.7; 95% CI 1.4-2.2, respectively). They benefited more often from full coverage (adjusted odds ratio 1.3; 95% CI 1.1-1.6), visited general practitioners more often (ratio of estimated marginal means 1.2; 95% CI 1.1-1.2) but specialists less often (adjusted odds ratio 0.7; 95% CI 0.6-0.8 for a visit to private ophthalmologist). They also felt less well informed about their condition.
Despite frequent access to full healthcare coverage, socio-economic position has an impact on the diagnosis of diabetes, health status and quality of diabetes care in France.
The aim of this study was to compare disease status and health care use 1 year before and 1 year after skilled nursing home (SNH) admission.
People over the age of 65 years admitted to SNH during the ...first quarter of 2013, covered by the national health insurance general scheme (69% of the population of this age), and still alive 1 year after admission were identified (n = 14,487, mean age: 86 years, women: 76%). Their reimbursed health care was extracted from the Système National d'Information Interrégimes de l'Assurance Maladie (SNIIRAM) National Health Insurance Information System.
One year after nursing home admission, the most prevalent diseases were cardiovascular/neurovascular diseases and neurodegenerative diseases (affecting 45% and 40% of people before admission vs 51% and 53% after admission, respectively). Physical therapy use increased (43% vs 64% of people had at least one physical therapy session during the year, with an average of 47 vs 84 sessions/person during the year), while specialist consultations decreased (29% of people consulted an ophthalmologist at least once during the year before admission vs 25% after admission; 27% vs 21% consulted a cardiologist). Hospitalization rates were lower during the year following institutionalization (75% vs 40% of people were hospitalized at least once during the year), together with a lower emergency admission rate and a higher day admission rate.
Analysis of the new French reimbursement database specific to SNH shows that nursing home admission is associated with a reduction of some forms of outpatient care and hospitalizations.
To estimate the incidence, characteristics and potential causes of lower limb amputations in France.
Admissions with lower limb amputations were extracted from the 2003 French national hospital ...discharge database, which includes major diagnoses and procedures performed during hospital admissions. For each patient, diabetes was defined by its record in at least one admission with or without lower limb amputation in the 2002-2003 databases.
In 2003, 17 551 admissions with lower limb amputation were recorded, involving 15 353 persons, which included 7955 people with diabetes. The crude incidence of lower limb amputation in people with diabetes was 378/100 000 (349/100 000 when excluding traumatic lower limb amputation). The sex and age standardized incidence was 12 times higher in people with than without diabetes (158 vs. 13/100 000). Renal complications and peripheral arterial disease and/or neuropathy were reported in, respectively, 30% and 95% of people with diabetes with lower limb amputation. Traumatic causes (excluding foot contusion) and bone diseases (excluding foot osteomyelitis) were reported in, respectively, 3% and 6% of people with diabetes and lower limb amputation, and were 5 and 13 times more frequent than in people without diabetes.
We provide a first national estimate of lower limb amputation in France. We highlight its major impact on people with diabetes and its close relationship with peripheral arterial disease/neuropathy and renal complications in the national hospital discharge database. We do not suggest the exclusion of traumatic causes when studying the epidemiology of lower limb amputation related to diabetes, as diabetes may contribute to amputation even when the first cause appears to be traumatic.
To estimate the nationwide prevalence of diagnosed and undiagnosed diabetes and pre-diabetes in adults residing in France.
A probability sample of a non-institutionalized civilian population residing ...throughout the whole of continental France was recruited from February 2006 to March 2007 for the French Nutrition and Health Survey. All individuals aged between 18 and 74 years who agreed to participate in the survey were included; thus there were 3115 participants, 2102 of whom were undergoing biochemical assessments. The prevalence of diagnosed diabetes was estimated using self-reported diabetes history and the prevalence of undiagnosed diabetes was estimated using fasting plasma glucose ≥ 7.0 mmol/l or HbA(1c) ≥ 6.5% (≥ 48 mmol/mol).
The prevalence of diagnosed diabetes was 4.6%, 95% CI 3.6-5.7. The prevalence of undiagnosed diabetes according to standard fasting plasma glucose criteria was 1% (95% CI 0.6-1.7) and contributed to less than 20% of all cases of diabetes. This proportion decreased with age from 30% in 30- to 54-year-olds to 12% in 55- to 74-year-olds. Based on HbA(1c) criteria, the prevalence of undiagnosed diabetes was 0.8% (95% CI 0.4-1.6).
The prevalence of diagnosed diabetes in adults in France is comparable with recent estimates from Northern Europe. The percentage of total diabetes that is undiagnosed is low in France, which may be explained by a widely practised strategy of opportunist screening. During the past years, improvements in diabetes care and increased awareness may have contributed towards decreasing the prevalence of undiagnosed diabetes more widely in Europe, and studies should further monitor such improvements.
To compare the 5-year mortality (overall and cause-specific) of a cohort of adults pharmacologically treated for diabetes with that of the rest of the French adult population.
In 2001, 10 000 adults ...treated for diabetes were randomly selected from the major French National Health Insurance System database. Vital status and causes of death were successfully extracted from the national registry for 9101 persons. We computed standardized mortality ratios.
Over 5 years, 1388 adults pharmacologically treated for diabetes died (15% of the cohort, 32.4/1000 person-years). An excess mortality, which decreased with age, was found for both genders standardized mortality ratio 1.45 (1.37-1.52). Excess mortality was related to: hypertensive disease 2.90 (2.50-3.33), ischaemic heart disease 2.19 (1.93-2.48), cerebrovascular disease 1.76 (1.52-2.03), renal failure 2.14 (1.77-2.56), hepatic failure 2.17 (1.52-3.00) in both genders and septicaemia among men 1.56 (1.15-2.09). An association was also found with cancer-related mortality: liver cancer in men 3.00 (2.10-4.15); pancreatic cancer in women 3.22 (1.94-5.03); colon/rectum cancer in both genders 1.66 (1.28-2.12). Excess mortality was not observed for breast, lung or stomach cancers.
Adults pharmacologically treated for diabetes had a 45% increased risk of mortality at 5 years, mostly related to cardiovascular complications, emphasizing the need for further prevention. The increased risk of mortality from cancer raises questions about the relationship between cancer and diabetes and prompts the need for improved cancer screening in people with diabetes.
In 1999, French legislators asked health insurance funds to develop a système national d'information interrégimes de l'Assurance Maladie (SNIIRAM) national health insurance information system in ...order to more precisely determine and evaluate health care utilization and health care expenditure of beneficiaries. These data, based on almost 66 million inhabitants in 2015, have already been the subject of numerous international publications on various topics: prevalence and incidence of diseases, patient care pathways, health status and health care utilization of specific populations, real-life use of drugs, assessment of adverse effects of drugs or other health care procedures, monitoring of national health insurance expenditure, etc. SNIIRAM comprises individual information on the sociodemographic and medical characteristics of beneficiaries and all hospital care and office medicine reimbursements, coded according to various systems. Access to data is controlled by permissions dependent on the type of data requested or used, their temporality and the researcher's status. In general, data can be analyzed by accredited agencies over a period covering the last three years plus the current year, and specific requests can be submitted to extract data over longer periods. A 1/97th random sample of SNIIRAM, the échantillon généraliste des bénéficiaires (EGB), representative of the national population of health insurance beneficiaries, was composed in 2005 to allow 20-year follow-up with facilitated access for medical research. The EGB is an open cohort, which includes new beneficiaries and newborn infants. SNIIRAM has continued to grow and extend to become, in 2016, the cornerstone of the future système national des données de santé (SNDS) national health data system, which will gradually integrate new information (causes of death, social and medical data and complementary health insurance). In parallel, the modalities of data access and protection systems have also evolved. This article describes the SNIIRAM data warehouse and its transformation into SNDS, the data collected, the tools developed in order to facilitate data analysis, the limitations encountered, and changing access permissions.
The purpose of this work is to review the recent publications on prevalence, incidence, mortality, characteristics and quality of care related to diabetes in the elderly population.
In France, the ...prevalence of drug-treated diabetes peaks at 14% by age 75-79 years, and at least one million people aged over 65 years have diabetes. Incidence rates for Northern Europeans rank between 3 and 7 per 1,000 person-years. The World Health Organization expects prevalent cases to further increase, due to better case ascertainment, better survival of people with diabetes, increase in obesity leading to a true increase in diabetes incidence, and, in developed countries, the important impact of population aging.
The burden of diabetes in the elderly population is already high. Even in the oldest age-groups, excess mortality risks associated with diabetes are significant and mostly related to cardiovascular disease, accounting for the loss of 3 to 6 years of life.
The cardiovascular risk of elderly people with diabetes is poorly controlled, increasing risks of diabetes complications, loss of cognitive functions and mobility, and dependency. Screening for lipid abnormalities and diabetes complications to prevent further damage is insufficient, and antihypertensive and hypolipidemic treatments are, in this population, underused, as in other countries. Specific adjustments of medical nutrition therapy are lacking. In long-term care facilities where the prevalence of diabetes is especially high (8 to 25%), quality of diabetes care is often poorer.
As the burden of diabetes is becoming heavier, specific monitoring of the health, quality of care and needs of elderly people with diabetes is required for adequate public health planning.
L’objectif de ce travail est de présenter une revue des publications récentes portant sur la prévalence, l’incidence, la mortalité, les caractéristiques et la qualité de la prise en charge des soins liés au diabète chez les sujets âgés.
En France, la prévalence du diabète traité par des médicaments antidiabétiques culmine à 14% pour les sujets âgés de 75 à 79 ans, et au moins un million de personnes de plus de 65 ans sont diabétiques. L’incidence du diabète dans les pays du Nord de l’Europe se situe entre 3 et 7 pour 1 000 personnes-années. L’Organisation Mondiale de la Santé s’attend à une augmentation progressive du nombre de cas avérés, en raison d’un meilleur diagnostic, d’une meilleure survie des sujets diabétiques, de l’augmentation de l’obésité conduisant à une augmentation de l’incidence de diabète, et dans les pays industrialisés, principalement au vieillissement de la population.
Le poids du diabète dans la population âgée est déjà élevé. Même dans les groupes d’âge le plus élevé, l’excès du risque de mortalité dû au diabète est important et principalement lié aux maladies cardio-vasculaires, et responsable de la perte de 3 à 6 ans de vie.
La prise en charge du risque cardio-vasculaire des sujets âgés ayant un diabète est insuffisante, ce qui augmente le risque de complications, la perte des fonctions cognitives et de la mobilité, et le risque de dépendance. Le dépistage des anomalies lipidiques et des complications du diabète afin de prévenir des atteintes plus graves, est insuffisant, et les traitements anti-hypertenseurs et hypolipidémiants sont, dans cette population, tout comme dans d’autres pays, sous-utilisés. Les mesures nutritionnelles thérapeutiques sont insuffisamment adaptées. Dans les établissements de soins de long terme, où la prévalence du diabète est particulièrement élevée (8 à 25%), la qualité des soins diabétiques est souvent encore moins bonne.
À l’heure où le poids et le coût social et économique du diabète deviennent de plus en plus important, un suivi spécifique de l’état de santé, de la qualité des soins et des besoins des sujets âgés ayant un diabète, s’avère imperative dans le cadre d’une politique adéquate de santé publique.
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