ORIGINAL RESEARCH ARTICLE
Pharmacoeconomics 1998 Jan; 13 (1 Pt 1): 51-59 1170-7690/98/0001-0051/$04.50/0 © Adis International Limited. All rights reserved.
Peripheral Arterial Obliterative Disease Cost of Illness in France Armelle Montron,1 Eric Guignard,1 Alain Pelc1 and Sylvie Comte2 1 Intercontinental Medical Statistics (IMS), Health Economics Department, Nanterre, France 2 Department of Pharmacoeconomics, LIPHA Laboratories, Lyon, France
Summary
The main purpose of this study, carried out in 1995, was to determine, using available sources, the cost of peripheral arterial obliterative disease (PAOD) in France over a 1-year period. This cost-of-illness study was based on a retrospective analysis of the available literature and databases. It involved a description of epidemiological data and a cost estimate of the different medical resources consumed over 1 year. For this latter purpose, a payer perspective was chosen. Data were extracted from national representative surveys and databases with respect to morbidity and mortality [from the National Institute of Health and Medical Research (Institut National de la Santé et de la Recherche Médicale; INSERM) and the National Sickness Insurance Fund for Salaried People (Caisse Nationale d’Assurance Maladie des Travailleurs Salariés; CNAMTS)], consultations, examination tests and drug prescriptions [from the French Medical Audit conducted by Intercontinental Medical Statistics (IMS)], hospitalisations [from the Statistical Unit of the Department of Health – Service des Statistiques, des Etudes et des Systemes d’Information (SESI) and the National Public Research Centre in Health Economics (Centre de Recherche d’Etude et de Documentation en Economie de la Santé; CREDES)] and related health expenditure from CNAMTS. In France, the prevalence of stage II PAOD (Leriche and Fontaine classification) in 1992 was estimated to be 675 000; 53% of these patients had undergone vascular or bypass surgery. The total annual cost of healthcare (including consultations, drugs, laboratory tests, hospitalisation and hydrotherapy) for the management of patients with PAOD ranged from 3.9 billion French francs (F) to F4.6 billion (1995 values), depending on the type of hospital considered. 50% of this cost was related to hospitalisations and 75% was covered by the CNAMTS. Although this study was only a partial evaluation and did not take into account indirect costs or nonmedical direct costs, such as transport and care by healthcare assistants and paramedics, these results may help to establish public health priorities and modify clinical practice to favour an earlier diagnosis of PAOD.
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Montron et al.
It is estimated that 800 000 individuals in France experience peripheral arterial obliterative disease (PAOD).[1] The prognosis of this disease is unfavourable; 20% of affected patients die within 5 years and 40% within 10 years of diagnosis.[1] The 2 main causes of death are coronary artery disease and stroke. In a recent article, Langley and Coons[2] highlighted the dearth of economic studies that have included an assessment of the overall costs of treating PAOD. No full analysis of the cost of PAOD from the perspective of the health system or the type of care provided (medical, paramedical or hydrotherapy) is currently available in France. The type of care provided depends on the stage of the disease, the extent of any motor deficiency, risk factors, concomitant disease, patient age and the ability of the patient to perform physical activities. The aim of this study was to determine the annual cost of direct medical care associated with PAOD in France according to the type of care provided, using the major medicoeconomic sources available. Methods General Principles
A retrospective analysis of the available French literature and databases was performed in 1995, with the aim of evaluating the cost of managing PAOD. The methodology included epidemiological and economic components. The latter component comprised an evaluation of the cost of direct medical care over a 1-year period from the perspective of the payers (the National Sickness Insurance Fund and the patients themselves). Sources of Data Epidemiological
Epidemiological data were obtained from surveys conducted by the National Sickness Insurance Fund for Salaried People [Caisse Nationale d’Assurance Maladie des Travailleurs Salariés (CNAMTS)],[3] the National Public Research Centre in Health Economics [Centre de Recherche Adis International Limited. All rights reserved.
d’Etude et de Documentation en Economie de la Santé (CREDES)][4,5] and the National Institute for Health and Medical Research [Institut National de la Santé et de la Recherche Médicale (INSERM)].[6] The surveys conducted by CNAMTS, CREDES and INSERM were carried out at different times and, in certain cases, this resulted in an important time lag between the published results and our study. The surveys used for our analysis are described below and were the most recent at the time of this study. Diagnosis
The codes used in these surveys to describe PAOD were those of the 9th International Classification of Diseases (ICD-9) as determined by the World Health Organization (WHO).[7] Codes 440 to 448 (diseases of the arteries, arterioles and capillaries), particularly code 440 (atherosclerosis) and code 447 (other diseases of the arteries and small arteries), were used to standardise diagnoses used across all parts of the study. Prevalence
Data from the Institut National des Statistiques des Etudes Economiques (INSEE)-CREDES Health Survey were used to estimate the prevalence of PAOD (personal communication, Dr Catherine Sermet, Maître de recherche, CREDES). This national decennial survey provides the annual number of patients per disease for the whole of France. We used the most recent survey, carried out in 1991.[4] In addition, a national representative survey conducted by CREDES in 279 French institutions from 1987 to 1988 was used to provide data on institutionalised patients; this survey included a random sample of 1680 patients aged 80 years.[5] Incidence
As certain forms of PAOD may be associated with minimal or no symptoms, it is difficult to determine the incidence of these conditions. Nevertheless, it was possible to estimate these figures using data from large-scale studies. Data derived from the Framingham and Basel surveys[8] were used to estimate the incidence of PAOD. As PAOD is included in the list of 30 chronic diseases eligible for full sickness insurance coverage Pharmacoeconomics 1998 Jan; 13 (1 Pt 1)
Cost of Peripheral Artery Disease in France
in France, most of the patients with this diagnosis are reported to CNAMTS. The last 1990/1991 CNAMTS publication was also used to estimate the incidence of these diseases.[3] However, these latter results only concerned the beneficiaries of the Régime Général de la Sécurité Sociale (i.e. wage earners) for the period 1990 to 1991, representing 80% of the French population.[3,9] Mortality
Mortality data for PAOD was provided by an INSERM publication.[6] INSERM is the French official body for mortality statistics. This publication was based on diagnoses stated on death certificates. Medical Resource Consumption Consultations, Drug Prescriptions and Examinations
The French Medical Audit, conducted by Intercontinental Medical Statistics (IMS) since 1963, was used to determine the number of physician consultations and the number and nature of prescriptions for drugs, laboratory tests and examinations necessary for the management of patients with PAOD over a 1-year period (March 1993 to February 1994).[10] This medical audit was based on a national representative sample of 800 medical practitioners, selected and stratified according to the following criteria: • doctor’s age and gender • medical speciality • country, region of work and size of urban unit. Each doctor participated in the study for 7 consecutive days each quarter, and collated information for every patient seen outside an institution during this period. The results were presented as the number of diagnoses noted during the period in question and were extrapolated for 1 year to all French doctors. IMS Medical Audits are the main source of data on physicians’ prescriptions in 80 countries throughout the world. In France, the French Medical Audit is used as a reference by governmental authorities to assess patterns of prescribing. The number of consultations for one diagnosis were counted as ‘equivalent consultations’. AttribuAdis International Limited. All rights reserved.
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ting a consultation or visit to each diagnosis naturally leads to an overestimation of the total number of consultations reported for all diseases. For example, in 1994, 306 million consultations or visits were covered by CNAMTS, and during the same period the French Medical Audit noted an average of 1.58 diagnoses per consultation.[11] If 1 diagnosis was considered equivalent to 1 consultation, this would result in health insurance reimbursements for 438 million consultations or visits. The number of equivalent consultations per medical speciality was therefore determined using the ratio of number of diagnoses for each of the diseases considered : average number of diagnoses per consultation. These latter data were collected in the French Medical Audit. Hospitalisation
The number of hospitalisations for PAOD was based on data provided by 2 surveys. The first was a survey of hospital morbidity conducted by the Statistical Unit of the Department of Health [Service des Statistiques des Etudes et des Systemes d’Information (SESI)] from 1 October 1984 to 30 June 1988.[12] This survey was representative of the annual activity of hospitals at the national level and included 77 430 hospital stays. It was used to provide a first estimate for the cost of care in PAOD. The SESI survey identified those diseases for which treatment was associated with short term hospitalisation in public (teaching and nonteaching) hospitals and private establishments. We used this survey to determine the number of hospitalisations per year for all diseases of the arteries. These data were extrapolated to the whole of France, according to whether short term hospitalisation was provided by medical (general medicine, emergency medicine, paediatric, medical intensive care, medical specialty, gynaecology/obstetrics or oncology) or surgical (general surgery, emergency surgery, paediatric surgery, surgical intensive care and surgical specialty) departments. The second was the CREDES national hospital survey,[13] which provided a second estimate of the cost of care in PAOD. This survey, published in Pharmacoeconomics 1998 Jan; 13 (1 Pt 1)
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Montron et al.
1995, was conducted using a national representative sample of 884 public and private establishments encompassing 4646 patients. It described the diagnoses of patients hospitalised in acute-care wards (e.g. medical, emergency, gynaecology/obstetric and surgical departments), in rehabilitation wards (e.g. physiotherapy clinic) and in long-stay wards (e.g. nursing home) for 1 specific day of the year. These data were then extrapolated to the whole of France. The extrapolated results were used in our cost-of-illness study by considering only the main diagnoses (i.e. those diseases leading up to hospitalisation, not the abovementioned ICD-9 codes reported as the associated diagnosis). For each of ICD-9 codes, the results were distributed among the different departments considered, according to the distribution pattern of hospital stays noted in the SESI hospital morbidity survey.[12] A correction was necessary in order to compare the results of the 2 surveys. The first survey was based on the number of hospitalisations per year, while the second was extrapolated from an analysis of the main diagnoses for 1 specific day. It was therefore necessary to correct the results of the second survey to provide data on hospitalisations for a 1-year period and not just for a single day. This was possible using the following calculation: (number of patients 365)/average duration of hospitalisation. The average duration of hospitalisation for diseases of the arteries, as provided by the SESI hospital morbidity survey and used in this calculation, was 13.8 days for hospitalisation in a public establishment and 12.2 days for hospitalisation in a private establishment. Hydrotherapy
Hydrotherapy data for patients with PAOD were derived from the annual statistics for hydrotherapy covered by the National Sickness Insurance Fund (80% of French inhabitants).[14] The latest publication concerned 1990/1991 statistics. Only data from spas at which PAOD is specifically treated were used (Bains les Bains, Bourbon Lancy and Royat). Adis International Limited. All rights reserved.
Costing
A cost-of-illness analysis was conducted to provide an estimate of the costs of direct medical care resources required for the management of patients with PAOD. Nonmedical costs (direct and indirect) were not taken into account in calculating the value of resources used. The sources used comprised: • cost of physician consultations from agreed national tariffs[15] • cost of drug therapy from the IMS Pharmaceutical Audit National Drug Price Database[10] • cost of monitoring and examinations (including laboratory tests) from the Agreed National Tariff List[15] • cost of hospitalisation from hospital cost data[16] • cost of hydrotherapy from CNAMTS data.[14] Costs related to transport, paramedical and social services were not included. A payer perspective was used and the results were determined separately for the different payers – health insurance and households (patient coverage) – according to the CNAMTS reimbursement rate applicable on 1 January 1995. Consultations, Drug Prescriptions and Examinations
The cost of equivalent consultations for general and specialist physicians was determined according to the agreed tariffs at 1 January 1995 (F105 for a general physician consultation and F145 for a specialist consultation). The rate of reimbursement was that of the CNAMTS at 1 January 1995 (70%). The cost of each drug unit was estimated using the retail prices listed in the IMS Pharmaceutical Audit National Drug Price Database on 1 January 1995. This database is an updated and exhaustive database of all drugs on the French market. The rates of reimbursement used were those of CNAMTS: 0% for nonreimbursable products, 35% for reimbursable non-essential products and 65% for essential products. The fraction not covered by CNAMTS was treated as a patient expense. The costs of laboratory examinations were estimated according to the Agreed National Tariff List [Union des Caisses Nationales de Sécurité Sociale Pharmacoeconomics 1998 Jan; 13 (1 Pt 1)
Cost of Peripheral Artery Disease in France
(UCANSS) – Nomenclature Générale des Actes Professionnels], based on the examination rating and the unit price of the ‘key letter’ prevailing on 1 January 1995.[15] For example, in this list, an electrocardiogram (ECG) is rated K6.5 (key letter K and examination rating 6.5); since the unit price of key letter K is F12.40, the cost of an ECG is F80.60 (12.40 6.5). It was assumed that all laboratory tests identified in the French Medical Audit were carried out in a private medical laboratory. Specialist consultations that may have been required for these examinations or tests were not taken into account. The reimbursement rate used was 60% for biological tests (key letter B) specialised examinations such as ECG or Doppler (key letter K), and radiological examinations or tests (key letter Z), with the exception of radiological examinations rated over Z50, for which the reimbursement rate was 100%. Hospitalisation
The costs associated with these data were estimated in different ways, according to the different finance methods used by each establishment. For hospitalisation in a public establishment, the type of hospital ward was taken into consideration by using the data for the average cost per admission from the group of public teaching hospitals in the Paris area (Assistance Publique-Hôpitaux de Paris): general medicine F12 828; paediatrics F12 915; medical intensive care F5528; medical specialisation F12 937; general surgery F12 731; surgical intensive care F17 515; surgical specialisation F15 994; and gynaecology/obstetrics F24 673.[16] The total cost of hospitalisation was obtained by multiplying the total number of admissions by the average cost per admission. For hospitalisation in a private establishment, the cost per day was estimated by using National Health Expenditure (Comptes Nationaux de la Santé) data and reimbursement statistics from the CNAMTS.[17,18] According to this data source, annual healthcare costs for admission to private hospitals, covered by all national sickness insurance funds, amounted to F61.7 billion in 1993. The amount not covered by national sickness insurance Adis International Limited. All rights reserved.
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funds was F7.4 billion (12% of the amount covered by national sickness insurance funds).[17] F39.7 billion for admission to private hospitals was reimbursed by CNAMTS in 1993;[18] the 12% not covered by CNAMTS should be added to this amount (F4.8 billion). As a result, the total cost for admission to private hospitals was F44.5 billion for households covered by CNAMTS for a total of 31 278 465 days of hospitalisation. The resulting average cost per day of hospitalisation (F1421) was used to evaluate the cost of admission to private hospitals, regardless of their specialty. As shown by the SESI survey,[12] the approximate cost per admission for a mean stay of 12.2 days in the private hospitals was F17 336, similar to the costs per public hospital admission. Hydrotherapy
The cost per hydrotherapy session was determined from the global costs covered by CNAMTS, including mandatory (medical supervision, treatment fees) and additional (accommodation, transport fees) benefits. The average cost of treatment was estimated using the following formula: global cost for all treatments/total number of applications for treatment accepted by CNAMTS. The total cost for the 484 284 treatments covered by CNAMTS in 1991 was F1.3 billion, equivalent to F2607 per treatment. These costs only corresponded to those indicated and covered by CNAMTS. Results Epidemiological Prevalence
The prevalence of stage II PAOD according to the Leriche and Fontaine classification was estimated to be 1 to 1.5% for men less than 50 years of age and 4 to 6% for men greater than or equal to 50 years of age;[19] there were 700 000 to 800 000 patients with this disease in France in 1990.[8] This result was confirmed by the 1992 INSEE-CREDES health survey which estimated that, for the whole of France, 673 808 patients experienced PAOD of whom 359 000 (53.3%) had undergone orthopaedic or bypass surgery. Pharmacoeconomics 1998 Jan; 13 (1 Pt 1)
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Montron et al.
100 Stage II patients
Localised illness
Morbidity and total mortality
25 deteriorations
20 to 30 nonfatal cardiovascular complications within 5 years
3 major amputations
30 died within 5 years
15 from stroke or heart attack 5 from another cardiovascular cause 10 from a noncardiovascular cause
Fig. 1. Outcome of 100 patients with symptomatic stage II peripheral arterial obliterative disease (Leriche and Fontaine classification).[19]
Of the French population aged 80 years living in institutions, 9.5% experienced artery and capillary diseases (mainly PAOD).[5] These diseases were described as very serious or of moderate severity in 11% and 36% of cases, respectively. Incidence
The incidence of stage II PAOD was determined from the Framingham and Basel studies, which monitored normal patients over several years. The annual incidence of the disease in France was 80 000 to 90 000 cases,[8] and was dependent on age (the incidence of stage II PAOD increases with age) and gender (men develop PAOD 10 years earlier than women), the existence of risk factors (smoking and diabetes mellitus),[20] the existence of atherosclerosis in other body regions, and the systolic blood pressure gradient between the ankle and arm. The results of the CNAMTS survey showed that diseases of the arteries, small arteries and capillaries were responsible for 66 643 requests for full coverage of health costs during 1991;[9] this represented almost 11% of the 611 373 requests made in total. Arteritis of the peripheral arteries (included in this group of disorders) was the fourth major disease in terms of full coverage of healthcare costs during 1991, necessitating 23 498 requests. This represented 35% of requests for full coverage for vascular disease (arteriopathy). Adis International Limited. All rights reserved.
Full coverage of healthcare costs was more often granted to men than to women, and the number of beneficiaries increased progressively between the ages of 34 and 69 years for both genders. Diseases of the arteries, small arteries and capillaries (WHO DRG codes 440 to 448) were the reason for full coverage of healthcare costs for 29 596 and 27 820 patients in 1990 and 1991, respectively.[9] All of these patients received full coverage for this condition included in the list of 30 chronic diseases eligible for full sickness insurance cover. Prognosis
In the year following the development of claudication, 10% of patients experienced a deterioration in health.[8] Figure 1 illustrates the evolution of the disease at the stage of intermittent claudication.[19] Mortality
In 1991, the mortality rate linked to circulatory diseases was 28.4 per 100 000 men and 26.3 per 100 000 women.[6] PAOD-associated mortality rates of 30, 50 and 70% were calculated for 5-, 10- and 15-year follow-up periods, respectively.[19] This represents a life expectancy that is reduced by approximately 10 years compared with that of the general population. About half of the deaths were attributable to coronary artery disease. Pharmacoeconomics 1998 Jan; 13 (1 Pt 1)
Cost of Peripheral Artery Disease in France
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therapies (17% of total prescriptions). CNAMTS covered 75% of the total costs.
Economic Evaluation
The total cost of healthcare in France for diseases of the arteries, small arteries and capillaries was F3.9 billion according to the first estimate of the cost of hospitalisation (SESI hospital morbidity survey) and F4.6 billion according to the second estimate of hospitalisation (CREDES national hospital survey) [table I]. This was equivalent to 0.7% of total healthcare costs for 1993. Hospitalisation was the largest contributing factor (47 to 55% of the total cost, depending upon the estimate used). The majority of stays were in public hospitals: 51% (n = 59 884) of total stays according to the first estimate of hospitalisation, and 76% (n = 137 933) according to the second estimate. Drug prescriptions contributed 33 to 39% of the total cost. The main therapeutic classes prescribed were cerebral and peripheral vasotherapeutics (64% of total prescriptions) and systemic venous
Discussion As mentioned previously, no comprehensive cost-of-illness studies on PAOD have been published.[2] This is the first economic evaluation conducted in France to estimate the direct medical costs for patients with PAOD from the payer’s perspective (CNAMTS and the patient) over a 1-year period. In France, the prevalence of stage II PAOD (Leriche and Fontaine classification) is estimated at 675 000. More than 50% of these patients have already undergone lower-limb vascular surgery. In this study, we estimated that the annual cost of the major medical resources required to care for patients with PAOD is F3.9 billion to F4.6 billion, depending on the type of hospital. Approximately 75% of these costs were covered by CNAMTS, and
Table I. Distribution of the cost of care [French francs (F; 1995 values); F1 = $US0.20] over a 1-year period for patients with diseases of the arteries, arterioles and capillaries Direct medical costs
Number of events (millions)
Cost (F billions) total (%)
proportion covered by: national health insurance
patient
First estimate of the cost of hospitalisation (based on the hospital morbidity study from SESI)[11] Consultations 3.572 0.398 (10.1) 0.278
0.119
Monitoring examinationsa
0.039
Drug prescriptions Hospitalisations Hydrotherapy Total
1.193
0.097 (2.5)
0.058
34.124
1.528 (39.0)
0.927
0.601
0.117
1.849 (47.1)
1.572
0.277
0.051b (1.3)
0.051
NA
3.923 (100.0)
2.886
1.036
0.022 39.028
[12]
Second estimate of the cost of hospitalisation (based on survey by CREDES) Consultations 3.572 0.398 (8.6)
0.278
0.119
Monitoring examinationsa
0.058
0.039
Drug prescriptions Hospitalisations Hydrotherapy Total
1.193
0.097 (2.1)
34.124
1.528 (33.1)
0.927
0.601
0.181
2.548 (55.1)
2.166
0.382
0.051c (1.1)
0.051
NA
4.622 (100.0)
3.480
1.141
0.022 39.092
a
Defined as laboratory tests and exploratory examinations (e.g. doppler and echography).
b
The total cost indicated was underestimated as it only corresponds to the expenses covered by CNAMTS. The costs covered by the patient and expenses for hydrotherapy covered by the patient have not been taken into account.
c
The total cost indicated was underestimated as it only corresponds to the expenses covered by the national sickness insurance fund. The costs covered by the patient and expenses for hydrotherapy covered by the patient have not been taken into account.
Abbreviation: CREDES = Centre de Recherche d’Etude et de Documentation en Economie de la Santé; NA = not available; SESI = Service des Statistiques des Etudes et des Systemes d’ Information.
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Pharmacoeconomics 1998 Jan; 13 (1 Pt 1)
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hospitalisation was the main expense. Depending on the estimate used, hospitalisation accounted for 47 to 55% of all costs for PAOD. This estimate does not cover nonmedical direct costs or indirect costs, so it must be considered a minimum estimate. Data concerning direct medical resources were obtained from national representative public and private surveys and databases. These allowed us to describe the use of medical resources related to PAOD, in both hospital and ambulatory settings. These sources were the most recent that were available at the time of our study, but some data were already 4 to 10 years old. We would like to highlight that no systematically collected data on hospital admission (in either public or private settings) were available in 1995; therefore, despite the time lag between their completion and the time of our study, these databases were the most relevant that we could use. CNAMTS and the Department of Health are the only official data providers for total health expenditure at a national level. CREDES and INSERM are the national research centres for health economics and medical research, respectively, and are mostly publicly funded. IMS is a private company that provides medical audits for 80 countries around the world, collected through national, representative physicians panels. In France, the IMS Medical Audit is considered by governmental authorities to be a reference for assessing prescribing patterns. No other sources in France are as representative or relevant to the issue we have described here. One could argue that we have estimated the cost of care for people with PAOD rather than the cost of PAOD itself. Obviously even if PAOD is the main diagnosis for hospitalisation, all the costs incurred during the hospitalisation of the patient are not necessarily related to PAOD (a part can be the consequence of the associated comorbidities). However, it is likely that the majority of them are. As the data collected in the French Medical Audit conducted by IMS clearly indicated for which disease a drug, laboratory test or an examination was prescribed, this problem is of lesser importance for ambulatory care costs. So, it is legitimate to conAdis International Limited. All rights reserved.
Montron et al.
sider that these results roughly reflect the cost of care for PAOD in France. The majority of data used in this cost-of-illness study were obtained from the national representative surveys of CREDES, CNAMTS and INSERM. When using different information sources, it is important to explain their respective methodologies in order to consider the limitations of the data and their impact on the results. Such considerations include the availability and quality of the data with respect to the problem studied, together with the need to make retrospective, average cost estimates, particularly for public establishments and for private establishments affiliated to the public sector. Comparison of different sources of the same data therefore provides a measure of the validity and reproducibility of results. For this reason, the SESI hospital morbidity survey,[12] which considered short periods of hospitalisation, and the CREDES national hospital survey,[13] which assessed short, medium and long term hospitalisation, were used. The results of both studies were extrapolated to the whole of France, and the goals of the 2 surveys differed such that the SESI survey provided the number of hospitalisations per year according to hospital departments, while the CREDES survey described the main diagnoses for an average day in the year. It was therefore necessary to adjust the CREDES data in order to compare the results of both surveys. This correction led to a hypothesis concerning medium-length stays in hospital. The length of stay used was that reported in the SESI survey. An evaluation of hospitalisation was conducted for public establishments on the basis of the cost of hospitalisation in the Assistance Publique-Hôpitaux de Paris. However, the cost of hospitalisation varies not only from 1 establishment to another, but also between regions. The average cost per day in private hospitals was determined using data provided by the National Health Expenditure (Comptes Nationaux de la Santé) and CNAMTS. For this reason, the average cost per day did not include costs covered by other systems, which encompass approximately 20% of the French population.[21] Pharmacoeconomics 1998 Jan; 13 (1 Pt 1)
Cost of Peripheral Artery Disease in France
Considerable progress has been achieved with cost-of-illness studies in France to date, and this is partly because the main reference institutions have conducted specific surveys on a regular basis. However, prudence is required when using the results of these surveys as they only provide partial cost estimates. In particular, indirect costs, costs of transportation and costs of ancillary medical and paramedical intervention were not taken into account. The partial estimate conducted in this study indicated that the care of patients with PAOD accounted for 0.7% of total healthcare costs for 1993 in France. These epidemiological and economic data may help to determine and establish public health priorities and also facilitate changes in medical practice by providing a rationale for earlier screening of PAOD; more than 50% of the total cost was linked to hospitalisation. They also show that advanced stages (claudication, decubitus pain, necrosis, etc.) are the most complex to care for and the most expensive because of the high relative contribution of the cost of hospitalisation. Earlier detection and management could have a favourable impact in limiting the severe consequences of the disease. Earlier detection of PAOD may be possible using the systolic index, as demonstrated by the promising results of the recent study by Boccalon and Lehert.[22]
59
6.
7.
8. 9.
10. 11.
12.
13.
14.
15.
16.
17. 18.
19.
Acknowledgements 20.
This study was funded by LIPHA Laboratories S.A. 21.
References 1. Les artériopathies des membres inférieurs : des conséquences socio-économiques très lourdes. Le Quotidien du Médecin 1993; 5157: 16 2. Langley PC, Coons SJ. Peripheral vascular disorders: a pharmacoeconomic and quality-of-life review. Pharmacoeconomics 1997; 11 (3): 225-36 3. Mission Statistique Médicale. Exonération du ticket. Paris: Caisse Nationale d’Assurance Maladie des Travailleurs Salariés (CNAMTS), 1993 4. Sermet C. De quoi souffre-t-on ? Description et évolution de la mortalité déclarée 1990-1991. Solidarité Santé 1994; 1: 37-56 5. Sermet C. La pathologie des personnes âgées de 80 ans et plus en institution: enquête nationale France 1987-1988. Paris:
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Centre de Recherche d’Etude et de Documentation en Economie de la Santé (CREDES), 1992 Sources médicales de décès-résultats définitifs France. Paris: Institut National de la Santé et de la Recherche Médicale (INSERM), 1991 Organisation Mondiale de la Sante. Classification internationale des Maladies (ICD-9). Geneva: Organisation Mondiale de la Sante, 1977 Cormier JM, editor. Les artériopathies des membres inférieurs I. Impact médecin: les dossier du praticien, 1991: 118 Mission Statistique Médicale. Exonération du ticket: modérateur pour affections de longue durée. Paris: Caisse Nationale d’Assurance Maladie des Travailleurs Salariés (CNAMTS), 1993 Etude Permanente de la Prescription Médicale (EPPMDOREMA). Nanterre: IMS France, 1994 Indicateurs statistiques, résultats 1993. Paris: Caisse Nationale d’Assurance Maladie des Travailleurs Salariés (CNAMTS), 1994 SESI. Fiches synthétiques par pathologies: enquête de morbidité hospitalière 1985-1987. Paris: Ministère de la Solidarité, de la Santé et de la Protection Sociale, 1990 Com-Ruelle L. Les étapes diagnostiques et la maladie principale des hospitalisés en 1992. Paris: Centre de Recherche d’Etude et de Documentation en Economie de la Santé (CREDES), 1995 Bulletin juridique: statistiques 1990-1991 sur les cures thermales prises en charges par le régime général de sécurité sociale et nomenclature des stations thermales. Paris: Union des Caisses Nationales de Sécurité Sociale (UCANSS), 1992 Nomenclature générale des actes professionnels et des actes de biologie médicales. Paris: Union des Caisses Nationales de Sécurité Sociale (UCANSS), 1995 Direction des Finances, Département de Contrôle de Gestion. Les coûts de l’assistance publique: Hôpitaux de Paris. Paris: Assistance Publique – Hôpitaux de Paris, 1994 SESI. Comptes nationaux de la santé 1991-1992-1993. Paris: La Documentation Française, 1995 Carnets statistiques: le régime général en 1993. Paris: Caisse Nationale d’Assurance Maladie des Travailleurs Salariés (CNAMTS), 1994 Dormandy J. Le devenir de l’artéritique. Sang, Thrombose et Vaisseaux; 1989 ; 1 (5) : 263-6 Chanu B. Histoire naturelle des artériopathies athéromateuses chroniques des membres inférieurs. Actualité d’Angeiologie 1988; XIII (5) : 111-23 Duriez M, Sandier S. Le système de santé en France: Organisation et Fonctionnement. Paris: Centre de Recherche d’Etude et de Documentation en Economie de la Santé (CREDES), 1994 Boccalon H, Lehert P. Diagnostic précoce de l’artériopathie des membres inférieurs a l’aide de mesures adaptées à la pratique généraliste: l’index systolique et la perception des pouls. J Mal Vasc 1995; 20: 28-37
Correspondence and reprints: Dr Eric Guignard, Health Economics Department, I.M.S. France, La Défense ‘Bergères’, 345 avenue Georges Clemenceau, TSA 30001, 92882 Nanterre CTC Cedex 09, France.
Pharmacoeconomics 1998 Jan; 13 (1 Pt 1)
