Entred Study, 2001–2003
The Entred 2001–2003 study (National Representative Sample of People with Diabetes) was conducted in partnership with the National Association for the Coordination of Diabetes Networks, the French National Health Insurance Fund, and the French Institute for Public Health Surveillance, with support from the French Diabetes Association.
This study had two complementary objectives:
to describe, assess, and monitor the health status of people with diabetes receiving treatment, as well as the methods and outcomes of their care;
to provide representative data enabling diabetes networks to evaluate themselves by comparing patients followed within the networks to those followed in standard practice (in Entred).
The sample of people with diabetes was randomly selected from the health insurance drug reimbursement databases, allowing for the combined use of reimbursement data and individual questionnaires. This unique feature of the Entred study thus enabled a comprehensive approach to the care of people with diabetes. We extend our
warmest thanks to the people with diabetes and the physicians who participated in Entred 2001–2003 for their significant contribution to the study, which helps improve knowledge about diabetes in France and guide efforts toward better diabetes care.
Diabetes surveillance should help improve the health and quality of life of people with diabetes by guiding ongoing public health initiatives (Action Plan for the Management and Prevention of Type 2 Diabetes, 2002–2005). The Entred 2001–2003 study (National Representative Sample of People with Diabetes) was conducted in partnership with the National Association for the Coordination of Diabetes Networks, the Health Insurance Agency, and the Institute for Public Health Surveillance, with support from the French Association of People with Diabetes, and had two complementary objectives:
to describe, assess, and monitor the health status of people with diabetes receiving treatment, as well as the methods and outcomes of their care;
to provide representative data that will enable diabetes networks to evaluate themselves by comparing patients followed within the networks to those followed in routine practice (in Entred).
The originality of Entred lay in the creation of a sample of people with diabetes selected at random from health insurance drug reimbursement records, as well as in the combined use of reimbursement data and individual questionnaires, enabling a comprehensive approach to the person with diabetes.
Entred 2001–2003 provided a description of the characteristics, health status, and medical care of people with diabetes treated in mainland France. The results available for 2001–2003 demonstrate the value of epidemiological surveillance using this methodology to quantify the remaining efforts needed to improve the health and quality of life of people with diabetes. In particular, new results would help measure the achievement of the objectives of the Public Health Framework Act:
to reduce the frequency and severity of diabetes complications, particularly cardiovascular complications;
ensure monitoring in accordance with the clinical best practice recommendations issued by the SFD (formerly Alfédiam), ANSES (formerly Afssaps), and HAS (formerly Anaes) for 80% of people with diabetes by 2008.
Sponsors, funders, partners
The sponsor of Entred 2001–2003
National Association for the Coordination of Diabetes Networks (Ancred)
A non-profit association established on March 14, 1999, and registered with the Prefecture on September 11, 1999, bringing together private and hospital-based professionals.
Purpose: to promote projects for diabetes care networks and to support the development of these networks.
Ancred - 18, avenue de la Vénerie - 91230 Montgeron
Entred’s Funders 2001–2003
Fund for the Quality of Outpatient Care (FAQSV)
FAQSV - CnamTS
50, Avenue du Pr A. Lemierre - 75986 Paris cedex 20
Institute for Public Health Surveillance (InVS)
Department of Chronic Diseases and Injuries
12, rue du Val d’Osne - 94415 Saint Maurice Cedex
Entred’s partner 2001–2003
French Association of Diabetics (AFD)
58, Rue Alexandre Dumas - 75544 Paris Cedex 11
Scientific Committee
The Executive Board
- President: D. Simon, Inserm U 258, Ancred, Paris
- Vice President: M-H. Bernard, President of Fenarediam, Lyon
- Vice President: J. Chwalow, Inserm U 341, Paris
- Vice-President: B. Detournay, Cemka, Paris
- Secretary: V. Coliche, Boulogne-sur-Mer General Hospital, Ancred
- Treasurer: M. Varroud-Vial, President of Ancred, Corbeil
- Project Manager: A. Fagot-Campagna, InVS, Saint-Maurice
Other members
- N. Beltzer, ORS Ile-de-France, Paris
- J. Bloch, InVS, Saint-Maurice
- E. Eschwège, Inserm U258
- S. Fosse, InVS, Saint-Maurice
- A. Hochart, ORS Franche-Comté, Besançon
- H. Isnard, InVS, Saint-Maurice
- P. Lecomte, Ancred, Tours
- M. Malinsky, Ancred, Thionville
- E. Mollet, Ancred, Dole
- F. Penfornis, Ancred, Besançon
- C. Petit, Ancred, Montgeron
- A.-L. Pham, AFD, Paris
- P. Preiss, AFD, Paris
- I. Romon, InVS, Saint-Maurice
- S. Scaturro, Ancred, Montgeron
- N. Vallier, CnamTS, Paris
- A. Weill, CnamTS, Paris
The following individuals contributed to the study:
- D. Dartois, Ancred, Montgeron
- R. Khelladi, Ancred, Montgeron
As well as:
- J. Dupin, Professional Master’s 2 intern, InVS, Saint-Maurice
- N. Jourdan-Da Silva, public health resident, InVS, Saint-Maurice
- C. Marant, Professional Master’s 2 intern, InVS, Saint-Maurice
- S. Nevanen, InVS, Saint-Maurice
- F. Livinec, public health resident, InVS, Saint-Maurice
- J. Tambekou, DEA intern, InVS, Saint-Maurice
- P. Brindel, public health intern, InVS, Saint-Maurice
- K. Ihaddadene, DESS intern, InVS, Saint-Maurice
For the Entred study (2001–2003), 10,000 individuals were randomly selected from among beneficiaries of the general health insurance scheme for salaried workers who were reimbursed for oral antidiabetic medications or insulin in the last quarter of 2001. Entred comprised five substudies:
Monitoring of reimbursement data for the 10,000 individuals from 2001 to 2003;
A questionnaire sent in 2002 to these 10,000 individuals (response rate = 45%);
A supplementary medical questionnaire sent to the physicians of diabetic patients who responded and provided their doctor’s contact information (response rate = 38%);
A survey of hospitals to determine the characteristics and causes of hospitalizations;
A mortality study
Detailed report on the Entred methodology
Questionnaires
Confidentiality and participants’ rights
Responses to the questionnaires provided by people with diabetes and their doctors are confidential and intended for Ancred
These responses are protected by medical and statistical confidentiality.
Data analysis is anonymous: during the study, last names, first names, and addresses are systematically removed from the survey database, and the data is processed with complete confidentiality.
The Entred survey has been granted certification number 901236 by the National Commission for Information Technology and Civil Liberties.
Law No. 78-17 of January 6, 1978, on data processing, files, and civil liberties, applies to responses to this survey.
This law guarantees data subjects the right to access and correct data concerning them.
This right may be exercised directly by contacting the physician in charge of the survey.
Key Findings
The diabetic population is aging. The average age is 64, and a quarter of people are over 75. Just over half of people with diabetes are men. Diabetes is a recent diagnosis for more than a quarter of respondents (diagnosed within the last 5 years) but a long-standing condition for another quarter (for at least 20 years). The vast majority of people (91%) have type 2 diabetes.
The level of vascular risk among people with diabetes is high: 93% of respondents report at least one risk factor other than diabetes, including current smoking (16%), high blood pressure (54%), high cholesterol (51%), and, most notably, being overweight (40%) or obese (34%).
Diagnosed coronary complications are common (17% for angina, heart attack, or coronary revascularization). They are common from the time of diagnosis: 14% of people with diabetes who were diagnosed less than 5 years ago already report at least one coronary complication. Better control of vascular risk factors could, however, prevent these complications.
Screening for microvascular complications is insufficient, particularly regarding ophthalmological and podiatric complications. In fact, 32% of physicians cannot provide information on their patient’s retinal condition, and only 43% of patients report having undergone a fundus examination within the past year; 43% of physicians do not know the result of the 10-gram monofilament test, an inexpensive test that assesses the sensitivity of a diabetic patient’s foot. Yet ophthalmological care (laser treatment) or podiatric care can prevent blindness or amputations.
Therapeutic management of diabetics must be intensified: 32% of diabetics are treated with a single oral antidiabetic medication but without metformin, as recommended; HbA1c levels are poorly controlled (HbA1c ≥7%) in more than half of cases (53%); control of blood pressure and lipid levels is also insufficient: 51% of people with diabetes have blood pressure of 140/90 mmHg or higher, and 26% have LDL levels of 1.3 g/L or higher. Intensifying dietary management and drug therapy would help better control vascular risk and prevent diabetes complications.
The quality of diabetes care improved between 2001 and 2003 but remains inadequate. In 2001, 66%, 72%, and 16% of people with diabetes, respectively, underwent at least one lipid profile, at least one serum creatinine test, and at least one urine albumin test, as recommended. HbA1c testing is recommended every 3 or 4 months, but is performed three times a year in only 30% of people, even though it should replace blood glucose testing, which is still performed too frequently (three times a year in 44% of people with diabetes). In 2003, 39% of patients received three HbA1c tests.
However, doctors and their patients are generally satisfied with diabetes care. Only dietary management poses a problem: doctors generally report being dissatisfied with the dietary care they provide, and patients often report having difficulty following the prescribed diet.
The cost of care is a barrier to treatment for one in five people with diabetes, and this primarily involves podiatry and dental care. Only 6% of people with diabetes are covered by universal health coverage (CMU), and 77% are exempt from copayments for a condition on the ALD list (diabetes or another illness), even though all of them could qualify.
The majority of people with diabetes (86% with type 2 diabetes and 69% with type 1 diabetes) are managed by general practitioners, without an annual referral to a private or hospital-based endocrinologist. Improving the management of people with diabetes therefore relies particularly on general practitioners. Support from podiatrists and dietitians, who currently provide care that is not reimbursed, appears necessary.
Learn more
Slideshows with commentary detail:
• the Entred methodology
• characteristics of the diabetic population
• vascular risk
factors • complications
• quality of life for people with
diabetes • therapeutic management
• Therapeutic management of cardiovascular risk in people with type 1
diabetes• Therapeutic management of cardiovascular risk in people with type 2
diabetes• the quality of medical
follow-up • the cost of care, patient and physician satisfaction, and physician
characteristics• general conclusions on the study results
A slide show without commentary presents
Detailed tables (medical reimbursement data from 2001–2003, patient and physician questionnaires)
National
Regional
Medical reimbursements 2001 to 2003 - Data from the Health Insurance Fund
Patient questionnaire
Physician Survey
