Entred Study (2007–2010)

The Entred 2007–2010 study (“Representative National Sample of People with Diabetes”) aims to deepen our understanding of the health status of people with diabetes in France, their medical care, their quality of life, their educational needs, and the cost of diabetes

Between 2007 and 2010, the project was sponsored by the French Institute for Public Health Surveillance, which funded the study in partnership with the French National Health Insurance Fund (for salaried workers and the social security system for the self-employed), the National Institute for Prevention and Health Education, and the French National Authority for Health.

Entred 2007-2010 received support from the French Diabetes Association (AFD), the National Council of the Order of Physicians, the French-Speaking Association for the Study of Diabetes and Metabolic Diseases (SFD), the National Federation of Regional Associations of Endocrinology, Diabetology, and Metabolism (Fénarédiam), the National Union of Physicians Specializing in Endocrinology, Diabetes, Metabolic Diseases, and Nutrition (Sedmen), and the National Association for the Coordination of Diabetes Networks (Ancred).

People with diabetes and their doctors, as well as the medical advisors from the French National Health Insurance who participated in Entred 2007–2010, are warmly thanked for their significant contribution to the study, which helps improve knowledge about diabetes in France and guide efforts toward better diabetes care.

The Entred study (“Representative National Sample of People with Diabetes”) was first conducted in 2001 and provided an overview of the health status of the diabetic population and their medical care in France in 2001. The results of this study were widely disseminated (articles, conference presentations, theses, website, etc.).

The Entred 2007–2010 study follows up on Entred 2001–2003 and uses a similar methodology, in order to examine possible changes since 2001, but also to address new important questions concerning people with diabetes.

To this end, the specific objectives of the study are to describe:

  • the health status of people with diabetes;

  • their healthcare journey (medical consultations with general practitioners and/or specialists,

  • paramedical consultations, hospitalizations);

  • the quality of care they receive;

  • the educational initiatives undertaken (counseling/training regarding diabetes in general or nutrition, physical activity, self-monitoring of blood glucose, etc.);

  • their experiences and needs regarding information and education;

  • their quality of life;

  • their socioeconomic characteristics;

  • the cost of diabetes.

The Entred 2007–2010 study focuses on a random sample of 10,705 people with diabetes, consisting of adults with diabetes living in mainland France or residing on Réunion Island, in Martinique, Guadeloupe, or French Guiana, as well as children with diabetes under the age of 18 residing in mainland France or in these same overseas departments.

The Entred 2007–2010 study consists of three sub-studies, all with the same objective but using slightly different methodologies and focusing on three different populations:

  • “Entred-Dom,” which involves 855 adults with diabetes residing on Réunion Island, in Martinique, Guadeloupe, or French Guiana;

  • “Entred-Enfant,” which involves 924 children with diabetes under the age of 18. Within this component, a specific study, called “Entred-Ado,” focuses on the subgroup of 624 adolescents with diabetes aged 11 to 17 as of August 1, 2007.

A report details the conduct of the second Entred study (National Representative Sample of People with Diabetes) conducted in 2007–2010, as well as the analytical methodology. The appendices to the report are available by clicking here

Key epidemiological findings (in brief)

The diabetic population, estimated at 2.4 million in mainland France and still growing, is generally older (median age of 66), economically more disadvantaged than the general population of the same age, and 23% of whom were born abroad. Type 2 diabetes is the most common form (92%, or 2.2 million people in mainland France). At the time of the study, the median duration of the condition was 9 years, which exposes patients to a high risk of complications.

Among people with type 2 diabetes, a notable decrease in vascular risk was observed between 2001 and 2007. While obesity became even more common (41%, +7 percentage points since 2001), glycemic control improved (median HbA1c: 6.9%, -0.3%), and blood pressure (median 130/80 mmHg, -3/-2 mmHg) and cholesterol (median LDL: 1.06 g/L, -0.18 g/L) decreased across all age groups. However, the frequency of diabetes complications has increased slightly, which is partly explained by more frequent screening for these complications, and may also be due to longer life expectancy among older adults and higher prevalence of diabetes among younger adults.

Antidiabetic treatments have intensified and therapeutic choices have changed, better aligning with current recommendations. However, glycemic control remains inadequate (HbA1c > 7%) for 41% of people with type 2 diabetes, exposing them to the risk of complications affecting the kidneys, eyes, and nerves. The currently recommended treatment escalation—involving the addition of one, then two, then three oral antidiabetic medications, followed by insulin if glycemic control remains inadequate—is therefore still not fully adhered to.

Preventive treatments for cardiovascular and kidney diseases have also been significantly intensified, resulting in a substantial decrease in blood pressure and cholesterol levels between 2001 and 2007. Here too, improvements remain possible, particularly regarding blood pressure control, since 49% of people with type 2 diabetes have blood pressure that strictly exceeds the recommended threshold of 130/80 mmHg.

Significant improvements in the quality of medical care have been observed, with the procedures necessary for screening and monitoring diabetes complications being performed more frequently. However, fundus examinations—necessary for screening for retinopathy—and urine albumin testing—necessary for screening for early kidney damage—are still performed too infrequently and have seen little progress. Thorough foot examinations, which aim to screen for neuropathy and peripheral vascular disease and to treat any lesions early, are performed far too infrequently.

This health assessment for people with type 2 diabetes is primarily intended for general practitioners, since they alone—without consulting a diabetologist—care for 87% of these patients. General practitioners are therefore key players in the progress made and that which remains to be done, serving as coordinators of the care pathway between healthcare professionals and diabetes specialists.

General characteristics of people with diabetes.

The diabetic population is aging: the median age is 66 and the average is 65, and a quarter (26%) are 75 or older. Compared to 2001, the age structure of the diabetic population has changed slightly, becoming flatter, with the medians and averages remaining unchanged. Just over half of people with diabetes (54%) are men, who are slightly younger than women with diabetes.

Most (84%) people with diabetes receive 100% coverage for a chronic condition (diabetes or another illness), a proportion that has increased by 7 percentage points since 2001; 6% are covered by Universal Health Coverage, a proportion that has remained stable since 2001 and affects few older adults. On average, the diabetic population is not financially well-off, as more than half (54%) report “barely making ends meet,” “unable to make ends meet without going into debt,” or “it’s just enough.” Monthly household income (wages, benefits, assistance, etc.) is below 1,200 euros for one-third (34%), and this income is lower than that of the general population, regardless of age, for those under 75 (source of comparison: INSEE’s 2006 Tax and Social Income Survey).

In total, 77% of people with diabetes were born in France, 12% in a Maghreb country, and 11% in another country.

General characteristics of diabetes: Type 2 diabetes remains just as common, most often diagnosed within the past 9 years, which corresponds to a high risk of complications.

As in 2001, the vast majority of people (91.9%) have type 2 diabetes (linked to a combination of insulin resistance and insulin deficiency, and treated with diet, oral antidiabetics, and/or insulin), 5.6% have type 1 diabetes (insulin deficiency linked to the destruction of pancreatic beta cells, requiring insulin treatment), and 2.5% have other types of diabetes (MODY, pancreatitis, cystic fibrosis, etc.) or provided insufficient information to classify them. Before age 45, more than half (54%) have type 1 diabetes. From age 45 onward, type 1 diabetes becomes proportionally marginal (8% between ages 45 and 54, 3% between ages 55 and 64, and then less than 1%). Insulin treatment, including type 1 diabetes, accounts for just under 1 in 5 people (20%) between the ages of 45 and 84.

The median duration of diabetes has not changed since 2001, remaining at 9 years (9 years for type 2 diabetes and 15 years for type 1), or 12 years on average, and nearly half of people with diabetes (48%) have therefore had diabetes for more than 10 years, which puts them at high risk for complications.

Diabetes was detected during a screening (check-up, blood test, pregnancy) for more than two-thirds (67%) of people with type 2 diabetes, for 18% due to suggestive symptoms, and for 15% too late, that is, upon the discovery of a complication.

While obesity is becoming even more common, glycemic control among people with diabetes is improving.

Overweight is the major modifiable risk factor for type 2 diabetes. The median body mass index (weight in kg divided by height in cm squared) of people with type 2 diabetes is estimated at 28.7 kg/m². However, this body mass is calculated based on weight and height reported by the patient, which most likely underestimates it. While 20% of people with type 2 diabetes have a BMI below 25 kg/m², 39% are overweight (25–29 kg/m²) and 41% are obese (≥30 kg/m²). These proportions are slightly higher in the insulin-treated subgroup (36% overweight and 45% obese) than in the non-insulin-treated subgroup (40% and 41%). Since 2001, the median body mass index has increased by 0.9 kg/m², and obesity has risen by 7 percentage points, particularly among those treated with insulin (+11 percentage points), at the expense of overweight individuals (-3 percentage points).

Overweight is not a recognized risk factor for type 1 diabetes. However, while 56% of people with type 1 diabetes are of normal weight, 30% are overweight (+3 percentage points since 2001) and 14% are obese (+4 percentage points). Similar rates are found in the general population (source: 2006 Obépi surveys). Nutritional management and weight control should therefore also be integrated into the management of type 1 diabetes.

Glycemic control, a specific goal of diabetes management, is estimated based on HbA1c levels, which reflect blood glucose levels over the past 3 months. An HbA1c level below 6.5% indicates good glycemic control. In 2007, the median HbA1c level was 6.9% for people with type 2 diabetes and 7.8% for those with type 1 diabetes, despite the latter group being younger. One-third (34%) of people with type 2 diabetes have good control (HbA1c ≤ 6.5%). However, 41% had an HbA1c level above 7% (15% above 8%). While glycemic control remains generally inadequate, it has improved, as the median HbA1c value has decreased by 0.3% since 2001 and the distribution has shifted toward lower values. In particular, there has been a drop in the proportion of people with an HbA1c above 8% (-6 percentage points).

A remarkable reduction in vascular risk among people with type 2 diabetes: blood pressure and cholesterol have decreased regardless of age.

The median blood pressure, as reported by physicians, is 130/80 mmHg among people with type 2 diabetes; only 14% are below the recommended threshold of 130/80 mmHg (+7 percentage points since 2001) and more than one-third (38%) are at or above 140/90 mmHg (-15 percentage points). Thus, since 2001, the median systolic blood pressure has fallen by 10 mmHg, the mean systolic by 3 mmHg, and the mean diastolic by 2 mmHg. A decrease is observed regardless of age and sex. However, blood pressure continues to be measured imprecisely, as it is very frequently reported in centimeters rather than millimeters of mercury, which may explain the high proportion of readings corresponding to the threshold value of 130/80 mmHg (45%). This is, however, a major cardiovascular risk factor.

Another major vascular risk factor, LDL cholesterol (or “bad” cholesterol) reported by physicians for 2007 or 2008 is estimated to have a median of 1.04 g/L, HDL cholesterol (or “good” cholesterol) at 0.49 g/L, and triglycerides at 1.30 g/L among people with type 2 diabetes. However, in one-quarter (24%) of cases, the doctor does not report an LDL cholesterol value; for one-third (34%), the level is below 1 g/L; for 24%, it is between 1 and 1.30 g/L; and for only 18%, it is at or above 1.30 g/L, the recommended threshold for individuals at high vascular risk. Since 2001, there has been significant progress: LDL levels are reported much more frequently (+15 percentage points), and the distribution of values has shifted toward much lower levels, regardless of age. The frequency of values below 1 g/L has increased by 22 percentage points, but it is possible that testing is being performed more frequently in people with normal levels. The frequency of high values (1.30 g/L or higher) has dropped by 9 percentage points.

Current smoking, the leading vascular risk factor, is reported by 13% of people with type 2 diabetes (and 39% of those with type 1, who are younger). In addition, 3% of people with type 2 diabetes (and 5% of those with type 1) reported having quit smoking within the past 3 years (which is also a vascular risk factor).

Albuminuria is also associated with a high vascular risk. However, this test is now more frequently available in physicians’ records than in 2001 (+3 points), and the frequencies of microalbuminuria (+4 points) and macroalbuminuria (+2 points) have increased slightly, at the expense of normal values (-3 points).

Overall, the vascular risk among people with type 2 diabetes, although decreasing, remains high in 2007: compared to the definitions established in the treatment recommendations of the Haute Autorité de Santé, 59% have a very high risk, 26% a high risk, 14% a moderate risk, and only 1% a low vascular risk.

The frequency of diabetes complications is increasing slightly.

A history of angina or myocardial infarction is reported by 16.7% of people with type 2 diabetes, a figure that has remained stable since 2001. However, the prevalence of coronary revascularization is 13.9% and has increased by 5 percentage points since 2001, bringing the total prevalence of coronary complications (including revascularization) to 20.8% (+3 percentage points). As in 2001, there may be an overestimation, as patients may confuse angioplasty (a procedure to revascularize the coronary arteries) with angiography (an examination of the coronary arteries without further intervention).

Based on data reported by people with type 2 diabetes, vision loss in one eye is estimated at 3.9% (stable since 2001) and the frequency of laser eye treatment at 16.6%, which has increased slightly since 2001 (+3 percentage points). There is likely an overestimation here as well, since patients may confuse laser treatment with fluorescein angiography (for retinal examination without any other intervention). Furthermore, vision loss in one eye and laser treatment may occur due to diabetes but also due to another condition. General practitioners, like diabetes specialists, rarely receive a report from the ophthalmologist (38% versus 51%). Based on their reports, the prevalence of diabetic retinopathy is estimated at only 7.9% and is therefore very likely underestimated.

A plantar ulcer—a foot lesion that can lead to amputation and indicates nerve damage and peripheral vascular disease—is reported by 9.9% of people with type 2 diabetes but by only 2.3% of their doctors. The increase between 2001 and 2007 was +4 percentage points for patient estimates and +1 percentage point for physician estimates. Again, while patient reports may lead to an overestimation (by confusing it with another condition, such as one of venous origin), those of physicians lead to an underestimation: their knowledge of their patients’ foot health is very incomplete, since 57% do not specify the level of foot health risk for their patients.

Dialysis or a kidney transplant, extremely serious but rare complications of diabetes, are reported by 0.3% of people with type 2 diabetes. Earlier renal complications are assessed, on the one hand, by testing for albumin in the urine (previously discussed as a vascular risk factor) and, on the other hand, by glomerular filtration rate. The glomerular filtration rate (estimated from serum creatinine levels using the MDRD equation) is missing (because serum creatinine levels are not reported by the physician) for 15% of people with type 2 diabetes, is normal for a quarter (23%), is between 60 and 90 mL/min/1.73 m² in 43%, and at a level indicating renal insufficiency (< 60 mL/min/1.73 m²) in 19%.

Significant improvements in the quality of medical care have been observed.

According to medical reimbursement data, 44% of people with type 2 diabetes received the three recommended HbA1c tests within the year to monitor glycemic control. However, 90% had at least one test within the year, and over two consecutive years, this percentage even reached 96%. Between 2001 and 2007, the practice of performing three annual HbA1c tests increased by 10 percentage points.

Regarding the monitoring of renal function in people with type 2 diabetes, a creatinine test was reimbursed within the year for 83% of patients, representing an 8-point increase since 2001; and a test for albuminuria or proteinuria for only 28%, which nevertheless corresponds to a 7-point increase. However, when comparing two consecutive years, 44% of people with type 2 diabetes received an albuminuria test.

Over the course of the year, lipid testing of any kind was reimbursed for 76% of patients (+8 percentage points compared to 2001), and LDL cholesterol testing for 72% of people with type 2 diabetes. An electrocardiogram or a cardiology consultation was performed for 39%, representing a 5-point increase. Over two years, 86% of patients underwent an LDL cholesterol test, and 57% had a consultation with a cardiologist or an ECG in private practice.

In contrast, the frequency of annual ophthalmology consultations remained nearly unchanged, with half (50%, +2 percentage points) of people with type 2 diabetes receiving one. Over two consecutive years, however, this percentage rose to 71%. Finally, the percentage of people with type 2 diabetes who received dental care during the year is 38%. This represents a 3-point increase compared to 2001.

It should be noted that these indicators reflect only procedures performed in private practice and for which reimbursement was claimed. They therefore do not account for additional monitoring conducted in public hospitals, which leads to an underestimation of the quality of care, both in 2001 and in 2007. Taking hospital stays into account (assuming that every hospitalized patient underwent an electrocardiogram, and if admitted to a medical ward, an albuminuria test) suggests that 45% of people with type 2 diabetes had an electrocardiogram or a cardiology consultation and 36% underwent an albuminuria test during the year.

The 2004 Public Health Act set a target for these tests to be performed on 80% of people with diabetes by 2008. Significant progress has been made toward this goal. However, it remains insufficient, particularly regarding three key indicators of the quality of medical care: screening for abnormal urinary albumin excretion (to detect kidney damage); the three HbA1c tests (to assess diabetes control); and fundus examination (to detect retinal damage).

Furthermore, thorough foot examinations—an indicator not specified by the Public Health Act, which aims to detect peripheral neurological and vascular damage and treat any lesions early—are performed far too infrequently. Thus, physicians provide the information necessary for assessing podiatric risk for only 62% of patients with type 2 diabetes, an increase of 12 percentage points since 2001. It should be noted that a high risk classification (grades 2 and 3), indicating a risk of amputation, now qualifies for reimbursement of podiatric care.

Diabetes treatments are becoming more intensive, and treatment options are changing.

Monotherapy with oral antidiabetic agents remains the most common treatment modality for type 2 diabetes (43%), followed by oral dual therapy (29%). Insulin therapy is prescribed for 17% of patients, and slightly more often in combination with an oral antidiabetic agent than as monotherapy (10% versus 7%). Triple oral therapy is prescribed in 8% of cases. Compared to 2001 data, oral monotherapy is less common (-5 percentage points), dual oral therapy slightly more common (+2 percentage points), and insulin therapy slightly more common (+2 percentage points in total), but only when combined with oral antidiabetic agents (+4 percentage points). Treatment with oral antidiabetic agents and insulin has therefore increased slightly.

Treatment with biguanides, recommended as first-line therapy for type 2 diabetes (62%), is the most commonly prescribed medication and has seen a significant increase of 12 percentage points since 2001. This increase has come at the expense of sulfonamide prescriptions (50%, -12 percentage points). The other classes of prescribed treatments are glitazones (13%), glinides (8%, +2 points), and alpha-glucosidase inhibitors (8%, -6 points). Therapeutic choices have thus shifted toward better alignment with recommendations, and glycemic control in people with type 2 diabetes has improved significantly, as evidenced by the decline in the average HbA1c level.

However, further intensification of antidiabetic treatments remains possible.

According to the Afssaps/HAS recommendations published in November 2006, the first-line treatment for type 2 diabetes as monotherapy is metformin. It is estimated, based on 2.2 million people with type 2 diabetes living in mainland France, that approximately 480,000 people are treated this way, but that another 440,000 are treated with monotherapy using another oral antidiabetic. Admittedly, intolerance or a contraindication to this treatment is possible.

The Afssaps/HAS recommendations published in November 2006 emphasized the importance of therapeutic escalation, which aims to maintain an HbA1c level that prevents or slows the progression of diabetes complications. Thus, still based on 2.2 million people with type 2 diabetes in mainland France, among those treated with oral monotherapy, 480,000 have well-controlled HbA1c (≤ 6.5%), and the other 440,000 could benefit from switching to dual oral therapy (HbA1c > 6.5%). Among those treated with dual oral therapy, 310,000 have HbA1c levels considered adequate (≤ 7%), and the other 310,000 could benefit from switching to triple oral therapy (HbA1c > 7%). Among those on oral triple therapy, 180,000 have an HbA1c ≤ 8%, and the other 40,000 could benefit from switching to insulin therapy (HbA1c > 8%). Finally, among those treated with insulin, 260,000 have an HbA1c ≤ 8% and the remaining 180,000 have an HbA1c > 8%. Thus, in total, 1.2 million people with type 2 diabetes—or 56%—are receiving treatment that meets the HAS’s glycemic targets, and 1 million people with type 2 diabetes could benefit from the recommended therapeutic escalation if poor glycemic control persists.

This therapeutic escalation is likely adjusted by physicians for patients whose life expectancy is reduced due to serious complications of diabetes or other diseases. However, 39% of younger patients with diabetes (<65 years) and 29% of those with newly diagnosed diabetes (within the last 5 years) have inadequately controlled HbA1c levels above 7%, which exposes them to a high risk of microvascular complications given their long life expectancy. Further improvements in treatment are still needed.

Preventive treatments for cardiovascular and renal diseases are becoming more common

Some form of antihypertensive treatment is prescribed for 75% of people with type 2 diabetes. Treatment with a thiazide diuretic is prescribed for 32%, with an angiotensin-converting enzyme (ACE) inhibitor for 28%, and with an angiotensin II receptor antagonist (ARBs) to 32% (i.e., 58% for one or the other of these last two classes, or 70% and 55%, respectively, for those with or without a history of coronary complications). Compared to 2007, the increases are significant: +12 percentage points for thiazides, +18 percentage points for ARBs (and -1 percentage point for ACEIs).

Lipid-lowering therapy is prescribed for 59% of people with type 2 diabetes (statins 47% and fibrates 10%), and for 80% versus 53% of those with or without a history of cardiovascular complications, respectively. The overall increase since 2001 is 18 points, driven by statins (+24 points) and at the expense of fibrates (-8 points).

Antithrombotic treatments (including antiplatelet agents), which aim to prevent cardiovascular complications, are prescribed for 40% of people with type 2 diabetes, and for 83% versus 28% of those with or without a history of cardiovascular complications. The overall increase since 2001 is 10 points.

It is important to note that cardiovascular complications (myocardial infarction, stroke, angina pectoris, etc.) are major complications of diabetes that can be prevented through better control of vascular risk factors, lifestyle and dietary management, and certain pharmacological treatments. While preventive treatments were significantly intensified between 2001 and 2007, further improvements are still needed. In particular, we have observed that blood pressure measurement is imprecise; that the intensification of antihypertensive treatment remains insufficient, with only 14% of people with type 2 diabetes falling below the recommended threshold of 130/80 mmHg; and that the overall vascular risk remains high.

Medical and Paramedical Consultations

General practitioners continue to provide very active follow-up care for patients with type 2 diabetes: on average, patients are seen 9 times a year during office visits or home visits. In addition, 10% of people with type 2 diabetes sought a consultation with a private endocrinologist or internist over the course of one year. This percentage has remained stable compared to 2001 (-2 percentage points). In contrast, the frequency of visits to private cardiology practices (37%) increased significantly between 2001 and 2007 (+5 percentage points).

Overall, it is estimated that over a two-year period, 4% of people with type 2 diabetes were treated by a hospital-based diabetes specialist (with or without referral to a private-practice diabetologist), 14% were treated by a private endocrinologist (without consulting a hospital-based specialist, but with a general practitioner), and 82% by a general practitioner, without consulting a diabetes specialist, whether private or hospital-based, which is generally stable compared to 2001. Among people with type 1 diabetes, the pattern of care over two years differs: 17% were treated by a hospital-based diabetes specialist, 34% by a private-practice endocrinologist, and 49% by a general practitioner alone.

These indicators, derived mostly from medical utilization data, do not, however, account for hospitalizations or hospital consultations in public facilities. They therefore underestimate the frequency of visits to specialists and paramedical professionals.

The frequency of nursing procedures is significant. Thus, one-quarter (25%) of people with type 2 diabetes received significant care from a private nurse (more than 10 procedures coded under AMI). According to their reports, one in five people with type 2 diabetes (20%) received a consultation with a dietitian (down 3 percentage points since 2001). Among obese individuals, half of those treated with insulin and 19% of those not treated with insulin received a dietary consultation. One in four people (24%) received podiatric care (+2 percentage points since 2001). Given the frequent and increasing prevalence of obesity and the podiatric risks in this population, podiatric and dietary follow-up appear necessary and likely insufficient.

Overall, this health assessment of people with type 2 diabetes is primarily intended for general practitioners, since they alone—without consulting a diabetes specialist—manage 87% of these patients. General practitioners are therefore the key players in the progress made and that which remains to be done, acting as coordinators of the care pathway between paramedical staff and diabetes specialists.

Hospitalizations

In 2007, 8,926 adults with diabetes who had received reimbursement for oral antidiabetic medications and/or insulin at least three times over the past 12 months were randomly selected from health insurance data. Medical records were available for all participants; a patient questionnaire was available for 48% (N=4,277) of patients, and a medical questionnaire for 28%. Hospital stays for individuals who did not refuse to participate in the study (N=7,534, 84%) were extracted from the PMSI between August 2006 and July 2009. The determinants of inpatient admissions (≥24 hours) were analyzed based on hospital stays recorded between August 2008 and July 2009.

Nearly one-third (31%) of people with diabetes (type 1: 45%; type 2: 31%, p<0.0001) had at least one hospital stay during the year: 13% for stays of less than 24 hours (type 1: 23%; type 2: 13%, p<0.0001), 24% for inpatient stays (type 1: 31%; type 2: 24%, p<0.0001). Patients admitted for inpatient care were older than other patients (median age, 69 years vs. 65 years), were more often covered 100% for a chronic condition (91%), and reported financial difficulties (59%), long-standing diabetes (≥10 years, 54%), and complications more frequently. They sought medical care and received insulin treatment (29%) more frequently. They had an average of 1.6 hospital stays, totaling 11 days of hospitalization per person. In multivariate analysis, advanced age, financial difficulties, a history of microvascular or coronary complications, inadequate glycemic control, and treatment with insulin alone were independently associated with the need for inpatient hospitalization among people with type 2 diabetes.

Hospitalizations remain common among people with diabetes, particularly among the elderly, frail, and disadvantaged. It is therefore essential to strengthen secondary prevention measures for these individuals.

Type 1 Diabetes

A total of 234 and 275 adults with T1D participated in Entred 2001 and Entred 2007, respectively, in mainland France. Data on medical reimbursement claims and questionnaires mailed to patients and their physicians were collected.

In 2007, the average age of adults with T1D was 42 years. Obesity had increased (14%; +4 percentage points since 2001), and 39% of participants reported smoking. The average HbA1c level was 7.9% (+0.2%) and blood pressure was 125/77 mmHg (-3/-1 mmHg). Angina or myocardial infarction was reported by 7% (stable), laser eye treatment by 24% (-1 percentage point), and an active or healed plantar ulcer by 12% (+6 percentage points) of participants. In total, 28% were being treated by a specialist (+7 percentage points); 35% (+8 percentage points) had undergone 3 HbA1c tests, 61% (+3 percentage points) a creatinine test, 42% (+7 percentage points) a proteinuria or albuminuria test, and 54% (+6 percentage points) a private ophthalmology consultation within the year.

In 2007, vascular risk remained high among people with T1D, particularly due to frequent smoking, rising obesity, and inadequate glycemic control. The frequency of complications had not decreased. As for the screening for complications, it had improved significantly over six years, although progress still needs to be made in this area.

Coming Soon

Further analyses from Entred will be published shortly, particularly those concerning limitations on activities related to diabetes, the impact of socioeconomic status on the quality of medical care and health status, and the prevalence of sleep apnea syndrome and sexual dysfunction.

REFERENCES:

  • French National Authority for Health (HAS), French Agency for the Safety of Health Products (Afssaps), Pharmacological Treatment of Type 2 Diabetes (update). Diabetes Metab 2007:3.

  • National Agency for Health Accreditation and Evaluation (ANAES). Management strategy for patients with type 2 diabetes, excluding the management of complications. Diabetes Metab 1999:25.

  • Charles MA, Eschwège E, Basdevant A. Monitoring the obesity epidemic in France: the Obepi surveys 1997-2006. Obesity 2008 Sep;16(9):2182-6

LEARN MORE:

  • Lecomte P, Criniere L, Fagot-Campagna A, Druet C, Fuhrman C. Underdiagnosis of obstructive sleep apnea syndrome in patients with type 2 diabetes in France: ENTRED 2007. Diabetes Metab 2013:39:139-147.

  • Druet C, Bourdel-Marchasson I, Weill A, Eschwège E, Penfornis A, Fosse S et al. Type 2 diabetes in France: epidemiology, trends in the quality of care, and social and economic burden. ENTRED 2007. Presse Med. 2013; 42: 830-38.

  • Documents provided to patients and physicians who participated in the Entred-Metropole study:

Brochure “Results of the 2007 Entred Study” for patients

Brochure “Results of the 2007 Entred Study” for physicians

  • Fagot-Campagna A, Weill A, Paumier A, Poutignat N, Fournier C, Fosse S, Roudier C, Romon I, Chantry M, Detournay B, Eschwège E, Rudnichi A, Druet C, Halimi S. What can be learned from the Entred 2007-2010 assessment? Medicine of Metabolic Diseases 2010;2(4):212-218.

  • Fagot-Campagna A, Fosse S, Roudier C, Romon I, Penfornis A, Lecomte P, Bourdel-Marchasson I, Chantry M, Deligne J, Fournier C, Poutignat N, Weill A, Paumier A, Escwège E, on behalf of the Entred Scientific Committee. Characteristics, vascular risk, and complications among people with diabetes in mainland France: significant changes between Entred 2001 and Entred 2007. Feuillets de Biologie 2010;294(LI):1-6.

  • Tiv M, Viel JF, Mauny F, Eschwège E, Weill A, Fournier C, Fagot-Campagna A, Penfornis A. Medication adherence in type 2 diabetes: the ENTRED study 2007, a French population-based study. PLoS One 2012; 7(3): e32412.

  • Druet C, Eschwege E, Poutignat N, Gautier A, Risse M, Fagot-Campagna A. According to ENTRED 2007, difficult metabolic control and frequent complications. Le Concours Médical Médecine Générale. Volume 134, Issue 6. June 2012.

  • Anne Fagot-Campagna. Type 1 diabetes: initial findings from the Entred 2007 study. Concours Médical, March 8–12, 2010:188–190, Issue 5.

  • Fagot-Campagna A on behalf of the Entred Scientific Committee. Health status of people with diabetes, quality of care, therapeutic education, and cost of diabetes: significant changes between 2001 and 2007 according to the Entred surveys. Quotidien du médecin, Thursday, November 26, 2009, page 18, issue 8665.

  • Fagot-Campagna A, Auleley GR, Fournier C, Poutignat N, Chantry M, Deligne J, Thammavong N, Romon I, Roudier C, Lasbeur L, Eschwège E, Varroud-Vial M, Halimi S, Weill A. A new ENTRED in 2007–2010: why, how? Diabetes Networks, June 2008: 4-7.

A summary outlines the key findings of the Entred 2007–2010 study.

Information Needs, Resource Utilization by People with Type 2 Diabetes, and Educational Initiatives (in a nutshell)

Most people with type 2 diabetes say they are well informed about their condition. However, this information does not fully satisfy their desire for more. In fact, three-quarters of them would like additional information, most often regarding diet and complications related to the disease, and less frequently regarding physical activity, which is one of the cornerstones of treatment. Information is primarily provided by the doctor, and despite the wishes expressed, patients are not very active in seeking out information.

The current educational approach is primarily based on face-to-face interactions during in-depth individual consultations. While few patients report wanting to participate in individual education and even fewer in group sessions, this may be due to a lack of awareness of these approaches. In fact, those who have participated in such programs report that they met their expectations and helped them better manage their diabetes; they would like to have the opportunity to participate again more often.

For physicians, the main challenge in managing patients with type 2 diabetes is ensuring their adherence to recommendations regarding diet and physical activity.

Doctors state that they have a role to play in education. Three-quarters of specialists and one-quarter of general practitioners do indeed offer consultations dedicated to therapeutic education, though this activity is less developed in private practice than in hospitals. Lack of time, as well as a shortage of professionals and support structures, are the main obstacles cited in implementing an educational approach.

Doctors would like to receive more training in this approach and have access to informational materials for patients, as well as consultation aids for both patients and themselves, in order to improve communication with patients.

Needs and Sources of Information and Education for Patients with Type 2 Diabetes

Eighty percent of people with type 2 diabetes say they are well or very well informed about their condition. However, this does not satisfy their desire for information, as 76% of people with type 2 diabetes would like additional information, particularly regarding diet (45%), possible diabetes-related complications (35%), and how to live well with diabetes (29%). Physical activity is rarely mentioned (18%), likely because its role in managing diabetes is underestimated and difficult to implement. The desire for additional information is strongest among younger people, those with complications from the disease, or those reporting financial difficulties.

People with type 2 diabetes obtain information primarily from doctors (82% of cases), much less frequently from the media (16%), from other healthcare professionals or family and friends (13% each), or from patient organizations (2%).

Despite the frequency of expressed desires for information, only half of the people (54%) report having sought information about diabetes on their own. When they actively seek information, the vast majority turn to books or written materials (42% of all people with type 2 diabetes) and much less frequently to the Internet (9%), a patient organization (2%), or a telephone helpline (less than 1%).

Educational efforts are primarily conducted through face-to-face interactions: over the past 12 months, in addition to their regular medical follow-up for diabetes, 15% of people with type 2 diabetes report having had in-depth discussions with a doctor (or nurse, dietitian, etc.) focused on diabetes management and daily treatment; 3% report having participated in group sessions (classes, lectures, workshops with several people with diabetes); less than 1% received telephone support.

While few people wish to receive individual education (28%) and even fewer group education (11%), this may be due to a lack of awareness of these approaches, as those who have received them report being satisfied: 73% say they met their expectations and 72% say they helped them live better with diabetes; these individuals would like to be able to benefit from them again more often.

Role of Physicians, Challenges Faced, and Needs

For doctors, whether diabetes specialists or general practitioners, the main difficulty encountered in managing diabetic patients is their adherence to recommendations regarding diet (65%) and physical activity (64%), as well as patients’ understanding of their diabetes (35%). The availability of a dietitian is a problem for 39% of doctors (more often for general practitioners and private specialists than for hospital-based specialists). The difficulty of providing psychological support to patients is raised by 21% of doctors.

Regarding the role they believe they should play in education, general practitioners primarily emphasize a coordinating role for the entire process (68%), on par with diabetologists and endocrinologists (66%). These specialists, for their part, more often highlight their role in identifying patients’ needs (82%), in monitoring their progress (79%), followed by referring patients to educational activities (58%), in implementing such activities (57%), and in providing patients with psychosocial support (57%). These various concerns are also shared by 41% to 54% of general practitioners, except for the implementation of educational activities, which only 20% believe is part of their role.

In practice, 71% of hospital-based specialists report that the majority of their patients receive therapeutic education, compared to 27% of private-practice specialists and 11% of general practitioners. Seventy-six percent of specialists schedule appointments for therapeutic education sessions that they conduct themselves, compared to 28% of general practitioners.

These practice patterns reflect the greater prevalence of educational programs in hospitals, which offer a diverse range of educational services. At the same time, they show that educational activities can also be established in private practice.

Among the barriers to developing an educational approach, general practitioners and specialists cite lack of time (76% and 79%) and lack of support staff and facilities (39% and 40%) as the top reasons, suggesting their difficulties in integrating this approach into care and coordinating it. Specialists highlight the lack of compensation for the activity (53%) as well as cultural and linguistic barriers (42%, more pronounced among hospital-based specialists who likely see a different patient population). General practitioners mention more often than specialists that patients do not feel the need for an educational approach (33%), a lack of training (26%), and a lack of appropriate materials (21%).

Doctors would like to receive more training in the educational approach and acquire different skills depending on whether they are general practitioners or specialists: for the former, this mainly involves proposing and negotiating goals (52%), providing appropriate information (48%), and identifying patients’ needs (37%). For specialists, this involves proposing and negotiating goals (45%), assessing changes (45%), and encouraging patients to express themselves (38%).

General practitioners would like to have informational materials for patients (40% of them versus 14% of specialists). Specialists more often mention the need for consultation support tools for themselves (40% of specialists and 32% of general practitioners) and for patients (35% of specialists and 28% of general practitioners).

In-depth analyses will be conducted to supplement these initial findings regarding the information and educational approach offered to people with diabetes.

In particular, a specific analysis will be conducted shortly based on responses from people with type 1 diabetes.

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  • Ricci P, Chantry M, Detournay B, Poutignat N, Kusnik-Joinville O, Raimond V, Thammavong N, Weill A, for the Entred Scientific Committee. Costs of care reimbursed by health insurance for people treated for diabetes: Entred Studies 2001 and 2007. Pratiques et Organisation des soins 2010, issue 1.

Out-of-Pocket Costs for Diabetic Patients

Out-of-pocket costs (RAC) for diabetic patients remain poorly estimated in France. An analysis of data from the 2007 Entred study was conducted for 263 patients with type 1 diabetes and 3,467 with type 2 diabetes.

In 2007, 54% of patients reported experiencing financial difficulties. More than 90% were enrolled in the Long-Term Illness (ALD) program, and 88% had supplemental health insurance. Their out-of-pocket costs, as defined by mandatory health insurance, averaged €660 (median: €434), representing 12% of expenses submitted for reimbursement in type 2 diabetes (compared to €486 (median: €296) and 6.3% in type 1). It was higher among patients without ALD status. Three categories were primarily affected: medications, medical devices, and dental care. Other forms of out-of-pocket costs were observed: dietitians, podiatrists, psychologists, and non-reimbursed medical devices. Among patients, 23% of those with type 1 diabetes and 17% of those with type 2 diabetes reported having foregone a healthcare service due to its cost over a 12-month period.

Health coverage for diabetic patients, although seemingly comprehensive, remains imperfect in France. The forgoing of care is explained not only by financial reasons but also by other factors related to the complexity of the social security system or insurance choices.

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Key epidemiological findings from Entred-DOM

Key epidemiological findings (in brief)

A younger and economically less advantaged population than in mainland France, and predominantly female.

The average age of people with diabetes in the French overseas departments is 63 years (vs. 65 years in mainland France). The diabetic population is predominantly female, with 65% women (vs. 46%). As in the general population, the diabetic population in the French overseas departments is more likely to be covered by the CMU.

The majority of people with diabetes in the French overseas departments have type 2 diabetes (96%), and 4% are classified as having type 1 diabetes.

High vascular risk but lower prevalence of obesity among people with type 2 diabetes in the French overseas departments compared to mainland France

Cardiovascular treatment is prescribed slightly less often to people with type 2 diabetes in the French overseas departments (75% vs. 77% in mainland France). Compared to mainland France, antihypertensives are prescribed more frequently, with the exception of ACE inhibitors and beta-blockers. Lipid-lowering drugs are prescribed less often than in mainland France.

These treatments indicate better management of vascular risk.

Blood pressure appears to be better controlled in the French overseas departments; the average blood pressure is 131/77 vs. 134/77 mmHg, and the proportion of people below the 130/80 mmHg threshold is higher (22% vs. 15%).

Average levels of LDL cholesterol and triglycerides are slightly lower than those found in mainland France (1.01 vs. 1.06 g/L and 1.38 vs. 1.52 g/L, respectively), while the average level of HDL cholesterol is similar.

Smoking is reported less frequently by people with diabetes in the French overseas departments than in mainland France (8% vs. 17% in mainland France). Similarly, overweight and obesity are less common in the French overseas departments than in mainland France (33% vs. 41% and 32% vs. 41%, respectively).

A different profile of type 2 diabetes complications between the French overseas departments and mainland France

Among people with type 2 diabetes, coronary complications are less common in the French overseas departments than in mainland France (9% vs. 17%); cerebrovascular complications are equally common (7%), as are foot complications (7% vs. 10%). In contrast, ophthalmological complications are more common there (17% vs. 13% of laser treatment cases reported by patients and 18% vs. 4% reported by physicians in Réunion).

In Réunion, the average glomerular filtration rate (GFR) for people with type 2 diabetes is 77 ml/min/1.73 m², similar to that in mainland France. Stages of macro- and especially microalbuminuria are more common in the French overseas departments than in mainland France (7% vs. 5% and 34% vs. 18%, respectively).

Insulin therapy is more common among people with type 2 diabetes in the French overseas departments than in mainland France

Monotherapy is less common in the French overseas departments than in mainland France (30% vs. 37%), whereas insulin therapy—either alone or in combination with oral antidiabetic drugs—is much more common (26% vs. 17%). As in mainland France, biguanides and sulfonylureas are the most commonly prescribed oral antidiabetics for people with type 2 diabetes in the French overseas departments (56% and 57%, respectively).

However, this more intensive treatment compared to mainland France is accompanied by a higher average HbA1c level in the French overseas departments (7.4% vs. 7.1%).

The quality of type 2 diabetes care is very similar to that in mainland France, and sometimes better

Two-thirds of people with type 2 diabetes (65%) consulted a general practitioner at least six times during the year, which is more frequent than in mainland France (56%). In total, 9% of people with type 2 diabetes in the French overseas departments received care or a consultation from a diabetologist during the year, which is similar to mainland France. Hospitalizations are less frequent than in mainland France, affecting 26% of patients during the year (vs. 31%).

As in mainland France, the proportion of people with type 2 diabetes receiving medical care in accordance with the 2008 guidelines is far from reaching 80%.

Screening for nephropathy is more common in the French overseas departments than in mainland France; 41% of people with type 2 diabetes undergo at least one albuminuria/proteinuria test vs. 28% in mainland France; furthermore, 76% undergo an annual creatinine test (vs. 83%). Only 30% receive a dental examination (vs. 38%), 36% receive three annual HbA1c tests (vs. 43% in mainland France), 30% receive a cardiology consultation or an ECG (vs. 39%), 51% have an ophthalmology consultation (vs. 50%), and 70% have a lipid panel (vs. 77%)

REFERENCE:

Ndong JR, Romon I, Druet C, Prévot L, Hubert-Brierre R, Pascolini E, et al. Characteristics, vascular risk, complications, and quality of care for people with diabetes in the overseas departments and comparison with mainland France: Entred 2007–2010, France. Bull Epidemiol Hebd 2010;42-43:432-6

Key epidemiological findings (in brief)

Characteristics and medical management

Half of the children with diabetes were boys. The average age was 12 years; 20% were under 8 years old, and 60% were 12 years or older. Among children with diabetes, 16% were covered by Universal Health Coverage, and 97% were receiving care for a chronic condition (diabetes or another disease).

Nearly all (97%) of the children with diabetes were treated with insulin (alone or in combination with an oral antidiabetic). Only 3% of children with diabetes were treated with one or two oral antidiabetics, primarily metformin; they were older, with an average age of 15, and 79% were girls.

One in ten children with diabetes had received reimbursement for an insulin pump in the past 12 months. These were more often girls (60% of children treated with a pump versus 48% of children treated with insulin without a pump).

The majority of children with diabetes were managed for their condition by hospital-based physicians (89%), 5% by private endocrinologists without referral to hospital-based physicians, 2% by private pediatricians without referral to either hospital-based physicians or private endocrinologists, and 4% by general practitioners alone.

Overall, 2% of children with diabetes had received at least one outpatient cardiology consultation or an ECG in the past 12 months, 38% had had at least one outpatient ophthalmology consultation, and 42% had had at least one outpatient dental or stomatology consultation.

Children with diabetes treated with insulin were more likely to receive these specialized consultations than children with diabetes not treated with insulin.

LEARN MORE:

Romon I, Lévy-Marchal C, Weill A, Deligne J, Chantry M, Paumier A, Thammavong N, Labeguerie M, Fagot-Campagna A, on behalf of the Entred Scientific Committee. Characteristics and medical management of children with diabetes in Entred-Enfant, the first representative sample of children treated for diabetes in France. Congress of the French-Speaking Association for the Study of Diabetes and Metabolic Diseases, Strasbourg, March 2009. Diabetes and Metabolism 2009;35:O4.

Hospitalization of children with diabetes

924 children (age <18 years) who received at least three reimbursements for oral antidiabetic medications and/or insulin during the period from August 1, 2006, to July 31, 2007, were randomly selected from among beneficiaries of two health insurance plans. Reimbursements for care and hospital stays were analyzed for the period from August 1, 2007, to July 31, 2008. Children not treated with insulin during this period were excluded.

Among the 884 children included (50% boys, mean age 12±4 years), 82% were primarily followed up in the hospital. During the study year, 52% of the children were hospitalized, 21% multiple times. Approximately one-third (36%) of the children were hospitalized for follow-up, and 13% for acute complications of diabetes.

Compared to children not hospitalized for diabetes follow-up, those hospitalized were more likely to use an insulin pump (p<0.01) and were primarily followed by a hospital physician (p<0.0001). Hospitalization for follow-up was less frequent among adolescents aged 15 years and older (p<0.02). Children hospitalized for acute complications of diabetes were more likely to have Universal Health Coverage (p<0.001) than children not hospitalized for acute complications. The rate of hospitalization for ketoacidosis was higher among girls than among boys (p<0.02).

Excessively frequent hospitalizations for acute complications could be partially prevented through better diabetes control. Diabetes management, involving an annual multidisciplinary assessment conducted primarily in a hospital setting, remained underutilized.

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