Abstract
France is a country of more than 60 million inhabitants, where indicators of health quality are favourable, with one of the longest life expectancies in the world, and one of the lowest rates of neonatal mortality. The burden of vascular diseases is smaller than in surrounding European countries of similar size (United Kingdom and Germany), even for stroke. However, the direct cost of health care provided to stroke patients is estimated between 2 and 2·5 billion Euros per year.
Introduction
Aging of the population will probably lead to an increased incidence of stroke, which may grow from 130 000 new cases per year in 2005, to 143 000 in 2015. Unfortunately, most stroke patients are still managed in small hospitals or in nonspecialised wards, where the necessary facilities for a modern approach to stroke care are not available. However, the government took the decision to improve stroke care in the country, and recently the parliament claimed that dedicated financial resources are necessary to succeed.
According to figures provided by the Institut National de la Statistique et des Etudes Economiques, France was, in 2005, a country of 62·8 million inhabitants, with one of the highest birth rates in Europe (807 800 per year), and of the lowest mortality rates (538 200 per year). This difference, together with an immigration rate of 92 000 persons per year (1) – half being from Europe – leads to an increase rate of 1 million inhabitants every 3 years, which is the most important rate that has been reported during the last 30 years (1). The French absolute gross domestic product is the 6th in the world ($2178 billion), and the 16th per inhabitant (35 854$ per inhabitant), between the Netherlands (36 600$) and Germany (34 577$). Social insurances, introduced by President Charles de Gaulle after World War II, were progressively generalised and currently cover approximately 70% of the cost of health, and 100% of the cost for serious disorders such as stroke. Indicators of health are favourable, with one of the longest life expectancies in the world (76·8 years in men and 83·8 in women), and one of the lowest rates of neonatal mortality (0·421%). However, the public health insurance has probably reached its limits, and despite many governmental programs, the deficit of health insurances estimated at 5·9 billion Euros in 2006.
The burden of vascular diseases seems smaller in France than in other European countries, but stroke was the direct or indirect cause of death for 37 000 persons in 2003 (2). Each year approximately 25 000–30 000 new patients need to be helped by social insurances for a long-lasting disease, on top of the 191 000 who are currently using these services (2).
Sources of data
Population-based registries
The only population-based stroke registry available in France is that of Dijon. It started in 1985, and includes all strokes occurring in inhabitants of the city of Dijon (150 000 inhabitants; 24th largest French city). There is a need for another population-based registry in France, and the Institut National de la Santé et de la Recherche Médicale has recently promoted a preliminary study to evaluate the feasibility in the community of Lille (1 143 125 inhabitants; 4th largest French city), where the population differs from that of Dijon by a younger age and a higher coronary risk.
Institutional sources
Governmental sources provide information on stroke patients admitted in public or private hospitals. The comparison of epidemiological data and hospital data shows that 95% of strokes are admitted in hospitals, mainly public.
Epidemiology
Incidence
The incidence rate for first-ever stroke found in the Dijon registry between 2000 and 2004 was 1000 per million inhabitants per year (3). This is much lower than the 1239 per million inhabitants found in London, UK and 1364 in Erlangen, Germany (4). Institutional sources show that approximately 130 000 patients are admitted every year in hospitals for a stroke or transient ischaemic attack (TIA) (2). The aging of the population will probably lead to an increase of stroke incidence, from 130 000 to 143 000 new cases per year in 2015 (2).
Mortality
The most recent data available from the Dijon registry shows an overall 28-day case-fatality rate of 10% with huge variations between 2·4% in lacunar infarcts and 24·5% in intracerebral haemorrhages (3).
Time trends
The changes in incidence, case-fatality rates, severity, risk factors and prestroke use of preventive treatments for first-ever stroke, were evaluated over a 20-year period in the Dijon stroke registry from 1985 to 2004 (3): age at first stroke onset increased by 5 years in men and 8 years in women (3). Comparing the 1985–1989 and the 2000–2004 periods, age-and gender-standardized overall incidences of first-ever stroke were stable, but the proportion of myocardial infarction significantly decreased, the incidence of cardio-embolic stroke significantly decreased, and that of lacunar stroke significantly increased (3). Twenty-eight-day case-fatality rates decreased significantly mainly for lacunar stroke and for primary cerebral haemorrhage (3). The proportion of hypercholesterolemia and diabetes significantly increased over time (3). Prestroke use of antiplatelet agents and oral anticoagulation significantly increased (3). A survey (5) conducted over the whole national territory that compared stroke and vascular mortalities between 1979 and 2001, found a dramatic 60% reduction of stroke case-fatality, twice higher that that of other causes of vascular death.
Risk factors
Data from the Dijon registry shows an overall breakdown of risk factors close to that of other EU countries, with 64% of hypertension, and 29% of hypercholesterolemia (3).
Medical cost of stroke in France
In the Dijon stroke registry, the mean cost per patient at 5 years was estimated at 34 638 € for stroke unit care (6). Patients in France are more likely to get assistance from their family than any other country in Europe (7).
Facilities available in French hospitals to treat stroke
Of 886 European hospitals admitting acute stroke patients, and treating one-third of all strokes supposed to have occurred in 2005, only 8·5% met criteria for comprehensive or primary stroke centres; of the 121 French hospitals included in this survey, only 1·7% met the criteria (8).
How to decrease the burden of stroke
Regional networks have been established to provide a similar level of care in an area around a stroke unit, such as in the Franche Comté (9) network with telemedicine. A TIA clinic run by Pierre Amarenco recently showed its efficacy to reduce the rate of ischaemic stroke after a TIA (10), and should serve as a model to reduce the burden of preventable stroke, and the cost.
Under the initiative of Marie-Germaine Bousser, a French Stroke Society (11) was formed in 1996 and has since promoted a better knowledge of the disease, guidelines, specialised training in stroke medicine organised by Jean-Louis Mas, recommended for managing a stroke unit; and discussions with health authorities. Patients and families have their own association (12).
In 2003 and 2007 the Ministry of Health decided to improve stroke care and promote regional networks, in collaborative effort with emergency physicians, radiologists, cardiologists and physiotherapists. All hospitals admitting more than 400 strokes per year were encouraged to organise stroke care units. At that time the ministry mandate did not include new resources. However, in 2006 it was decided that stroke care units needed, and would be given more funding than conventional care. This move was an effective motivator for hospital managers.
In 2007, the newly elected parliament published an important report on stroke management in France and claimed that 140 stroke care units are needed before 2010 to improve overall stroke management (2), this will need targeted funding of at least 150 millions Euros per year (2).