Country of the month - France

Report prepared by:

Dr Marie-Christine Iliou, MD, Cardiologist

National CVD Prevention Coordinator for France

Cardiac Rehabilitation and Secondary Prevention Department. Corentin Celton. Hopitaux Universitaires Paris Ouest.
The Assistance publique – Hôpitaux de Paris (AP-HP), France

Contact: email

Documents to download

• Full report
• CV and publications MC Iliou

Health care

The French health system combines a universal coverage for all (active and non–active) with a public–private mix of hospital and ambulatory care facilities mostly financed by the National Health Insurance (NHI) system. All residents automatically get health insurance coverage, funded by employers, workers or public funds depending on their occupational status. Cardiovascular diseases (CVD) management, including interventions and cardiac rehabilitation (CR), as well as prevention screening and chronic treatment with evidence-based medications are fully covered by the NHI, whichever the medical services used (public or private physicians or institutions). In addition, 90% of the population subscribes to a complementary health insurance to cover additional health expenses not covered by the NHI.

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Risk factors

Sources:
1) Guignard R, Beck F, Richard JB et al. Evolutions barometer sante. 2015; 31: 1-6
2) Fagot-Camapgna A, Romon I, Fosse S et al. Synthese epidemiologique INVS 2010
3) Programme national nutrition santé 2011-2015  and de Saint Pol T. INSEE Première 2007; 1123
4)  Enquête assureurs prévention 2014 and Institut national de prevention et education pour la santé.  Baromètre santé nutrition 2008
5) OECD, CV disease and iabetes: policies for better health and quality of care. 2015
6) BEH 2008 (49-50)478-491
7) de Peretti C, Perel C, Chin F et al. Mean LDL cholesterol and hypercholesterolemia prevalence in adults ENNS , Metropolitan France. BEH 2013: 378-85

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Main actors

In France, numerous actors are involved in CV prevention: institutional agencies (National Institute for Prevention and Education on Health, Ministries of Health and Sports, National Health Authority, etc.) or organisations (French Federation of Cardiology, French Society of Cardiology, patient association called "Alliance du Coeur", etc.). The main stakeholders are General Practioniners (GPs), private or public cardiologists and specialists working in preventive institutions.

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Prevention activities

A large number of initiatives for promoting CV health are developed in France, initiated by a vast array of institutions, organisations, private insurances and groups. Coordination is somehow lacking.

Important health promotion projects are implemented at the national and/or regional level. These projects are conducted and coordinated by numerous stakeholders.

Among campaigns on health protection and promotion, one should mention French Federation of Cardiology initiatives, national regulation promoting health in all commercials for food and certain drinks (alcohol and sodas) on mass media, interventions on the workplace, implementation and diffusion of the European Guidelines on CVD Prevention in clinical practice, etc.

A low level of training in primary and secondary prevention is currently proposed in medical education programs, whereas educational training for CV prevention and rehabilitation, or for smoking cessation are organised by universities, CV societies or foundations, but on a volunteer basis. Better education in these crucial issues is needed.

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Cardiac Rehabilitation

Cardiac Rehabilitation (CR) in France is based on phase II and III (maintenance) programs.

Phase II programmes are delivered in one of the 130 dedicated public or private CR centres to both residential and out-patients. Since 2008, according to a national regulation, all centres are regularly audited by a Regional Agency of Health, in order to be certified in multifaceted rehabilitation and patient education. Since 2012, a national degree for CV prevention and rehabilitation has been created to train high quality personnel; it has met striking success. The Cardiac Rehabilitation Working Group from the French Society of Cardiology (called GERS) assembles cardiologists and paramedics involved in CR to publish national guidelines and improve scientific knowledge. The French health organisation allows for early CR after any serious cardiovascular event. Currently, 36 % of patients after myocardial infarction (MI) undergo CR (only 22 % in 2011), and around 50 to 60 % after cardiac surgery.

Phase III maintenance is delivered to around 14 500 patients every year in 206 patients’ clubs under the supervision of the French Federation of Cardiology. Its cost is however not covered by the NHI and is directly supported by the attendants.

Although continuously increasing in recent years, CR referral rate appears currently limited by an insufficient availability of beds and ambulatory facilities.

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Aims for the future

• To translate guidelines' preventive measures into a National Heart Action Plan
• To promote better cooperation and coordinated actions between all actors (health professionals, patient associations, public organisations and health foundations)
• To continually reduce the risk factor burden, especially smoking, inappropriate nutrition and physical inactivity
• To take into consideration the increasing number of elder people to provide specific prevention

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Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.