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Épidémiologique De La Prise En Charge De L'asthme Au Maroc

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Épidémiologique De La Prise En Charge De L'asthme Au Maroc Université Mohammed V Faculté de Médecine et de Pharmacie Rabat Centre d’Etudes Doctorales des Sciences de la Vie et de la Santé ANNEE: 2014 THESE N°: 11/14 CSVS Evaluation pharmaco-économique & pharmaco- épidémiologique de la prise en charge de l’asthme au Maroc Equipe de recherche :Pharmaco-épidémiologie & Pharmaco-économie Thése présentée et soutenue publiquement le : …………………...….. Melle Imane GHANNAME Née le 30 juin 1984 à Rabat Pour obtenir le grade de : Doctorat Spécialité : Sciences du médicament JURY Pr Mohammed HASSAR Président Faculté de médecine et de pharmacie de Rabat Pr Yahia CHERRAH Directeur de Thése Faculté de médecine et de pharmacie de Rabat Pr Wiam EL KHATTABI Faculté de médecine et de pharmacie de Casablanca Pr Mounia SERRAJ Rapporteurs Faculté de médecine et de pharmacie de Fes Pr Redouane ABOUQAL Faculté de médecine et de pharmacie de Rabat Pr Samir AHID Faculté de médecine et de pharmacie de Rabat Pr Leila HERRAK Faculté de médecine et de pharmacie de Rabat Mr Abdelmajid BELAICHE Consultant industriel (Pharmed) I L'élève dit à ses maîtres que le temps s'écoulera toujours trop vite pour tout ce qui lui reste à apprendre. Denis Diderot (1713-1784) I Résumé L’asthme représente une cause majeure de morbi-mortalité, il affecte environ 300 millions individus dans le monde. En raison de sa prévalence élevée, ses coûts exhaussés et la prévention possible de ses exacerbations, l’asthme est une priorité de santé publique. La mise en œuvre d’une prise en charge standardisée de l’asthme, accessible à la majorité des malades pourrait permettre d’améliorer leur qualité de vie, la qualité des services et de diminuer les coûts de la santé. Dans le but de contribuer à l’avancement des connaissances sur le sujet, cette thèse s’intéresse à la thérapeutique antiasthmatique en milieu ambulatoire au Maroc. Dans ce contexte, l’objectif de ce travail est de définir les caractéristiques de la dépense de médicaments antiasthmatiques au plan national par rapport à d’autres pays et d’analyser l’impact des stratégies adoptées par le Ministère de la Santé en vue d’ajuster les besoins à la consommation de cette classe thérapeutique. D’autant plus, il reflète la prise en charge de l’asthme dans la pratique réelle auprès des pneumologues de Rabat. Pour atteindre ces objectifs, nous avons utilisé, dans un premier lieu, les données de ventes privées des antiasthmatiques de la filiale marocaine de l’IMS Health entre 1999 et 2010. La mesure de la quantité pharmaceutique a été exprimée en Defined Daily Doses/1000 habitants/jour (DID), préconisée par l’OMS. Les résultats observés de cette mesure démontrent que l'usage des antiasthmatiques par les patients marocains demeure faible malgré l’implantation de l’AMO; améliorant l’accessibilité au traitement des patients éligibles à ce régime surtout pour les molécules à coût élevé notamment les associations fixes LABA-ICS qui se sont imposés dans les prescriptions, car plus efficaces; et l’implication de l’état dans la promotion du médicament générique. Par la suite, au terme d’une cohorte observationnelle MOSAR (Multicenter Observational Study of Asthma in Rabat)réalisée de manière prospective, sur un horizon temporel de 42 mois, auprès des trois services publics de pneumologie de Rabat sur des patients souffrants d’asthme ; nous disposons d’une base de données sociodémographique, clinique, paraclinique et thérapeutique, qui renseigne sur un groupe de 424 patients asthmatiques suivis dans le temps. Dans ce manuscrit, nous avons rapporté les résultats de la II phase transversale qui nous a permis d’établir un profil clinico-épidemiologique des patients asthmatiques à Rabat et a indiqué que le contrôle de l’asthme peut être accompli dans une bonne proportion de patients et est associé à une meilleure qualité de vie. En outre, elle a mis en exergue que l’association fixe (Bêta-2-LDA+CSI) est la thérapie la plus utilisée agissante à la fois sur le contrôle de l'asthme et sur la qualité de vie dans un contexte marocain réel montrant de meilleurs résultats cliniques en faveur de cette famille. Par ailleurs, elle nous a permis de conclure que la stratégie thérapeutique a adopté par le médecin traitant ne doit pas négliger le contexte socioéconomique et doit être ajustée à chaque patient, en fonction de son pouvoir d’achat; de l’adhésion à la couverture médicale et des autres maladies chroniques concomitantes pour trouver le bon équilibre (dépenses/conséquences)en s’appuyant sur des évaluations pharmaco-épidémiologiques-pharmaco-économiques. Ce mémoire constitue une ébauche pour l’établissement d’un état des lieux de la prise en charge de l’asthme au Maroc en attendant l’analyse, la modélisation et l’interprétation des résultats de la phase longitudinale de la cohorte MOSAR incluant la partie pharmaco- économique . ________________________________________________________ Mots clés: Asthme, antiasthmatiques, pharmacoéconomie, pharmacoépidémiologie, consommation, prise en charge, Maroc. III Abstract Asthma is a major cause of morbidity and mortality, it affects approximately 300 million people worldwide. Because of its high prevalence, its increasing costs and the possibility to prevent its exacerbations, asthma is a public health priority. The implementation of standard case management of asthma, accessible to the majority of patients could improve their quality of life, the quality of services and reduce health care costs. In order to contribute to the advancement of knowledge on the subject, this thesis is interested in the anti-asthma treatment in outpatient settings in Morocco. In this context, the objective of this work is to define the characteristics of the expenditure of asthma medications nationally compared to other countries, to analyze the impact of the strategies adopted by the Ministry of Health in order to adjust the consumer needs for this therapeutic class. Especially, this work reflects the asthma management in the actual clinical practice by Rabat pulmonologists . To achieve these objectives, we used a private sales data of antiasthmatic from IMS Health Morocco (Intercontinental Marketing Services) between 1999 and 2010. The consumption of the drugs was expressed in Daily Defined Doses/1000 inhabitants/day (DID) recommended by WHO. The findings shows that the use of antiasmathics by marocain patients remains low, despite the introduction of the AMO (compulsory health insurance scheme), that allows access to treatment for patients eligible for this therapeutic, especially for molecules considered as high priced, including fixed combinations LABA-ICS that have already established themselves in the presciptions as more effective, and the involvement of the government in promoting the generic drug. After this market research, we performed in a prospective manner over 42 months, an observational cohort MOSAR (Multicenter Observational Study of Asthma in Rabat) in three pneumology public health services in patients with asthma. In summary, as a result of this cohort study, we have an important database that includes sociodemographic, clinical, paraclinical and therapeutic information reported on a group of 424 patients with asthma monitored over time. IV In this manuscript, we reported the results of the cross-phase that allowed us to establish a clinico-epidemiological profile of asthmatic patients in Rabat and indicate that asthma control can be achieved in a large proportion of patients and that is associated with a better quality of life. In addition, it was highlighted that the fixed combination (Beta-2- LDA+CSI) is the most used therapy, acting both on asthma control and quality of life in a real Moroccan context and showing better outcomes for this family. Moreover, the study also allowed us to conclude that the treatment strategy adopted by the treating physician should not neglect the socio-economic context and must be adjusted to each patient, based on its purchasing power; onits health insurance sheme and other concomitant chronic disease to find the right balance (expenditure /consequences) based on pharmaco-pharmacoeconomic evaluations. This thesis is a start to set up a pathway forward for asthma management in Morocco pending analysis, modeling and results interpretation of the of the longitudinal phase of the cohort MOSAR including pharmacoeconomic part. ________________________________________________________ Keywords: Asthma, antiasthmatics, pharmacoeconomics, pharmacoepidemiology, consumption, case management. V ملخص يشكل مرض الربو عامﻻ رئيسيا للوفاة ، فهو يؤثر على نحو 033 مليون شخص في جميع أنحاء العالم . نظرا ﻻنتشاره الواسع و تكاليفه المرتفعة و كذا البحث الدائم عن الوقاية للحد من تفاقمه ،فان هذه اﻻسباب تجعل هذا المرض من أولويات الصحة العامة. يمكننا عن طريق تقديم رعاية طبية موحدة في مواجهة مرض الربو ،تكون في متناول غالبية المرضى، ان نقوم بتحسين نوعية حياتهم ، ونوعية الخدمات وكذا تخفيض تكاليف الرعاية الصحية. و من أجل المساهمة في تقدم المعرفة حول هذا الموضوع، ترتكز هذه اﻷطروحة حول العﻻج المضاد للربو في الوسط اﻻستشفائي في المغرب. في هذا السياق ، يكون الهدف من هذا العمل هو تحديد ما يميز كلفة اﻹنفاق على أدوية الربو على الصعيد الوطني مقارنة بدول أخرى و تحليل تأثير اﻻستراتيجيات المعتمدة من قبل وزارة الصحة من أجل ضبط احتياجات المستهلك من هذه المجموعة العﻻجية. زيادة على ذلك فانه يركز الضوء على تأثير الدعم في الممارسة الفعلية بين أخصائيي أمراض الجهاز التنفسي بالرباط. لتحقيق هذه اﻷهداف ، كانت استعانتنا بمعطيات المبيعات الخاصة لمضادات الربو التابعة ل IMS-Health بين عامي 9111 و 0393، عبرنا عن قياس كمية هذه اﻷدوية بالجرعات اليومية المحددة / 9333 نسمة / يوم )DID( على النحو الموصى به من قبل منظمة الصحة العالمية. و قد اظهرت نتائج هذا القياس أن استخدام مضادات الربو من طرف المرضى المغاربة ما زال متدنيا على الرغم من اعتماد التأمين الصحي اﻹلزامي الذي يعتبر وسيلة لتحسين فرص الحصول على العﻻج للمرضى المؤهلين لهذا النظام وخاصة عندما يعتمد العﻻج على اﻷدوية ذات الكلفة العالية خصوصا اﻷدوية المركبة )بيتاـ0ـاﻷدرينالية طويلة ـ الستيرويدات المستنشقة( التي تفرض نفسها لكونها اﻻكثر نجاعة و فاعلية، و على الرغم من مشاركة الدولة في تطوير اﻷدوية الهجينة. ارتباطا بذلك، و عن طريق دراسة أترابيّة لرصد و متابعة مرضى الربو MOSAR” (Multicenter“ (Observational Study of Asthma in Rabat مجراة بطريقة مستقبلية، على مدى فترة زمنية من 20 شهرا، على مستوى ثﻻث مصالح عمومية لﻷمراض التنفسية بالرباط.
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