Réseau REDSIAMValue of a national administrative database to guide public decisions: From the système national d’information interrégimes de l’Assurance Maladie (SNIIRAM) to the système national des données de santé (SNDS) in FranceL’utilité d’une base médico-administrative nationale pour guider la décision publique : du système national d’information interrégimes de l’Assurance Maladie (SNIIRAM) vers le système national des données de santé (SNDS) en France
Introduction
Health insurance administrative databases are increasingly frequently and effectively used to guide public decisions in many countries [1], [2], [3], [4], [5], [6], [7]. In addition to monitoring the various types of medical expenditures, these databases can also be used to conduct epidemiological studies on the health status of populations, their health care utilisation and health care expenditure, evaluate medical practices or health system experimentations. They can also be used for international comparisons [8], [9], [10], [11], [12].
These databases present a number of advantages. They comprise very large population samples and can sometimes even cover the entire population, ensuring high statistical power, without biases related to the representativity of a sample, thereby allowing more detailed analyses of subgroups according to age or specific geographical territories, for example. Use of these databases is much less expensive that conducting specific surveys in populations or health care institutions, by providing rapid access to data collected in a standardized format [13], [14], [15], [16], [17], [18].
In France, the système national d’information interrégimes de l’Assurance Maladie (SNIIRAM) [national health insurance information system] was gradually developed from 1999 onwards. It initially provided essentially aggregate data to various authorities, but was subsequently transformed into a functional tool with the availability of individual data in 2006. The SNIIRAM data warehouse comprises the characteristics and medical information of the beneficiaries of the various national health insurance schemes, as well as the in-hospital or office medicine health care reimbursed to this population. Cash payments related to sickness, disability or death are also recorded. After a detailed review of data protection and the possible risks of re-identification of persons as a result of data sharing and the growing use of these data by numerous organisations, the 2016 health system modernisation act used SNIIRAM as the cornerstone to create the système national des données de santé (SNDS) [national health data system] (http://www.snds.gouv.fr/) [19], [20], [21], [22]. Broadening of the scope of SNIIRAM and launching of SNDS will allow increased use of these data for public health purposes.
This article describes the SNIIRAM data warehouse and its transformation into SNDS, the data that it contains, the tools that have been developed to facilitate analyses, the potential limitations encountered during analyses and interpretations, and the changing modalities of data access.
Section snippets
From creation of SNIIRAM to the birth of SNDS
The Social Security system, created in France in 1945, is now composed of several schemes constructed around various occupational sectors (Fig. 1) [23], [24]. Of the 66 million inhabitants in France at the end of 2015, the general scheme covers salaried employees of the private sector and their dependents (i.e. about 76% of the population living in France), as well as people covered by sections locales mutualistes (SLM) [local mutualist sections], essentially civil servants, employees of
Beneficiaries are identified in SNIIRAM by an pseudonymised identifier
Constitution of the SNIIRAM data warehouse is based on reliable identification of individuals by the numéro d’inscription au répertoire (NIR) [social security number] derived from the répertoire national d’identification des personnes physiques (RNIPP) [national repertory for the identification of individuals], based on registry office data, including legal immigrants. SNIIRAM therefore allows registry office certification for social security bodies and the fiscal administration and management
SNIIRAM échantillon généraliste des bénéficiaires (EGB)
In 2005, a decree concerning SNIIRAM implemented the EGB, which is managed by CNAMTS and has been the subject of a specific approval from CNIL. It is derived from a 1/97th random sample based on the confidential number of the control key of each individual's NIR (beneficiaries or dependents) ranging between 1 and 97. A preliminary study based on randomisation of the RNIPP ensured that the distribution by five-year age-groups and by sex of the population living in France was independent of
External data that can be linked to SNIIRAM
An administrative database that will be linked to SNIIRAM, allowing identification of older people living in établissements d’hébergement pour personnes âgées dépendantes (EHPAD) [nursing homes] not included in the regulatory framework of SNIIRAM. This Resid-Ehpad system, governed by a special decree, allows nursing homes attached to a pivotal general scheme health fund to transmit the lists of their residents, together with dates of admission and discharge, to national health insurance. The
Use of SNIIRAM for epidemiological and economic purposes: advantages and limitations
SNIIRAM data therefore provide a wealth of information that can be used for public health purposes to guide decision-making. However, these data were not initially collected for research purposes and they can therefore be subject to random or systematic measurement errors, which can have major consequences when defining study populations, exposures, events and covariables. However, in the case of outpatient care, errors should not concern administrative data, which are entered by computer, as
Valorization in the form of scientific publications based on national health insurance databases
Between 2007 and 2016, more than 400 scientific publications (210 SNIIRAM/EGB) based on national health Insurance data (Table 5) were identified in the MEDLINE database (search and Figure in Supplementary material – S1 and S2). From 2009, the annual number of publications has linearly increased to reached 80 in 2016. Seventy-eight percent of publications were in English (Supplementary material, Table S3). However, a lack of homogeneity in the English terms used to describe the French national
Access to SNDS
The data access permission policy in the context of upgrade to SNDS has recently been defined by decree [27]. Modification of the French personal data protection in the field of health studies act (fusion of chapters IX and X) and access request circuits are defined in a second decree [74].
Conclusion
France now has an extensive medical and administrative information system, which has largely contributed to public health information and as an aid to decision-making, and has given rise to a large number of international publications. However, it is difficult to find these publications by using simple search terms. The use of acronyms (SNDS or SNIIRAM) is word-consuming when they are first described in full. Nevertheless, the data source must be indicated in the abstract. An appropriate
Disclosure of interest
The authors declare that they have no competing interest. They are employed by CNAMTS, the SNIIRAM administrator.
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