Comparison of the Working Alliance in Blended Cognitive Behavioral Therapy and Treatment as Usual for Depression in Europe: Secondary Data Analysis of the E-COMPARED Randomized Controlled Trial

BACKGROUND

Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression.

OBJECTIVE

This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3-month assessments.

METHODS

We conducted a secondary data analysis of the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment-as-usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory-Short Revised-Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale-Client [SUS-C]) at 3 months and baseline demographic information. Data from baseline and 3-month assessments were analyzed using linear regression models that adjusted for a set of baseline variables.

RESULTS

Of the 945 included participants, 644 (68.2%) were female, and the mean age was 38.96 years (IQR 38). bCBT was associated with higher composite WAI-SR-C scores compared to TAU (B=5.67, 95% CI 4.48-6.86). There was an inverse association between WAI-SR-C and PHQ-9 in bCBT (B=-0.12, 95% CI -0.17 to -0.06) and TAU (B=-0.06, 95% CI -0.11 to -0.02), in which as WAI-SR-C scores increased, PHQ-9 scores decreased. Finally, there was a significant interaction between SUS-C and WAI-SR-C with regard to an inverse association between higher WAI-SR-C scores and lower PHQ-9 scores in bCBT (b=-0.030, 95% CI -0.05 to -0.01; P=.005).

CONCLUSIONS

To our knowledge, this is the first study to show that bCBT may enhance the client working alliance when compared to evidence-based routine care for depression that services reported offering. The working alliance in bCBT was also associated with clinical improvements that appear to be enhanced by good program usability. Our findings add further weight to the view that the addition of internet-delivered CBT to face-to-face CBT may positively augment experiences of the working alliance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02542891, https://clinicaltrials.gov/study/NCT02542891; German Clinical Trials Register DRKS00006866, https://drks.de/search/en/trial/DRKS00006866; Netherlands Trials Register NTR4962, https://www.onderzoekmetmensen.nl/en/trial/25452; ClinicalTrials.Gov NCT02389660, https://clinicaltrials.gov/study/NCT02389660; ClinicalTrials.gov NCT02361684, https://clinicaltrials.gov/study/NCT02361684; ClinicalTrials.gov NCT02449447, https://clinicaltrials.gov/study/NCT02449447; ClinicalTrials.gov NCT02410616, https://clinicaltrials.gov/study/NCT02410616; ISRCTN Registry ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725?q=ISRCTN12388725&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10; ClinicalTrials.gov NCT02796573, https://classic.clinicaltrials.gov/ct2/show/NCT02796573.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-016-1511-1.

Aortic valve replacement for aortic stenosis: Influence of centre volume on TAVR adoption rates and outcomes in France

BACKGROUND

Transcatheter (TAVR) has supplanted surgical (SAVR) aortic valve replacement (AVR).

AIM

To evaluate whether adoption of this technology has varied according to centre volume at the nationwide level.

METHODS

From an administrative hospital-discharge database, we collected data on all AVRs performed in France between 2007 and 2019. Centres were divided into terciles based on the annual number of SAVRs performed in 2007-2009 ("before TAVR era").

RESULTS

A total of 192,773 AVRs (134,662 SAVRs and 58,111 TAVRs) were performed in 47 centres. The annual number of AVRs and TAVRs increased significantly and linearly in low-volume (<152 SAVRs/year; median 106, interquartile range [IQR] 75-129), middle-volume (152-219 SAVRs/year; median 197, IQR 172-212) and high-volume (>219 SAVRs/year; median 303, IQR 268-513) terciles, but to a greater degree in the latter (+14, +16 and +24 AVRs/centre/year and +16, +19 and +31 TAVRs/centre/year, respectively; PANCOVA<0.001). Charlson Comorbidity Index and in-hospital death rates declined from 2010 to 2019 in all terciles (all Ptrend<0.05). In 2017-2019, after adjusting for age, sex and Charlson Comorbidity Index, there was a trend toward lower death rates in the high-volume tercile (P=0.06) for SAVR, whereas death rates were similar for TAVR irrespective of tercile (P=0.27). Similar results were obtained when terciles were defined based on number of interventions performed in the last instead of the first 3years. Importantly, even centres in the lowest-volume tercile performed a relatively high number of interventions (150 TAVRs/year/centre).

CONCLUSIONS

In a centralized public healthcare system, the total number of AVRs increased linearly between 2007 and 2019, mostly due to an increase in TAVR, irrespective of centre volume. Progressive declines in patient risk profiles and death rates were observed in all terciles; in 2017-2019 death rates were similar in all terciles, although lower in high-volume centres for SAVR.

Effectiveness of a School- and Primary Care-Based HPV Vaccination Intervention: The PrevHPV Cluster Randomized Trial

Importance

The human papillomavirus (HPV) vaccine is safe and effective, yet vaccination coverage remains below public health objectives in many countries.

Objective

To examine the effectiveness of a 3-component intervention on HPV vaccination coverage among adolescents aged 11 to 14 years 2 months after the intervention ended, each component being applied alone or in combination.

Design, Setting, and Participants

A cluster randomized trial with incomplete factorial design (PrevHPV) was conducted between July 1, 2021, and April 30, 2022, in French municipalities receiving 0, 1, 2, or 3 components of the intervention. Randomization was stratified by school district and municipalities' socioeconomic level. Analyses were carried out on 11- to 14-year-old adolescents living in all participating municipalities, regardless of what had been implemented.

Intervention

The PrevHPV intervention had 3 components: (1) educating and motivating 11- to 14-year-old adolescents in middle schools, along with their parents; (2) training general practitioners (GPs) on up-to-date HPV information and motivational interviewing techniques; and (3) free HPV vaccination at school.

Main Outcomes and Measures

The primary outcome was HPV vaccination coverage (≥1 dose) 2 months after the intervention ended among 11- to 14-year-old adolescents living in participating municipalities, based on the French national reimbursement database and data collected during the trial in groups randomized to implement at-school vaccination.

Results

A total of 91 municipalities comprising 30 739 adolescents aged 11 to 14 years (15 876 boys and 14 863 girls) were included and analyzed. Half the municipalities were in the 2 lowest socioeconomic quintiles and access to GPs was poor in more than two-thirds of the municipalities. Thirty-eight of 61 schools (62.3%) implemented actions and 26 of 45 municipalities (57.8%) had at least 1 trained GP. The median vaccination coverage increased by 4.0 percentage points (IQR, 2.0-7.3 percentage points) to 14.2 percentage points (IQR, 9.1-17.3 percentage points) at 2 months. At-school vaccination significantly increased vaccination coverage (5.50 percentage points [95% CI, 3.13-7.88 percentage points]) while no effect was observed for adolescents' education and motivation (-0.08 percentage points [95% CI, -2.54 to 2.39 percentage points]) and GPs' training (-1.46 percentage points [95% CI, -3.44 to 0.53 percentage points]). Subgroup analyses found a significant interaction between at-school vaccination and access to GPs, with a higher effect when access was poor (8.62 percentage points [95% CI, 5.37-11.86 percentage points] vs 2.13 percentage points [95% CI, -1.25 to 5.50 percentage points]; P = .007 for interaction).

Conclusions and Relevance

In this cluster randomized trial, within the context of the late COVID-19 pandemic period and limited school and GP participation, at-school HPV vaccination significantly increased vaccination coverage. The trial did not show a significant effect for training GPs and education and motivation, although it may be observed after more time has elapsed after the intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT04945655.

Reducing length of stay after transfemoral transcatheter aortic valve implantation: the FAST-TAVI II trial

BACKGROUND AND AIMS

The length of stay (LOS) after transcatheter aortic valve implantation (TAVI) remains extremely variable whereas early discharge has been shown to be feasible and safe. The study objective was to evaluate the efficacy and safety of an intervention aimed at reducing LOS after transfemoral TAVI.

METHODS

FAST-TAVI II is a prospective, multicentre, cluster, randomized, controlled study including patients with severe symptomatic aortic stenosis, who had transfemoral TAVI. The intervention consisted in a dedicated training programme to implement 10 quality of care measures to reduce LOS with an implementation phase of eight weeks. The primary endpoint was the proportion of patients discharged early within 3 days. Secondary endpoints included: LOS, 30-day mortality and 30-day incidence of readmission for cardiovascular events.

RESULTS

During the study period, 969 patients were enrolled in the intervention group and 860 patients in the control group. Mean age was 81.9 ± 6.6 years and mean EuroSCORE II was 4.4 ± 4.5%. Early discharge was achieved in 563 (58.1%) patients in the intervention group vs. 364 (42.3%) patients in the control group (P < .0001). Median LOS was significantly reduced in the intervention group compared to the control group [3 (IQR: 3) vs. 4 days (IQR: 3), P < .0001]. Thirty-day mortality was low and similar in the two groups (0.5% vs. 0.9%, P = .30), as were 30-day readmissions (4.6% vs. 2.8%, P = .28).

CONCLUSIONS

The intervention was simple and fast to implement, and was effective and safe to reduce LOS and increase the proportion of patients discharged early after TAVI (NCT04503655).

Impact of the coronavirus disease 2019 pandemic on aortic valve replacement and outcomes in France

BACKGROUND

The coronavirus disease of 2019 (COVID-19) pandemic lockdowns limited access to medical care. The impact on surgical (SAVR) and transcatheter (TAVR) aortic valve replacement (AVR) has been poorly described.

AIM

We sought to evaluate the impact of the COVID-19 pandemic on the number and modalities of AVR, patient demographics and in-hospital outcomes at the nationwide level.

METHODS

Using the French nationwide administrative hospital discharge database, we compared projected numbers and proportions of AVR and hospital outcomes, obtained using linear regressions derived from 2015-2019 trends, with those observed in 2020.

RESULTS

In 2020, 21,382 AVRs were performed (13,051 TAVRs, 5706 isolated SAVRs and 2625 SAVRs combined with other cardiac surgery). Compared with the 2020 projected number of AVRs (24,586, 95% confidence interval [CI] 23,525-25,646), TAVRs (14,866, 95% CI 14,164-15,568), isolated SAVRs (6652, 95% CI 6203-7100) and SAVRs combined with other cardiac surgery (3069, 95% CI 2822-3315), there were reductions of 13.0%, 12.2%, 14.2% and 14.5%, respectively. These trends were similar regardless of sex or age. In 2020, the mean age, Charlson Comorbidity Index and hospital admission duration continued to decline, and the proportion of females remained constant, following 2015-2019 trends. Overall, 2020 in-hospital mortality was higher than projected (2.0% observed vs. 1.7% projected; 95% CI 1.5-1.9%), with no increased pacemaker implantation, but more acute kidney injury and cerebrovascular accidents in some surgical subsets.

CONCLUSIONS

During the COVID-19 pandemic, fewer TAVR and SAVR procedures were performed, with increased in-hospital mortality and periprocedural complications. Extended follow-up will be important to establish the long-term effect of the COVID-19 pandemic on patient management and outcomes.

Impact of follow-up by peer support workers on mental health service users' global functioning and self-stigmatisation

OBJECTIVES

The introduction of the first French professional peer support workers training program. (« Médiateurs de santé pairs en santé mentale ») led to a series of evaluations. After a number of qualitative studies demonstrating benefits of peer support for all stakeholders, our objective was to evaluate its direct effects for users by focusing on repeated quantitative measures: global functioning and self-stigma scores. The hypothesis was that peer support would improve the former and decrease the latter.

METHOD

The procedure was based on a one-year follow-up of two groups of mental health service users. Both groups received usual care, either with or without additional peer support. All of them were asked to respond to three questionnaires at the beginning of the study and 6 and 12 months later: a sociodemographic and clinical questionnaire, a global functioning scale and a self-stigmatization scale. Samples included 85/64/35 participants at the three stages for the PHM group, and 205/157/105 for the control group.

RESULTS

Peer support improved global functioning. Nevertheless, it had no impact on self-stigmatization scores which remained rather low throughout the observational period.

CONCLUSIONS

Despite difficulties concerning follow-up of service users during the course of the study and the reluctance to integrate a new profession based on experiential knowledge, it appears that the hope of recovery can improve global functioning of people with mental disorders. The reasons for low self-stigmatization and its stability over time remain to be explored.

Association of Age and Sex With Use of Transcatheter Aortic Valve Replacement in France

BACKGROUND

Current guidelines recommend selecting surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) based on age, comorbidities, and surgical risk. Nevertheless, reports from the United States suggest a rapid expansion of TAVR in young patients.

OBJECTIVES

The authors sought to evaluate the trends in TAVR uptake at a nationwide level in France according to age and sex.

METHODS

Using a nationwide administrative database, we evaluated age- and sex-related trends in TAVR uptake, patient demographics, and in-hospital outcomes between 2015 and 2020.

RESULTS

A total of 107,397 patients (44.0% female) underwent an isolated aortic valve replacement (AVR) (59.1% TAVR, 40.9% SAVR). In patients <65 years of age, the proportion of TAVR increased by 63.2% (P < 0.001) from 2015 to 2020 but remained uncommon at 11.1% of all AVR by 2020 (12.4% in females, 10.6% in males) while TAVR was the dominant modality in patients ≥65 years of age. In patients undergoing TAVR, the Charlson comorbidity index (CCI) (P = 0.119 for trend) and in-hospital mortality (P = 0.740 for trend) remained unchanged in patients <65 years of age but declined in those ≥65 years of age irrespective of sex (all P < 0.001 for trends). Females were older (P < 0.001), had lower CCI (P < 0.001), were more likely to undergo TAVR (P < 0.001), and experienced higher in-hospital mortality (TAVR, P = 0.015; SAVR, P < 0.001) that persisted despite adjustment for age and CCI.

CONCLUSIONS

In France, the use of TAVR remained uncommon in young patients, predominantly restricted to those at high risk. Important sex differences were observed in patent demographics, selection of AVR modality, and patient outcomes. Additional research evaluating the long-term impact of TAVR use in young patients and prospective data evaluating sex differences in AVR modality selection and outcomes are needed.

Association of mental disorders with costs of somatic admissions in France

OBJECTIVES

Mentally ill patients have worse health outcomes when they suffer from somatic conditions compared to other patients. The objective of this study was to assess the association of mental illness with hospital inpatient costs for somatic reasons.

METHODS

All adult inpatient stays for somatic reasons in acute care hospitals between 2009 and 2013 were included using French exhaustive hospital discharge databases. Total inpatient costs were calculated from the all-payer perspective and compared in patients with and without a mental disorder. Only patients who had been admitted at least once for a mental disorder (either full-time or part-time) were considered to be mentally ill in this study. Generalized linear models with and without interaction terms studied the factors associated with hospital inpatient costs.

RESULTS

17,728,424 patients corresponding to 37,458,810 admissions were included. 1,163,972 patients (6.57%) were identified as having a mental illness. A previous full-time or part-time admission for a mental disorder significantly increased hospital inpatient costs (+32.64%, 95%CI=1.3243-1.3284). Interaction terms found an increased impact of mental disorders on costs in patients with low socio-economic status, as well as in men, patients aged between 45 and 60, and patients with a cardiovascular disease or diabetes.

CONCLUSION

Mentally ill patients have higher hospital costs than non-mentally ill patients. Improving curative and preventive treatments in those patients could improve their health and decrease the burden on healthcare systems.

Co-development of a school-based and primary care-based multicomponent intervention to improve HPV vaccine coverage amongst French adolescents (the PrevHPV Study)

INTRODUCTION

Despite various efforts to improve human papillomavirus (HPV) vaccine coverage in France, it has always been lower than in most other high-income countries. The health authorities launched in 2018 the national PrevHPV research programme to (1) co-develop with stakeholders and (2) evaluate the impact of a multicomponent complex intervention aimed at improving HPV vaccine coverage amongst French adolescents.

OBJECTIVE

To describe the development process of the PrevHPV intervention using the GUIDance for rEporting of intervention Development framework as a guide.

METHODS

To develop the intervention, we used findings from (1) published evidence on effective strategies to improve vaccination uptake and on theoretical frameworks of health behaviour change; (2) primary data on target populations' knowledge, beliefs, attitudes, preferences, behaviours and practices as well as the facilitators and barriers to HPV vaccination collected as part of the PrevHPV Programme and (3) the advice of working groups involving stakeholders in a participatory approach. We paid attention to developing an intervention that would maximise reach, adoption, implementation and maintenance in real-world contexts.

RESULTS

We co-developed three components: (1) adolescents' and parents' education and motivation using eHealth tools (web conferences, videos, and a serious video game) and participatory learning at school; (2) general practitioners' e-learning training on HPV using motivational interviewing techniques and provision of a decision aid tool and (3) easier access to vaccination through vaccination days organised on participating middle schools' premises to propose free of charge initiation of the HPV vaccination.

CONCLUSION

We co-developed a multicomponent intervention that addresses a range of barriers and enablers of HPV vaccination. The next step is to build on the results of its evaluation to refine it before scaling it up if proven efficient. If so, it will add to the small number of multicomponent interventions aimed at improving HPV vaccination worldwide.

PATIENT OR PUBLIC CONTRIBUTION

The public (adolescents, their parents, school staff and health professionals) participated in the needs assessment using a mixed methods approach. The public was also involved in the components' development process to generate ideas about potential activities/tools, critically revise the successive versions of the tools and provide advice about the intervention practicalities, feasibility and maintenance.

Impact of Deprivation on the Incidence and Severity of Tuberculosis in Children: A Retrospective Study from 2007 to 2020 in a Tertiary Care Center in Paris, France

OBJECTIVE

To assess the association between deprivation and the incidence and clinical severity of tuberculosis (TB) in children.

STUDY DESIGN

Children ≤18 years old who were admitted for TB between 2007 and 2020 at a tertiary hospital were included in this retrospective study. Deprivation was assessed using the French Deprivation Index. TB severity was assessed using the Wiseman classification. Multivariate analyses were carried out.

RESULTS

In total, 222 patients were included. The median age was 10.8 years (IQR 4.5-14.4). TB was considered severe in 126 patients (56.8%), with 50% of the patients included in the 2 most deprived groups. The most-deprived children had a TB incidence that was 58 times greater than that of the least-deprived children (95% CI 28.49-119.40). There was no significant association between deprivation and severity in the multivariable analysis after adjusting for age and circumstances of diagnosis. Deprivation was associated with an increased length of stay in the most-deprived groups (OR 3.79, 95% CI 1.55-10.23). There was a trend toward a greater proportion of symptomatic children in the most-deprived group.

CONCLUSIONS

TB incidence and hospital length of stay increased with deprivation levels but not with the severity of TB.

France: Health System Review

This review of the French health system analyses recent developments in health organisation and governance, financing, healthcare provision, recent reforms and health system performance. Overall health status continues to improve in France, although geographic and socioeconomic inequalities in life expectancy persist. The health system combines a social health insurance (SHI) model with an important role for tax-based revenues to finance healthcare. The health system provides universal coverage, with a broad benefits basket, but cost-sharing is required for all essential services. Private complementary insurance to cover these costs results in very low average out-of-pocket (OOP) payments, although there are concerns regarding solidarity, financial redistribution and efficiency in the health system. The macroeconomic context in the last couple of years in the country has been affected by the Covid-19 pandemic, which resulted in subsequent increases of total health expenditure in France in 2020 (3.7%) and 2021 (9.8%). Healthcare provision continues to be highly fragmented in France, with a segmented approach to care organization and funding across primary, secondary and long-term care. Recent reforms aim to strengthen primary care by encouraging multidisciplinary group practices, while public health efforts over the last decade have focused on boosting prevention strategies and tackling lifestyle risk factors, such as smoking and obesity with limited success. Continued challenges include ensuring the sustainability of the health workforce, particularly to secure adequate numbers of health professionals in medically underserved areas, such as rural and less affluent communities, and improving working conditions, remuneration and career prospects, especially for nurses, to support retention. The Covid-19 pandemic has brought to light some structural weaknesses within the French health system, but it has also provided opportunities for improving its sustainability. There has been a notable shift in the will to give more room to decision-making at the local level, involving healthcare professionals, and to find new ways of funding healthcare providers to encourage care coordination and integration.

Defining the Characteristics of an e-Health Tool for Suicide Primary Prevention in the General Population: The StopBlues Case in France

With over one million deaths per year in the world, suicide is a major public health problem that could be significantly reduced by effective prevention programs. E-health tools are of particular interest for primary prevention as they can address a broad population including people unaware of their own risk and provide information and help without the fear of stigma. Our main objective was to define the overall characteristics of an e-health tool for suicide primary prevention in the French general population by defining the characteristics of the IT features; the content of the information delivered; the best way to structure it; and how it should be relayed and by whom. The research was carried out through a literature review and a co-construction phase with stakeholders. Four types of strategies may guide the construction of e-health tools for suicide primary prevention: education and awareness, (self-)screening, accessing support, and mental health coping. They should be accessible on different devices to reach the most users, and language and content should be adapted to the target population and to the issue being addressed. Finally, the tool should be consistent with ethical and quality best practices. The e-health tool StopBlues was developed following those recommendations.

Promoting HPV vaccination at school: a mixed methods study exploring knowledge, beliefs and attitudes of French school staff

BACKGROUND

HPV vaccine coverage in France remained lower than in most other high-income countries. Within the diagnostic phase of the national PrevHPV program, we carried out a mixed methods study among school staff to assess their knowledge, beliefs and attitudes regarding HPV, HPV vaccine and vaccination in general, and regarding schools' role in promoting HPV vaccination.

METHODS

Middle school nurses, teachers and support staff from four French regions participated between January 2020 and May 2021. We combined: (i) quantitative data from self-administered online questionnaires (n = 301), analysed using descriptive statistics; and (ii) qualitative data from three focus groups (n = 14), thematically analysed.

RESULTS

Less than half of respondents knew that HPV can cause genital warts or oral cancers and only 18% that no antiviral treatment exists. Almost 90% of the respondents knew the existence of the HPV vaccine but some misunderstood why it is recommended before the first sexual relationships and for boys; 56% doubted about its safety, especially because they think there is not enough information on this topic. Schools nurses had greater knowledge than other professionals and claimed that educating pupils about HPV was fully part of their job roles; however, they rarely address this topic due to a lack of knowledge/tools. Professionals (school nurses, teachers and support staff) who participated in the focus groups were unfavourable to offering vaccination at school because of parents' negative reactions, lack of resources, and perceived uselessness.

CONCLUSIONS

These results highlight the need to improve school staff knowledge on HPV. Parents should be involved in intervention promoting HPV vaccination to prevent their potential negative reactions, as feared by school staff. Several barriers should also be addressed before organizing school vaccination programs in France.

Health check-ups for the French under-consuming agricultural population: A pilot evaluation of the Instants santé MSA program

BACKGROUND

The social protection scheme in charge of farmers and agricultural employees (MSA) in France has developed a two-step health promotion program with a nurse appointment followed by a consultation with a doctor of the participant's choosing to reach its under-consuming beneficiaries and enroll them back into a care pathway. Our objective was to carry out a pilot evaluation of this program.

METHODS

The evaluation was carried out on the population invited during the second semester of 2017 using data from the program's service providers (date of invitation, of nurse appointment…), regional MSA bodies (consultation voucher), and reimbursement data (other care consumption). Participation rates were calculated overall and by participant characteristics. Medical needs were identified during the nurse appointment and new care pathways were assessed using reimbursement data. Multivariable regression models identified factors associated with participation.

RESULTS

2366 beneficiaries were included in the analysis. 1559 (65.89%) were men and mean age was 52.41 (standard deviation = 14.86). 409 (17.29%) attended the nurse appointment. There was a significant increase in participation with age, in farmers vs. employees (odds ratio = 1.905, 95% confidence interval = 1.393-2.604), and in people living in the most disadvantaged areas (odds ratio = 1.579, 95% confidence interval=1.079-2.312). Participation to the consultation following the nurse appointment was high (62.35%-73.11%). 87.53% of participants had at least one medical need, and new care pathways were more frequent among those who had attended the nurse appointment (55.50% vs. 34.80%, p < 0.0001).

CONCLUSIONS

This pilot evaluation shows promising results which need to be confirmed with a national evaluation of the program and longer-term evidence.

Le tabagisme en psychiatrie : réalités et implications pour sa prise en charge

OBJECTIVE

This study looks at tobacco use among persons with psychiatric disorders and its management in public psychiatric units in France.

METHODS

A thematic analysis based on semi-directive interviews with 10 patients and 9 caregivers was carried out.

RESULTS

Patients use tobacco to deal with their emotions and mood swings. However, mental health professionals, who only focus on mental disorders and addictions that have a direct impact on behaviors, disregard smoking addiction. Moreover, tobacco is sometimes integrated into the way services operate. However, it would be too simplistic to reduce the issue of smoking cessation to a matter of goodwill of caregivers. The structural dimension of smoking was evident, particularly in psychiatric hospitals, where it was an important bargaining chip and activity.

CONCLUSIONS

Patients desire to receive individualized smoking-cessation interventions. This underlines the relevance of a public health intervention co-construction that goes beyond simply prescribing nicotine substitutes. This intervention should take into account characteristics of tobacco consumption among psychiatric patients, and the need to offer such interventions when patients are stabilized. In the meantime, psychiatric caregivers should be encouraged to engage in shared decision-making processes with patients for tobacco-use reduction and cessation.

Codevelopment and evaluation of a multicomponent intervention to improve HPV vaccination in France

Background

HPV vaccine coverage (VC) in France has always been lower than in most high-income countries. The French authorities launched in 2018 the PrevHPV national research program aimed at codeveloping with stakeholders and evaluating the impact of a multicomponent intervention to improve HPV VC among French adolescents.

Methods

We identified three components to address main barriers to HPV vaccination in France: adolescents’ and parents’ education and motivation (component 1); general practitioners (GPs)’ training (component 2); and access to vaccination at school (component 3). We developed the intervention using the UK Medical Research Council framework for developing complex interventions as a guide. We used (i) findings from published evidence; (ii) primary data on knowledge, attitudes, behavior and preferences collected through a mixed methods approach (quantitative/qualitative studies, discrete choice experiment); (iii) the advice of stakeholders (e.g., adolescents, parents, school nurses, GPs) involved in working groups. We will evaluate the effectiveness, efficiency and implementation of the components (applied alone or in combination) through a pragmatic cluster randomized controlled trial. The primary endpoint is the HPV VC (≥ 1 dose) among adolescents aged 11-14 years, 2 months after the end of the intervention, at the municipality level.

Results

Primary data highlighted the need to improve adolescents, parents and school staff knowledge on HPV and to help GPs communicate with patients on this topic. They provided guidance on the most effective communication contents. For each component, we codeveloped tools with a participatory approach (e.g., eHealth tools for adolescents, a decision aid tool for GPs). The trial will end in June 2022; 90 middle schools (i.e., about 40,000 adolescents) and 46 GPs accepted to participate.

Conclusions

Should the intervention prove effective, results from the implementation evaluation will help us refine it before scaling it up.

Key messages

• The PrevHPV study is supported by the French health authorities and conducted by a multidisciplinary consortium to tackle a long-lasting public health concern in France.

• It will add to the small number of studies that compared the effectiveness of various strategies to promote HPV vaccination and will provide key results on cost-effectiveness and implementation.

Aortic valve replacement for aortic stenosis in France – influence of centers' volumes on TAVR adoption rate and outcomes

Aims

Over the last decade, transcatheter aortic valve replacement (TAVR) became extensively used, now being the recommended as first line procedure for aortic valve replacement (AVR) in selected patients' populations. It is unknown whether TAVR adoption rate and variability in outcomes is influenced by centers' volume.

Methods

From a French administrative hospital-discharge database, we collected all AVR performed in France between 2007 and 2019. Centers were stratified to terciles based on their annual SAVR per year per center during 2007–2009 (“pre TAVR era”).

Results

There was 218,489 AVRs (153,747 SAVR and 74,732 TAVR) performed in 46 centers between 2007–2019. Number of total AVR and even more so number of number of TAVR significantly and linearly increased from 2007 to 2019 in all terciles but faster in the high volume tercile (+17, +17 and +31 AVR/center/year in the low, middle and high terciles respectively, P [ANCOVA]&lt;0.001; +11, + 19 and +33 TAVR/center/year in the low, medium and high tercile respectively, P [ANCOVA] &lt;0.00, Figure 1). The age of patients underwent TAVR remained grossly unchanged in all three terciles, however, the Charlson index declined from 2010 to 2019 (from 1.35±1.42 to 0.65±1.04, from 1.21±1.40 to 0.65±1.05 and from 1.53±1.58 to 0.81±1.21, in the low, middle and high terciles, P for trend &lt;0.001, 0.021, and &lt;0.001, respectively). Charlson score in the years 2017–2019, was higher in the high than middle and low terciles (0.87±1.22, 0.76±1.11 and 0.65±1.04, respectively, P&lt;0.0001). The in-hospital mortality rate for TAVR significantly declined from 2010 to 2019 for TAVR in all terciles (from 8.3% to 2.1%, from 7.5% to 2.5% and from 8.2% to 2.1% for low, middle and high TAVR terciles, respectively; p for trend = 0.002, 0.001 and &lt;0.001, respectively, Figure 2). Average mortality in 2017–2019 was similar in all terciles (2.3%, 2.5% and 2.2% for low, middle and high terciles, respectively, P=0.47). After adjusting for age, sex and Charlson score, mortality was higher in the low tercile compared with middle and high terciles (OR 1.15, P&lt;0.001, confidence interval [CI] 1.0–1.2, and OR 1.18, P&lt;0.001, CI 1.1–1.2, respectively).

Conclusions

From 2007 to 2019 total AVR linearly increased, mostly due to increase in TAVR, irrespective of centers' volume, but increase rate was higher in high volume centers. A constant decline in patients risk profile, with a striking decrease in mortality rate, was observed in all volume terciles. High-volume centers patients' have higher risk profile, with adjusted mortality slightly lower than medium and low volume centers.

Funding Acknowledgement

Type of funding sources: None.

A comparison of individual and ecological indicators of social deprivation and their association with hospital efficiency in the context of infectious diseases in two French general paediatric departments

BACKGROUND

To identify deprivation indicators usable in everyday practice and included in medico-administrative databases, particularly with infectious diseases, which represent the greatest proportion of hospitalizations. Our objective was to compare ecological indicators to individual questionnaires and apply both types to the study of the impact of deprivation on hospital efficiency.

METHODS

We conducted an epidemiological observational prospective multicentre study in two French public hospitals between 20 October 2016 and 20 March 2017. Children hospitalized for one of the four most common infectious diseases were included and their parents were asked to answer the Evaluation of Precarity and Inequalities in Health Examination Centers (EPICES) questionnaire. The ecological indicator French DEPrivation index (FDep) was derived from patients' address, both at the zip code and at a smaller geographical area (IRIS [ilôts de regroupement pour l'information statistique]) level. Correlation and concordance between the three indicators were assessed. The endpoint used to assess the impact on hospital efficiency was the ratio between patients' length of stay (LOS) and the national LOS of their disease-related group.

RESULTS

Data were available for 540 patients with a mean age of 9 mo. A total of 56.1% of patients were considered deprived with EPICES, 50.4% with zip code FDep and 45.7% with IRIS FDep. Concordance between EPICES and either type of FDep was <0.1. There was no increase in LOS compared with national LOS with any of the indicators.

CONCLUSIONS

Individual and ecological indicators do not measure the same aspects of deprivation. The decision to use one or the other must be carefully weighed when studying the impact of deprivation on the healthcare system.

Social inequalities in access to care at birth and neonatal mortality: an observational study

OBJECTIVE

To look at the association of socioeconomic status (SES) with the suitability of the maternity where children are born and its association with mortality.

DESIGN

Retrospective analysis of a prospective cohort constituted using hospital discharge databases.

SETTING

France POPULATION: Live births in 2012-2014 in maternity hospitals in mainland France followed until discharge from the hospital.

MAIN OUTCOME MEASURE

Unsuitability of the maternity to newborns' needs based on birth weight and gestational age, early transfers (within 24 hours of birth) and in-hospital mortality.

RESULTS

2 149 454 births were included, among which 155 646 (7.2%) were preterm. Preterm newborns with low SES were less frequently born in level III maternities than those with high SES. They had higher odds of being born in an unsuitable maternity (OR=1.174, 95% CI 1.114 to 1.238 in the lowest SES quintile compared with the highest), and no increase in the odds of an early transfer (OR=0.966, 95% CI 0.849 to 1.099 in the lowest SES quintile compared with the highest). Overall, newborns from the lowest SES quintile had a 40% increase in their odds of dying compared with the highest (OR=1.399, 95% CI 1.235 to 1.584).

CONCLUSIONS

Newborns with the lowest SES were less likely to be born in level III maternity hospitals compared with those with the highest SES, despite having higher prematurity rates. This was associated with a significantly higher mortality in newborns with the lowest SES. Strategies must be developed to increase health equity among mothers and newborns.

Conditions for the Successful Integration of an eHealth Tool "StopBlues" Into Community-Based Interventions in France: Results From a Multiple Correspondence Analysis

Background

For over a decade, digital health has held promise for enabling broader access to health information, education, and services for the general population at a lower cost. However, recent studies have shown mixed results leading to a certain disappointment regarding the benefits of eHealth technologies. In this context, community-based health promotion represents an interesting and efficient conceptual framework that could help increase the adoption of digital health solutions and facilitate their evaluation.

Objective

To understand how the local implementation of the promotion of an eHealth tool, StopBlues (SB), aimed at preventing psychological distress and suicide, varied according to local contexts and if the implementation was related to the use of the tool.

Methods

The study was nested within a cluster-randomized controlled trial that was conducted to evaluate the effectiveness of the promotion, with before and after observation (NCT03565562). Data from questionnaires, observations, and institutional sources were collected in 27 localities where SB was implemented. A multiple correspondence analysis was performed to assess the relations between context, type of implementation and promotion, and use of the tool.

Results

Three distinct promotion patterns emerged according to the profiles of the localities that were associated with specific SB utilization rates. From highest to lowest utilization rates, they are listed as follows: the privileged urban localities, investing in health that implemented a high-intensity and digital promotion, demonstrating a greater capacity to take ownership of the project; the urban, but less privileged localities that, in spite of having relatively little experience in health policy implementation, managed to implement a traditional and high-intensity promotion; and the rural localities, with little experience in addressing health issues, that implemented low-intensity promotion but could not overcome the challenges associated with their local context.

Conclusions

These findings indicate the substantial influence of local context on the reception of digital tools. The urban and socioeconomic status profiles of the localities, along with their investment and pre-existing experience in health, appear to be critical for shaping the promotion and implementation of eHealth tools in terms of intensity and use of digital communication. The more digital channels used, the higher the utilization rates, ultimately leading to the overall success of the intervention.

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-020-04464-2

Impact of a school-based and primary care-based multicomponent intervention on HPV vaccination coverage among French adolescents: a cluster randomised controlled trial protocol (the PrevHPV study)

INTRODUCTION

Vaccination is an effective and safe strategy to prevent Human papillomavirus (HPV) infection and related harms. Despite various efforts by French authorities to improve HPV vaccine coverage (VC) these past few years, VC has remained far lower than in most other high-income countries. To improve it, we have coconstructed with stakeholders a school-based and primary care-based multicomponent intervention, and plan to evaluate its effectiveness, efficiency and implementation through a cluster randomised controlled trial (cRCT).

METHODS AND ANALYSIS

This pragmatic cRCT uses an incomplete factorial design to evaluate three components applied alone or in combination: (1) adolescents and parents' education and motivation at school, using eHealth tools and participatory learning; (2) general practitioners' training on HPV using motivational interviewing techniques and provision of a decision aid tool; (3) free-of-charge access to vaccination at school. Eligible municipalities (clusters) are located in one of 14 preselected French school districts and must have only one secondary school which enrols at least 2/3 of inhabitants aged 11-14 years. A randomisation stratified by school district and deprivation index allocated 90 municipalities into 6 groups of 15. The expected overall sample size estimate is 41 940 adolescents aged 11-14 years. The primary endpoint is the HPV VC (≥1 dose) among adolescents aged 11-14 years, at 2 months, at the municipality level (data from routine databases). Secondary endpoints include: HPV VC (≥1 dose at 6 and 12 months; and 2 doses at 2, 6 and 12 months); differences in knowledge, attitudes, behaviours, and intention among adolescents, parents and general practitioners between baseline and 2 months after intervention (self-administered questionnaires); incremental cost-effectiveness ratio. Implementation measures include dose, fidelity, adaptations, reached population and satisfaction (activity reports and self-administered questionnaires).

ETHICS AND DISSEMINATION

This protocol was approved by the French Ethics Committee 'CPP Sud-Est VI' on 22 December 2020 (ID-RCB: 2020-A02031-38). No individual consent was required for this type of research; all participants were informed of their rights, in particular not to participate or to oppose the collection of data concerning them. Findings will be widely disseminated (conference presentations, reports, factsheets and academic publications).

TRIAL REGISTRATION NUMBER

NCT04945655.

Trends in aortic valve replacement for aortic stenosis: a French nationwide study

AIMS

Transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) has profoundly changed the management of patients with aortic valve stenosis (AS). Large unbiased nationwide data regarding TAVR implementation, impact on SAVR and their respective outcomes are scarce.

METHODS AND RESULTS

Based on a French administrative hospital-discharge database, we collected data on all consecutive aortic valve replacements (AVRs) performed in France for AS between 2007 and 2019 [106 253 isolated SAVR (49%), 46 514 combined SAVR (21%), and 65 651 TAVR (30%)]. The number of AVR linearly increased between 2007 and 2019 (from 10 892 to 23 109, P for trend < 0.0001) due to a marked increase in TAVR (from 253 to 13 030, P for trend < 0.0001), while SAVR increased up to 2013 and then declined (10 892 in 2007, 12 699 in 2013, and 10 079 in 2019). The Charlson index decreased linearly for TAVR, but in two steps for SAVR (2011 and 2017). In-hospital mortality rates of both SAVR and TAVR declined (both P for trend < 0.0001) and were similar or lower for TAVR than for isolated SAVR in patients 75 years or above in the last 3 years (2017-19). Complication rates of TAVR also declined but permanent pacemaker rates remained high and length of stay substantial (16.7% and median 6 days, respectively, in 2017-19).

CONCLUSION

The number of AVR has doubled in a decade and TAVR has become the dominant form of AVR in 2018. The improvement in patient profiles seems to have anticipated the demonstrated benefit of TAVR in intermediate and low-risk patients. In patients 75 years or older, TAVR should be considered as the first option. We also highlight two important areas for improvement, the high permanent pacemaker rates, and the long length of stay even in the contemporary era. Our results may have major implications for clinical practice and policymakers.

Current treatment of symptomatic aortic stenosis in elderly patients: Do risk scores really matter after 80 years of age?

BACKGROUND

According to the guidelines, surgical aortic valve replacement (SAVR) is recommended in patients at low surgical risk (EuroSCORE II<4%), whereas for other patients, the decision between transcatheter aortic valve implantation (TAVI) and surgery should be made by the Heart Team, with TAVI being favoured in elderly patients.

AIM

The RAC prospective multicentre survey assessed the respective contributions of age and surgical risk scores in therapeutic decision making in elderly patients with severe symptomatic aortic stenosis.

METHODS

In September and October 2016, 1049 consecutive patients aged ≥ 75 years were included in 32 centres with on-site TAVI and surgical facilities. The primary endpoint was the decision between medical management, TAVI or SAVR.

RESULTS

Mean age was 84±5 years and 53% of patients were female. The surgical risk was classified as high (EuroSCORE II>8%) in 18% of patients, intermediate (EuroSCORE II 4-8%) in 34% and low (EuroSCORE II≤4%) in 48%. TAVI was preferred in 71% of patients, SAVR in 19% and medical treatment in 10%. The choice of TAVI over SAVR was associated with older age (P<0.0001) and a higher EuroSCORE II (P=0.008). However, the weight of EuroSCORE II in therapeutic decision making markedly decreased after the age of 80 years. Indeed, 77% of patients aged ≥ 80 years were referred for TAVI, despite a low estimated surgical risk.

CONCLUSIONS

The impact of risk scores depends strongly on age, and decreases considerably after 80 years, most patients being referred for TAVI, independent of their estimated surgical risk. Despite medical advancements, 10% of patients were still denied any intervention.

Estimation of the Width of Uncertainty in Care Consumption and Costs When Using Common Data Collection Tools in Economic Evaluations: A Benchmark for Sensitivity Analyses

OBJECTIVES

This study aimed to evaluate the uncertainty related to the use of common collection tools to assess costs in economic evaluations compared with an exhaustive administrative database.

METHODS

A pragmatic study was performed using preexisting cost-effectiveness studies. Patients were probabilistically matched with themselves in the French National Health Data System (Système National des Données de Santé [SNDS]), and all their reimbursed hospital and ambulatory care data during the study were extracted. Outcomes included the ratio of the number of each type of resources consumed using trial data (case report forms for ambulatory care and local hospital data for hospital care) versus the SNDS and the ratio of corresponding costs. Mean ratios and 95% confidence intervals (CIs) were calculated using bootstrapping. The impact of the collection tool on the result of the economic evaluation was calculated with the difference in costs between the 2 treatment arms with both collection methods.

RESULTS

Five cost-effectiveness studies were included in the analysis. A total of 397 patients had the SNDS hospital data, and 321 had ambulatory care data. Common collection tools underestimated hospital admissions by 13% (95% CI 8-20), corresponding costs by 5% (95% CI 2-14), and ambulatory acts by 41% (95% CI 33-51), with large variations in costs depending on the study. There was no change in the economic conclusion in any study.

CONCLUSIONS

The use of common collection tools underestimates healthcare resource consumption and its associated costs, particularly for ambulatory care. Our results could provide useful evidence-based estimates to inform sensitivity analyses' parameters in future cost-effectiveness analyses.