Cost-utility of oral methylprednisolone in the treatment of multiple sclerosis relapses: Results from the COPOUSEP trial

BACKGROUND

Studies have shown that oral high-dose methylprednisolone (MP) is non-inferior to intravenous MP in treating multiple sclerosis relapses in terms of effectiveness and tolerance. In order to assist with resource allocation and decision-making, its cost-effectiveness must also be assessed. Our objective was to evaluate the cost-utility of per os high-dose MP as well as the cost-savings associated with implementing the strategy.

METHODS

A cost-utility analysis at 28 days was carried out using data from the French COPOUSEP multicenter, double-blind randomized controlled non-inferiority trial and the statutory health insurance reimbursement database. Costs were calculated using a societal perspective, including both direct and indirect costs. An incremental cost-effectiveness ratio was calculated and bootstrapping methods assessed the uncertainty surrounding the results. An alternative scenario analysis in which MP was administered at home was also carried out. A budgetary impact analysis was carried at five years.

RESULTS

In the conditions of the trial (hospitalized patients), there was no significant difference in utilities and costs at 28 days. The incremental cost-effectiveness ratio was €15,360 per quality-adjusted life-year gained. If multiple sclerosis relapses were treated at home, oral MP would be more effective, less costly and associated with annual savings up to 25 million euros for the French healthcare system.

CONCLUSIONS

Oral MP is cost-effective in the treatment of multiple sclerosis relapses and associated with major savings.

The cost of child abuse and neglect in France: The case of children in placement before their fourth birthday

BACKGROUND

Despite the high prevalence of child abuse and neglect and its consequences on health, very few studies have evaluated the trajectories of children in placement in France, and there are no cost studies available.

OBJECTIVE

To estimate the cost of abuse and neglect in children in placement before their 4th birthday in France.

PARTICIPANTS AND SETTING

A cohort of children in placement before their 4th birthday in a single nursery between February 1994 and June 2001 was followed from birth until they left care.

METHODS

Child protective services (CPS), health, health and social, and judiciary services utilization was derived from a qualitative analysis of the children's files and valued with their unit costs in 2013 euros from the societal perspective. Total costs and mean annual cost per child followed by CPS were calculated overall, by cost category, and by status at admission to the nursery.

RESULTS

129 children were included. Mean age at first admission was 1.9 years (SD = 1.3). The mean length of follow-up by CPS was 14.3 years (SD = 5.0). Mean annual cost per child was estimated at €53,265 (SD = 42,077), with CPS costs representing 78% of costs. 80% of health care costs were due to psychiatric care. Children with no identified psychosocial risk factors had significantly higher psychiatric care costs and health and social care costs than pre-term children and children with identified psychosocial risk factors.

CONCLUSION

More research should be carried out to address early and comprehensively the multiple needs of children followed by CPS in the short- and long-term.

Impact of Ed-LinQ: A Public Policy Strategy to Facilitate Engagement between Schools and the Mental Health Care System in Queensland, Australia

Ed-LinQ is a mental health policy initiative to enhance the early detection and treatment of children with mental illness by improving the liaison between schools and health services in Queensland, Australia. We measured its impact from policy to practice to inform further program developments and public strategies. We followed a mixed quantitative/qualitative approach. The Adoption Impact Ladder (AIL) was used to analyse the adoption of this initiative by end-users (decision makers both in the health and education sectors) and the penetration of the initiative in the school sector. Survey respondents included representatives of schools (n = 186) and mental health providers (n = 78). In total, 63% of the school representative respondents were at least aware of the existence of the Ed-LinQ initiative, 74% were satisfied with the initiative and 28% of the respondent schools adopted the initiative to a significant extent. Adoption was higher in urban districts and in the health sector. The overall level of penetration in the school sector of Queensland was low (3%). The qualitative analysis indicated an improvement in the referral and communication processes between schools and the health sectors and the importance of funding in the implementation of the initiative. Mapping of existing programs is needed to assess the implementation of a new one as well as the design of different implementation strategies for urban and rural areas. Assessing the adoption of health policy strategies and their penetration in a target audience is critical to understand their proportional impacts across a defined ecosystem and constitutes a necessary preliminary step for the evaluation of their quality and efficiency.

Lessons learned from an e-mental health intervention: The promotion of stopblues in 41 french cities

Introduction

For more than a decade, digital health has held promise for enabling a much broader population to have access to health information, education and services. However, the increasing number of studies on the subject show mixed results and currently, there is a certain disillusionment regarding its benefits. And yet, the Covid-19 crisis has revealed the importance of developing digital-based complementary support to existing resources.

Objectives

Factors associated with higher utilization rates among the target audience need to be investigated.

Methods

In 2018, 41 French cities enrolled in an intervention program aimed at promoting StopBlues®, a digital health tool that helps prevent mental distress and suicide among the general population. After two years of experimentation, a Multiple Correspondence Analysis (MCA) was performed using quantitative and qualitative data collection methods from institutional sources, questionnaires and web analytics tools.

Results

Finding trends show that higher utilization rates were associated with the involvement of general practitioners (GPs) in the promotion of StopBlues and the use of digital marketing channels. Context-specific characteristics also played an important role in the adoption of the tool.

Conclusions

The local context has a strong influence on how digital tools are locally promoted and accepted. Further research is needed to understand how local actors and specifically GPs can be involved in suicide prevention. More broadly, the challenge today is to ensure acceptance of digital health technology among targeted populations by adapting the digital offer to their needs and promoting the available tools.

Disclosure

No significant relationships.

The benefits of involving general practitioners in the promotion of e-health tools for primary prevention of suicide in the general population: The stopblues case

Introduction

In France about 10,000 suicides/year are recorded. General practitioners (GPs) have an important role in prevention, with consultation rates between 20% and 76% the day preceding suicide. StopBlues is an application/website for primary prevention of suicide in the general population. Its promotion was supported by municipalities and involved GPs.

Objectives

To evaluate how the involvement of GPs in the promotion of StopBlues had an impact on its utilization.

Methods

StopBlues was promoted in 25 French municipalities randomly assigned to a ‘basic’ promotion group organized by municipalities only or an ‘intensified’ promotion group that also includes promotion in GPs’ waiting rooms. StopBlues users were asked how they found out about StopBlues. After two years, an ad hoc questionnaire was sent to all GPs (N=2,111).

Results

StopBlues users from those municipalities (N=885) were 16% to learn about StopBlues from GPs, 93% of them living in municipalities with ‘intensified’ promotion. In the ‘basic’ group, where no GPs have heard about StopBlues, 15% would like to know more about it/will have a look at it and 8% will use it and recommend it to colleagues. Half of GPs from the ‘intensified’ group had heard about the program, with 24% who recommended StopBlues to some patients. 21% of GPs agreed that they will use it and recommend it to colleagues.

Conclusions

Involving GPs in the use of e-health tools is of major interest to improve their utilization. Our results show that GPs are in need of those in dealing with patients with psychological pain/distress.

Disclosure

No significant relationships.

Adaptation of a french e-health tool for suicide prevention in young populations: Modalities and benefits

Introduction

France’s suicide rate is among the highest in Europe, with the young among the more at risk than others. Several European projects have demonstrated the effectiveness of using e-tools in suicide prevention particularly for hard-to-reach populations. Lessons from StopBlues, an e-health tool (application/website) for suicide prevention in the general population developed in 2018 which was promoted by municipalities and general practitioners, shows the necessity to adapt its content for young people.

Objectives

The objective is to develop an e-health tool, BlueZberry, for suicide prevention targeting adolescents and young adults with psychological pain by adapting StopBlues and its promotional plan.

Methods

The detailed content of BlueZberry and its promotional plan were determined via a literature review and 26 individual and group interviews with experts and youth with StopBlues as a starting part.

Results

The literature review and interviews confirmed the need to adapt the tool according to age of the user since the context and source of psychological pain vary rapidly at this time of life. BlueZberry consists of three modules for age groups 12-14, 15-17 and 18-25 years with specific graphics and messages. Its locally organized promotion should include youth hangouts on top of usual places.

Conclusions

This adaptation of StopBlues will reach a larger audience by offering a more suitable solution for this vulnerable population. A web-portal will serve as an entry point for both StopBlues and BlueZberry where users will be redirected to one of the tools/modules according to their profile and respective needs.

Réduire le tabagisme dans les prisons : éléments théoriques et méthodologiques nécessaires à la co-construction d’une intervention en contexte pénitentiaire

Révélateur des inégalités sociales de santé, le tabagisme en établissement pénitentiaire exige des interventions visant sa réduction d’être adaptées aux spécificités du milieu carcéral. Dans le cadre de la recherche interventionnelle TABAPRI, nous avons mobilisé une première étude sociologique afin d’apporter des connaissances sur cette problématique. Une enquête a été réalisée au sein de trois établissements pénitentiaires, précédant les phases de construction, d’implémentation et d’évaluation de l’intervention. Cet article décrit d’une part la démarche méthodologique et d’autre part, la contribution de la sociologie, tant dans ses apports conceptuels que méthodologiques, à la construction d’une intervention. Notre travail a notamment souligné l’importance d’aménager des espaces d’échange permettant aux professionnels et aux personnes détenues de construire ensemble les modalités d'intervention qui participent à la réduction du tabagisme en détention.

Integration of eMental health technologies into traditional community-based interventions

Background

Very little research has been conducted to appraise the merits of including municipalities and their local health providers in the promotion of digital health programmes. While more and more municipalities have locally implemented a health strategic plan and have focused on building local network of professionals, how do the latter react to the implementation of innovative e-mental health community-based programmes?

Methods

In 2018, 42 French municipalities volunteered to promote StopBlues, a digital health tool aimed at preventing mental distress and suicide. In each municipality, a local delegate was responsible for the promotion of the tool. Using observations, questionnaires and interviews with the delegates, we analysed how the promotion of StopBlues® was conducted in each setting. 2/3 of these municipalities started the promotion directly, and in 2019, a second wave of municipalities launched the promotion with a stronger support from the research team backed by the French World Health Organization Collaborating Centre for Research and Training in Mental Health (WHOCC).

Results

The use of digital technology in the implementation of a mental health programme received a mixed reception from the local health professionals because of its innovative aspect. 2/3 of the delegates declared that they were struggling to create a stronger network of local partners including private medical practioners. 63% of the respondents stated that their municipalities got involved in the programme for networking purposes.

Conclusions

Digital technologies have initiated a paradigm shift in the way community-based health programmes are set up but need to strengthen their territorial anchorage in order to be accepted and used at the local level.

Key messages

Digital technology can be a strong lever against health inequities but its effectiveness has to be studied carefully. Digital technolgy has to be implemented in local settings with the collaboration of local actors in order to be accepted and used.

The PRINTEMPS study: protocol of a cluster-randomized controlled trial of the local promotion of a smartphone application and associated website for the prevention of suicidal behaviors in the adult general population in France

BACKGROUND

Suicide constitutes a cause of death which could be prevented by e-health programs accessible to the general population. Effective promotion has the potential to maximize the uptake of such programs. However, few e-health programs have been combined with promotion campaigns. The primary objective of this trial is to assess the effectiveness of a tailored promotion, at a local level, of a mobile application and website offering evidence-based content for suicide prevention (the StopBlues program), and to compare the effectiveness of two types of local promotion in terms of their impact on suicidal acts. Secondary objectives focus on the effectiveness of the promotion in terms of the intensity of utilization of the StopBlues program, help-seeking behaviors and the level of psychological impairment of program users.

METHODS/DESIGN

This is a three-arm, parallel-group, cluster-randomized controlled trial, with before-and-after observation. Thirty-four clusters, corresponding to geographical areas sharing a common local authority in France, will be included. They will be randomly assigned to one of the following arms with a ratio of 1:1:1: a control group; a basic promotion group in which promotion of the StopBlues program will be done by local authorities; and an intensified promotion group in which basic promotion will be supplemented by an additional one in a general practitioner's waiting room. The primary outcome measure will be the number of suicidal acts within each cluster over a 12-month period following the launch of the intervention. Baseline data will be collected for each cluster over the 12-month period prior to the trial. Secondary outcomes will include length of use of the StopBlues program, measures of help-seeking behaviors and level of psychological distress among users of the program, as well as the cost-effectiveness and budgetary impact of its promotion. A more sustained promotion by local authorities will also be implemented after 12 months in the control group and assessed using the same outcome measures.

DISCUSSION

This research should contribute to the sparse evidence base regarding the promotion of e-health programs and will support the wider delivery of the intervention evaluated if proven effective.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03565562. Registered on 11 June 2018.

The state of the art in European research on reducing social exclusion and stigma related to mental health: A systematic mapping of the literature

Stigma and social exclusion related to mental health are of substantial public health importance for Europe. As part of ROAMER (ROAdmap for MEntal health Research in Europe), we used systematic mapping techniques to describe the current state of research on stigma and social exclusion across Europe. Findings demonstrate growing interest in this field between 2007 and 2012. Most studies were descriptive (60%), focused on adults of working age (60%) and were performed in Northwest Europe—primarily in the UK (32%), Finland (8%), Sweden (8%) and Germany (7%). In terms of mental health characteristics, the largest proportion of studies investigated general mental health (20%), common mental disorders (16%), schizophrenia (16%) or depression (14%). There is a paucity of research looking at mechanisms to reduce stigma and promote social inclusion, or at factors that might promote resilience or protect against stigma/social exclusion across the life course. Evidence is also limited in relation to evaluations of interventions. Increasing incentives for cross-country research collaborations, especially with new EU Member States and collaboration across European professional organizations and disciplines, could improve understanding of the range of underpinning social and cultural factors which promote inclusion or contribute toward lower levels of stigma, especially during times of hardship.

Socioeconomic Status of Newborns and Hospital Efficiency: Implications for Hospital Payment Methods

OBJECTIVES

Studies have shown a consistent impact of socioeconomic status at birth for both mother and child; however, no study has looked at its impact on hospital efficiency and financial balance at birth, which could be major if newborns from disadvantaged families have an average length of stay (LOS) longer than other newborns. Our objective was therefore to study the association between socioeconomic status and hospital efficiency and financial balance in that population.

METHODS

A study was carried out using exhaustive national hospital discharge databases. All live births in a maternity hospital located in mainland France between 2012 and 2014 were included. Socioeconomic status was estimated with an ecological indicator and efficiency by variations in patient LOS compared with different mean national LOS. Financial balance was assessed at the admission level through the ratio of production costs and revenues and at the hospital level by the difference in aggregated revenues and production costs for said hospital. Multivariate regression models studied the association between those indicators and socioeconomic status.

RESULTS

A total of 2 149 454 births were included. LOS was shorter than the national means for less disadvantaged patients and longer for the more disadvantaged patients, which increased when adjusted for gestational age, birth weight, and severity. A 1% increase in disadvantaged patients in a hospital's case mix significantly increased the probability that the hospital would be in deficit by 2.6%.

CONCLUSIONS

Reforms should be made to hospital payment methods to take into account patient socioeconomic status so as to improve resource allocation efficiency.

Using the Personalized Advantage Index for Individual Treatment Allocation to Blended Treatment or Treatment as Usual for Depression in Secondary Care

A variety of effective psychotherapies for depression are available, but patients who suffer from depression vary in their treatment response. Combining face-to-face therapies with internet-based elements in the sense of blended treatment is a new approach to treatment for depression. The goal of this study was to answer the following research questions: (1) What are the most important predictors determining optimal treatment allocation to treatment as usual or blended treatment? and (2) Would model-determined treatment allocation using this predictive information and the personalized advantage index (PAI)-approach result in better treatment outcomes? Bayesian model averaging (BMA) was applied to the data of a randomized controlled trial (RCT) comparing the efficacy of treatment as usual and blended treatment in depressive outpatients. Pre-treatment symptomatology and treatment expectancy predicted outcomes irrespective of treatment condition, whereas different prescriptive predictors were found. A PAI of 2.33 PHQ-9 points was found, meaning that patients who would have received the treatment that is optimal for them would have had a post-treatment PHQ-9 score that is two points lower than if they had received the treatment that is suboptimal for them. For 29% of the sample, the PAI was five or greater, which means that a substantial difference between the two treatments was predicted. The use of the PAI approach for clinical practice must be further confirmed in prospective research; the current study supports the identification of specific interventions favorable for specific patients.

European mental health research resources: Picture and recommendations of the ROAMER project

As part of the Roamer project, we sought to have a picture of the available mental health research (MHR) funding, capacity-building and infrastructures resources and to establish consensus-based recommendations that would allow an increase of European MHR resources and enable better use and accessibility to them. The methods fell into three sections (i) a review of the literature, (ii) a mental health-related keywords search within the Cordis^®, On-Course^® and Meril^® databases which contain information on European research funding, training and infrastructures. These reviews provided an overview that was presented to (iii) two experts workshops with 28 participants drawn from academic which identified gaps and produced recommendations. The literature review illustrates the debates in the scientific community on funding, training and infrastructures. The database searches estimated the fraction of health research resources available for mental health. Eight overarching goals for MHR resources were identified by the workshops; each of them was carried out with several practical recommendations. Resources for MHR are scarce considering the burden of mental disorders, the high rate of return of MHR and the under-investment of the field. The recommendations are urgently warranted to increase resources and their optimal access and use.

Variations in the use of caesarean section: a Comparison between France and Australia

Background

There has been a rise in obstetric intervention during labour and birth including rates of caesarean section around the world. The rates of caesarean section are lower in France (20%) than Australia (34%). Both countries have universal health care systems. Australia has a well-established program of obstetric benchmarking and national data collection for comparing maternal and perinatal outcomes taking into account maternity units and maternal characteristics. Although the optimal caesarean section rate is not known, variation in caesarean section rates raise questions about what is driving variation in practice and whether the right care is being delivered. The World Health Organisation has recently released non-clinical recommendations aiming to reduce unnecessary caesarean sections, including that births are classified by Robson classification for easier comparison.

Methods

We aim to compare rates of mode of birth in 2 tertiary hospitals- one in France and one in Australia using Robson classification. This project will investigate differences in patient casemix, and obstetric management that may lead to differences in outcome. In addition, we will try to explore differences in the health systems including clinical activity, induction rates, staffing (number, type (medical, nursing, midwifery)), and models of care.

Outcomes

Caesarean section is one of the most common operations performed in hospitals. Important variations of surgical rates raise question regarding whether access to this procedure is optimized. Determining current practice and outcomes of women in two different settings will provide important data to inform hospital practice and further research. In addition, this research may inform national guidelines about indications for caesarean section.

Impact of mental illness on in-patient hospital costs for somatic disorders and associated factors

Background

People suffering from mental disorders are in poorer somatic health that the general population. This is due in part to poor quality of care in primary care settings, which can in turn have a major impact on hospitals and healthcare systems, in particular in terms of costs. Our objective was to assess the economic burden of acute care admissions for somatic diseases in patients with a mental illness compared to other patients and analyse the factors associated with it.

Methods

An exhaustive study using French hospital discharge databases was carried out between 2009 and 2013. Total acute hospital costs were calculated from the all payer perspective (statutory health insurance, private health insurances and patient out-of pocket payments). A multivariate regression modelled the association between mental illness and hospital costs while adjusting for other explanatory variables, with and without interaction terms.

Results

37,458,810 admissions were included in the analysis. 1,163,972 patients (6.54%) were identified as being mentally ill. Mean total hospital costs at five years per patient were €8,114. Costs per mentally ill patient were on average 34% higher than for a non-mentally patient (€10,637 vs. €7,949). A longitudinal analysis of costs showed a widening of the gap between the two groups as time went by, from 1.60% in 2009 to 10.51% in 2013. In the multivariate model, mental disorders were significantly associated with increased costs, and interaction terms found an increased impact of mental illness on costs in deprived patients.

Conclusions

Improving quality of primary care and health promotion in people with a mental illness both for their own sake and to decrease the economic burden on the healthcare system, is of vital importance.

Key messages

There is a significant increase in hospital costs for somatic care in patients with a mental illness compared to other patients, in particular in patients who are also deprived. It is necessary to improve primary care and health promotion in mentally ill patients, for their sake and for the sake of healthcare systems.

StopBlues: a French e-health device to prevent suicide in the general population

Background

France is one of the Western European countries most affected by suicide, an epidemiological burden and high societal cost of several million euros/year. Several European projects have either implemented web-based interventions for care of mental disorders or recommended online actions which have demonstrated their effectiveness for suicide prevention.

The objective of the project was the construction of an application and website to prevent suicide in the general population, with its promotion being supported at the local authority level.

Methods

The detailed content of the devices and promotional tools available to local authorities was determined through literature reviews and expert groups (psychiatrists, local authorities’ workers and potential users).

Results

An application and website were constructed with two parts: a public interface with videos (psychological suffering, coping strategies and help available), an emergency button, a map with local resources and contact information (psychiatrists, psychologists, associations...), tips and videos to overcome a period of psychological suffering; and a private interface requiring registration giving access to self-assessment questionnaires and a safety plan to fill in case of crisis. 40 local authorities are involved in StopBlues promotion, with a referent each, responsible of contact with our team, and local organization of promotion.

Conclusions

Since 04-2018, StopBlues is available at www.stopblues.fr and can be downloaded on iOs and Android. Its promotion is part of a cluster randomized trial with 3 arms: a control group with no promotion, a group with promotion by local authorities, and a group with promotion by local authorities and general practitioner’s waiting room. As promotion could have different intensities depending on budgets and referent’s involvement, we decided to extend it for another year, with local authorities of group control receiving additional financial and organizational support.

Key messages

As the first e-health program for suicide primary prevention in the French general population, StopBlues’ main goal is to help people find solutions that suit them and direct them to the right help. Local authorities are a key level to promote primary health prevention programs.

Using e-health to shorten treatment delay in patients with severe aortic stenosis

Background

Transcatheter aortic valve replacement (TAVR) is a relatively new alternative to open surgery in patients with a severe aortic stenosis at high risk of surgery but there are important variations in treatment delay which can lead to increased morbidity and mortality. Those delays have many causes, including patients’ unawareness of the urgency, delays in obtaining the necessary preoperative tests and organizational factors at the hospital level. The aim of our study was to co-construct an e-health tool for patients and their families to empower them and improve knowledge on the disease and TAVR to ultimately decrease the delay between the medical decision for TAVR and the actual procedure.

Methods

A prospective study was first carried out to identify organizational factors associated with variations in treatment delay (both at the patient and hospital level). A preliminary survey was sent to all TAVR centers in France to understand and describe their organization. Descriptive analyses were then carried out on the answers. In a second step, two focus groups were carried with, the first with patients and carers and the second with healthcare professionals in order to elaborate the e-health tool.

Results

A website has been developed for patients and their families. It includes information in video form on aortic stenosis and its different treatments, on TAVR, the necessary tests required prior to TAVR (with a geolocalisation of available facilities nearby so that patients may know where to go), and what they can expect during the hospital admission and after their release. Patients undergoing TAVR will be informed of the website’s existence by their cardiologist. Web pages intended for healthcare professionals who are not TAVR specialists (general practitioners…) will also be available on the website.

Conclusions

A cluster randomized controlled trial will now test the efficacy and efficiency of the e-health tool in reducing TAVR treatment delay.

Key messages

We built a e-health tool in collaboration with patients, carers and healthcare professionals to increase patients’ knowledge on aortic stenosis and TAVR. The website will provide information through videos to empower patients and ultimately decrease treatment delay and its associated morbi-mortality.

Association of Pediatric Inpatient Socioeconomic Status With Hospital Efficiency and Financial Balance

IMPORTANCE

In health care systems in which hospital reimbursement is based on a national mean length of stay (LOS), disadvantaged patients with an increased LOS may be a source of inefficiency. This implication has been reported in adult patients, but pediatric data have been scarce.

OBJECTIVE

To examine the association of patient socioeconomic status with hospital efficiency and financial balance in pediatrics.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained data from the French national hospital discharge database covering a 3-year period, from January 1, 2012, to December 31, 2014. Statistical analyses were performed between June 2016 and December 2018. All inpatient stays in hospital pediatric wards in mainland France by children older than 28 days or younger than 18 years (n = 4 121 187) were included. Admissions with coding errors or missing values for social disadvantage and/or cost calculations were excluded.

EXPOSURE

Social disadvantage was estimated with an ecological indicator, the FDep, available at the patient's postcode of residence and divided into national quintiles.

MAIN OUTCOMES AND MEASURES

Efficiency was assessed through the variations in patient LOS compared with different national mean LOS (for pediatric patients, pediatric patients with a similar condition, and pediatric patients with a similar condition and severity level). Hospital financial balance was assessed at the admission level through the ratio of production costs to revenues and at the hospital level through the difference between aggregated revenues and production costs. Multivariate regression models examined the association between these indicators and socioeconomic status.

RESULTS

A total of 4 121 187 admissions were included (2 336 540 [56.7%] male; mean [SD] age, 7.4 [5.8] years). In all, 1 561 219 patients (37.9%) were in the 2 most disadvantaged quintiles. Patient LOS was shorter than the national mean LOS (mean [SD], 1.73 [4.21] days) for patients in the least disadvantaged quintile and longer for those in the more disadvantaged quintile (mean [SD], 1.67 [4.33] days vs 1.82 [4.14] days). This difference was higher for diagnosis related groups that included both adult and pediatric patients (mean [SD], 1.46 [4.22] days vs 1.61 [4.13] days) compared with those dedicated to pediatric patients (2.22 [4.13] days vs 2.12 [4.53] days). Patients in the most disadvantaged quintile were associated with a 3.2% increase in LOS (odds ratio, 1.0322; 95% CI, 1.0302-1.0341) compared with the national mean LOS. Social disadvantage was also associated with a significant increase in financial deficit for hospitals with 20% to 60% of patients in the 2 most disadvantaged quintiles (estimate: -€146 389; 95% CI, -€279 566 to -€13 213).

CONCLUSIONS AND RELEVANCE

Patient socioeconomic status appears to be statistically significantly associated with an increase in LOS and cost in French hospitals with pediatric departments. This finding suggests that initiating reform in hospital payment methods may improve resource allocation efficiency and equity in access to pediatric care.

Association of social deprivation with 1-year outcome of ICU survivors: results from the FROG-ICU study

Purpose

Intensive care unit survivors suffer from prolonged impairment, reduced quality of life, and higher mortality rates after discharge compared to the general population. Socioeconomic status may play a partial but important role in mortality and recovery. Therefore, the detection of factors that are responsible for poor long-term outcomes would be beneficial in designing targeted interventions for at-risk populations.

Methods

For an endpoint analysis, 1834 intensive care unit patients with known French Deprivation Index (FDep) scores were included from the French and euRopean Outcome reGistry in Intensive Care Units (FROG-ICU) study, which was a prospective, observational, multicenter cohort study performed in 20 French intensive care units in 13 different hospitals. Socioeconomic status was defined by using the FDep score [represented as quintiles when referring to the general French population, as quintiles when referring to the FROG-ICU cohort, or as dichotomized data (which was defined as a FDep ≤ 0 for nondeprived patients)] and by using a detailed social questionnaire that was completed 3 months after discharge. The primary outcome included an all-cause, 1-year mortality after ICU discharge when regarding socioeconomic status. The secondary outcomes included both ICU and hospital lengths of stay, both short- and medium-term mortality, and the quality of life, as assessed during the 1-year follow-up by using the Medical Outcome Survey Short Form-36 (SF-36). The Revised Impact of Event Scale (IES-R) was used to evaluate the symptoms of post-traumatic stress disorder, and the Hospital Anxiety and Depression Scale (HADS) was used to screen for anxiety and depression.

Results

Of the 1447 patients who were discharged alive from the ICU, 19.2% died over the following year. No association was found between 1-year mortality and socioeconomic status, regardless of whether this association was analyzed in quintiles (p = 0.911 in the quintiles of the general French population; p = 0.589 in the quintiles of the FROG-ICU cohort itself) or as dichotomized data [nondeprived (n = 177; 1-year mortality of 18.2%) versus deprived (n = 97; 1-year mortality of 20.5%; p = 0.304)]. Moreover, no differences were found between the nondeprived and the deprived patients in the ICU and hospital lengths of stay, ICU mortalities, in-hospital mortalities, or 28-day mortalities. The SF-36 was below the score for the normal French population throughout the follow-up period. Socially deprived patients showed significantly lower median scores in the physical function subscale [55, interquartile range (IQR) (28.8–80) vs. 65, IQR (35–90); p = 0.014], the physical role subscale [25, IQR (0–75) vs. 33.3, IQR (0–100); p = 0.022], and the overall physical component scale [47.5, IQR (30–68.8) vs. 54.4, IQR (35–78.8); p = 0.010]. Up to 31.6% of survivors presented symptoms that indicated post-traumatic stress disorder, and up to 31.5% of survivors reported clinically meaningful symptoms of anxiety or depression.

Conclusions

A lower socioeconomic status was associated with lower self-reported physical component scores in the nondeprived patients. Psychiatric symptoms are frequently reported after an ICU stay, and subsequent interventions should target those fields.

Trial registration

ClinicalTrials.gov NCT01367093; registered on June 6, 2011.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5412-5) contains supplementary material, which is available to authorized users.

The balance of adult mental health care: provision of core health versus other types of care in eight European countries

AIMS

Although many mental health care systems provide care interventions that are not related to direct health care, little is known about the interfaces between the latter and core health care. 'Core health care' refers to services whose explicit aim is direct clinical treatment which is usually provided by health professionals, i.e., physicians, nurses, psychologists. 'Other care' is typically provided by other staff and includes accommodation, training, promotion of independence, employment support and social skills. In such a definition, 'other care' does not necessarily mean being funded or governed differently. The aims of the study were: (1) using a standard classification system (Description and Evaluation of Services and Directories in Europe for Long Term Care, DESDE-LTC) to identify 'core health' and 'other care' services provided to adults with mental health problems; and (2) to investigate the balance of care by analysing the types and characteristics of core health and other care services.

METHODS

The study was conducted in eight selected local areas in eight European countries with different mental health systems. All publicly funded mental health services, regardless of the funding agency, for people over 18 years old were identified and coded. The availability, capacity and the workforce of the local mental health services were described using their functional main activity or 'Main Types of Care' (MTC) as the standard for international comparison, following the DESDE-LTC system.

RESULTS

In these European study areas, 822 MTCs were identified as providing core health care and 448 provided other types of care. Even though one-third of mental health services in the selected study areas provided interventions that were coded as 'other care', significant variation was found in the typology and characteristics of these services across the eight study areas.

CONCLUSIONS

The functional distinction between core health and other care overcomes the traditional division between 'health' and 'social' sectors based on governance and funding. The overall balance between core health and other care services varied significantly across the European sites. Mental health systems cannot be understood or planned without taking into account the availability and capacity of all services specifically available for this target population, including those outside the health sector.