[Care for patients with chronic illness - concepts, assessment and foreign experiences]

The growing number of people with chronic diseases is a major challenge for health care systems in terms of morbidity, mortality, quality of care and financial impact. A range of organizational concepts for structured chronic disease care have been developed to address this challenge. The purpose of this literature review is to identify the key concepts, results and success factors of recent initiatives in this area. Four main concepts related to the broader notion of integrated care were identified: case management, disease management, the chronic care model and population management. The available evidence suggests that the expected results in terms of health gains and cost reductions have only been partially achieved, but that the quality of care has improved. The study identified several critical success factors for initiatives aimed at improving chronic care: the integration of patient education, the implementation of a patient identification system, provider feedback, primary care performance and financial incentives. Improved care for patients with chronic illness requires a range of interdependent measures. However, it is important to note that initiatives in this area are not usually associated with shortterm savings, but represent an investment for the future.

Cost effectiveness of full coverage of the medical management of smoking cessation in France

OBJECTIVE

To estimate the incremental cost effectiveness of full coverage of the medical management of smoking cessation from the perspective of statutory health insurance (SHI) in France.

DESIGN AND POPULATION

Cost-effectiveness analysis based on a Markov state-transition decision analytic model was used to compare full SHI coverage of smoking cessation and actual coverage based on an annual €50 lump sum per insured person among current French smokers aged 15-75 years. We used a scenario approach to take into account the many different behaviours of smokers and the likely variability of SHI policy choices in terms of participation rate and number and frequency of attempts covered.

INTERVENTIONS

Drug treatments for smoking cessation combined with six medical consultations including individual counselling.

MAIN OUTCOMES MEASURES

The cost effectiveness of full coverage was expressed by the incremental cost-effectiveness ratio (ICER) in 2009 euros per life-year gained (LYG) at the lifetime horizon.

RESULTS

The cost effectiveness per LYG for smokers ranged from €1786 to €2012, with an average value of €1911. The minimum value was very close to the maximum value with a difference of only €226. The cost-effectiveness ratio was only minimally sensitive to the participation rate, the number of attempts covered and the cessation rate.

CONCLUSIONS

Compared to other health measures in primary and secondary prevention of cardiovascular disease already covered by SHI, full coverage of smoking cessation is the most cost-effective approach.

Improving participation in colorectal cancer screening: targets for action

OBJECTIVE

Our aim was to determine whether physician-related factors influenced patient participation in colorectal cancer (CRC) screening programs and to identify patient characteristics associated with lower participation in order to facilitate the development of targeted actions to improve participation.

METHOD

A retrospective cohort study was conducted in a French department during its first CRC screening campaign from June 2007 to May 2010. Data for 157,766 patients followed by 903 general practitioners (GPs) were analyzed. Patient participation was assessed using multilevel logistic modeling.

RESULTS

The overall participation rate was 30% (95% confidence interval [95% CI], 29.8-30.2) and varied across the 903 GPs from 0% to 75.5% (median, 30; interquartile range, 24-35). Inter-GP variance explained only 5.5% of the participation rate variance. Participation was significantly lower in males (odds ratio [OR], 0.79; 95% CI, 0.78-0.91), the youngest age group (55-59 years, OR, 0.61; 95% CI, 0.58-0.63), and patients living in socioeconomically deprived areas (OR, 0.82; 95% CI, 0.77-0.87).

CONCLUSION

Targeted actions to improve CRC screening participation should focus on patients younger than 60 years, males, and individuals living in deprived areas. Actions to enhance the influence of GPs on patient participation should be directed to the overall population of GPs.

Delphi approach to select rare diseases for a European representative survey. The BURQOL-RD study

OBJECTIVES

The BURQOL-RD project is intended to develop a disease based model capable of quantifying the socio-economic burden and health-related quality of life for patients with rare diseases (RDs) and their caregivers in Europe. We described the methodology used to select a set of 10 RDs to be approached in a pilot study.

METHODS

BURQOL-RD project includes 23 partners from 8 European countries: Spain, UK, France, Germany, Sweden, Italy, Hungary and Bulgaria. A two-round Delphi panels in combination with Carroll diagram was used to generate consensus in the selection of the 10 RDs among the project participants.

RESULTS

The two Delphi rounds yielded a prioritised list, to which the Carroll diagram was applied, taking into account three determinants: prevalence, availability of effective treatment and need for carer. The final set of RD to be studied was obtained: cystic fibrosis, Prader-Willi syndrome, haemophilia, duchenne muscular dystrophy, epidermolysis bullosa, fragile X syndrome, scleroderma, mucopolysaccharidosis, juvenile idiopathic arthritis and histiocytosis.

CONCLUSIONS

This methodology permitted the generation of an equilibrated set of RDs for the pilot study of BURQOL-RD project. The model will be suitable for application in a wide range of RDs.

Public and nonprofit funding for research on mental disorders in France, the United Kingdom, and the United States

OBJECTIVE

To document the investments made in research on mental disorders by both government and nonprofit nongovernmental organizations in France, the United Kingdom, and the United States.

DATA SOURCES

An exhaustive survey was conducted of primary sources of public and nonprofit organization funding for mental health research for the year 2007 in France and the United Kingdom and for fiscal year 2007-2008 in the United States, augmented with an examination of relevant Web sites and publications. In France, all universities and research institutions were identified using the Public Finance Act. In the United Kingdom, we scrutinized Web sites and hand searched annual reports and grant lists for the public sector and nonprofit charitable medical research awarding bodies. In the United States, we included the following sources: the National Institutes of Health, other administrative entities within the Department of Health and Human Services (eg, Centers for Disease Control and Prevention), the Department of Education, the Department of Veterans Affairs, the Department of Defense, and the National Science Foundation and, for nonprofit funding, The Foundation Center.

DATA EXTRACTION

We included research on all mental disorders and substance-related disorders using the same keywords. We excluded research on mental retardation and dementia and on the promotion of mental well-being. We used the same algorithm in each country to obtain data for only mental health funding in situations in which funding had a broader scope.

RESULTS

France spent $27.6 million (2%) of its health research budget on mental disorders, the United Kingdom spent $172.6 million (7%), and the United States spent $5.2 billion (16%). Nongovernmental funding ranged from 1% of total funding for mental health research in France and the United States to 14% in the United Kingdom.

CONCLUSIONS

Funding for research on mental disorders accounts for low proportions of research budgets compared with funding levels for research on other major health problems, whereas the expected return on investment is potentially high.

Registry of transcatheter aortic-valve implantation in high-risk patients

BACKGROUND

Transcatheter aortic-valve implantation (TAVI) is an emerging intervention for the treatment of high-risk patients with severe aortic stenosis and coexisting illnesses. We report the results of a prospective multicenter study of the French national transcatheter aortic-valve implantation registry, FRANCE 2.

METHODS

All TAVIs performed in France, as listed in the FRANCE 2 registry, were prospectively included in the study. The primary end point was death from any cause.

RESULTS

A total of 3195 patients were enrolled between January 2010 and October 2011 at 34 centers. The mean (±SD) age was 82.7±7.2 years; 49% of the patients were women. All patients were highly symptomatic and were at high surgical risk for aortic-valve replacement. Edwards SAPIEN and Medtronic CoreValve devices were implanted in 66.9% and 33.1% of patients, respectively. Approaches were either transarterial (transfemoral, 74.6%; subclavian, 5.8%; and other, 1.8%) or transapical (17.8%). The procedural success rate was 96.9%. Rates of death at 30 days and 1 year were 9.7% and 24.0%, respectively. At 1 year, the incidence of stroke was 4.1%, and the incidence of periprosthetic aortic regurgitation was 64.5%. In a multivariate model, a higher logistic risk score on the European System for Cardiac Operative Risk Evaluation (EuroSCORE), New York Heart Association functional class III or IV symptoms, the use of a transapical TAVI approach, and a higher amount of periprosthetic regurgitation were significantly associated with reduced survival.

CONCLUSIONS

This prospective registry study reflected real-life TAVI experience in high-risk elderly patients with aortic stenosis, in whom TAVI appeared to be a reasonable option. (Funded by Edwards Lifesciences and Medtronic.).

Colorectal cancer in France

Colorectal cancer (CRC) presents a substantial health burden in France, as the third cause of new cancer cases after breast and prostate cancers and the second cancer mortality cause representing nearly 12% of cancer deaths and almost 10% of annual life year loss due to cancer. Its prognosis has dramatically improved since the 1970s due to earlier diagnosis and an increase in the number of cases eligible for surgery. The first cancer plan implemented for the period 2003-2006 led to further improvements via, amongst others, implementing a national cancer institute (INCA), developing research, improving the quality of care and facilitating access to innovative treatments. The second cancer plan (2009-2013) aims to expand the scope of the existing cancer plan including improving primary and secondary prevention. Indeed, CRC national screening was recently implemented across France, however, the rate of the target population actually screened remains low while earlier detection of CRC at early stages should lead to an increase in France's CRC survival rates.

France: Health system review

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The French health care system is a mix of public and private providers and insurers. Public insurance, financed by both employees and employer contributions and earmarked taxes, is compulsory and covers almost the whole population, while private insurance is of a complementary type and voluntary. Providers of outpatient care are largely private. Hospital beds are predominantly public or private non-profit-making. The French population enjoys good health and a high level of choice of providers. It is relatively satisfied with the health care system. However, as in many other countries, the rising cost of health care is of concern with regards to the objectives of the health care system. Many measures were or are being implemented in order to contain costs and increase efficiency. These include, for example, developing pay-for-performance for both hospitals and self-employed providers and increasing quality of professional practice; refining patient pathways; raising additional revenue for statutory health insurance (SHI); and increasing the role of voluntary health insurance (VHI). Meanwhile, socioeconomic disparities and geographic inequality in the density of health care professionals remain considerable challenges to providing a good level of equity in access to health care. Organizational changes at the regional level are important in attempting to tackle both equity and efficiency-related challenges. While the organizational structure of the system remained very stable until the mid 1990s, in the following decade many changes occurred and several new institutions were created. Concurrently, the respective power and involvement of the parliament, government, local authorities and SHI in the policy-making process have evolved. However, the Ministry of Health has retained substantial control over the health system, although ongoing reforms at both the regional and the national levels may challenge its traditional role. This edition of the French HiT was written concurrently with the vote and implementation of the 2009 Hospital, Patients, Health and Territories Act, which dramatically changed again the organizational structure and management of the health care system at the regional and local level. In order to ensure a comprehensive description and understanding of the system, the HiT, therefore, describes both the previous organization and the reorganization following the Act. However, the implementation process of the Act and its formal application was still a work in progress at the time of completing the French HiT.

[Outcome evaluation of education in asthmatic children: the Robert-Debré hospital's experience]

INTRODUCTION

Asthma, the most frequent chronic disease in childhood, is often treated by a continuous preventive treatment associated to the treatment of attacks. This therapeutic scheme fits well with educative skills. The Robert Debré's asthma school has been created in December 1999. Two nurses specialized in child asthma education are working in the school, helped by the pediatric pulmonologists. Children 6-year-old or more, that are treated in the hospital for asthma may be sent to the asthma school for education. They receive individual or collective education for cognitive, psycho-affective and sensory-motor targets related to asthma.

AIM OF THE STUDY

To evaluate the outcome of educative action in childhood asthma and to study hospitalizations costs.

METHODS

SUBJECTS

children who received education for the first time in the year 2000 or 2001 and in whom exhaustive computerized data were available were eligible for the study.

METHODS

retrospective and comparative study one-year-before/one-year-after the first educational intervention, assessed by comparison of the numbers of scheduled medical consultations and hospitalizations (and their cost).

RESULTS

Sixty-six children were studied. We registered a significant increase of scheduled medical consultations (177 vs. 223; P < 0.03), and a very significant decrease of hospitalizations for asthma attacks (32 vs. 11; P < 0.001) without influence of the number of educational interventions and with a 52% decrease in costs (84,788 vs. 40,073 euros; P < 0.03).

CONCLUSION

Asthmatic children education is a useful tool to improve medical follow-up and to decrease hospitalizations number. In a two-year survey, the decrease of cost in a group of 66 children is 44,715 euros.