Respiratory syncytial virus-related hospital stays in adults in France from 2012 to 2021: A national hospital database study

BACKGROUND

Respiratory syncytial virus (RSV) causes lower respiratory tract infections (LRTI) that may lead to hospitalization or death. The present study aimed to assess the burden of RSV infections in hospitalized adults.

METHODS

RSV-related hospitalizations were identified from the nationwide hospital claims database in France (PMSI) from 2012 to 2021 using ICD-10 codes J12.1, J20.5, J21.0 or B97.4, and outcomes assessment focused on 2016-2020. In-hospital outcomes included length of stay, need for intensive care (ICU) and in-hospital all-cause mortality. Post-discharge outcomes included 30-day readmission for decompensation, 90-day RSV-related readmission, and 30 and 60-day in-hospital mortality.

RESULTS

A cumulated number of 17 483 RSV-related stays were identified representing a rate of 72.0 cases per million stays. The outcomes assessment included 12,987 patients: 55.8 % were females and the mean age was 74.1 ± 16.4 years, with 57 % ≥ 75 years. Most of patients (78.6 %) had at least one comorbidity, mainly chronic respiratory (56.3 %) and cardiovascular diseases (41.3 %), or diabetes (23.5 %). A co-infection was found in 22.4 %, primarily bacterial (12 %). The mean length of stay was 12.3 ± 13.1 days. Overall, 10.9 % were admitted to an ICU and in-hospital mortality was 7.3 %. In-hospital outcomes were higher in cases of co-infection. Among 12 033 patients alive at discharge from the index stay, 6.5 % were readmitted with RSV within 90 days, 8.1 % for decompensation within 30 days, and 5.6 % died within 60-day.

CONCLUSION

This study demonstrated the high burden of RSV infections in older adults and those with chronic conditions, and the need for preventive strategies.

Coûts des hospitalisations et des soins de suite et de réadaptation liés au COVID-19 en France en 2020

Introduction

A l'origine d'une pandémie depuis 2020, la maladie liée au coronavirus SARS-CoV-2 (COVID-19) représente une surcharge importante pour les systèmes de santé. La surveillance nationale a dénombré un total de 261 123 cas d'infection ayant nécessité une hospitalisation en 2020 et 64 078 décès. Cette étude a pour objectif d'estimer la charge économique des hospitalisations, des soins de suite et de réadaptation (SSR) et des hospitalisations à domicile (HAD) liée au COVID-19 en France en 2020.

Matériels et méthodes

Une cohorte rétrospective incluant tous les patients hospitalisés avec un code diagnostic (CIM-10 ; principal, secondaire ou associé) relatif au COVID-19 entre le 1er janvier et le 31 décembre 2020 a été conduite à partir des données du PMSI (Programme de médicalisation des systèmes d'information : MCO, SSR et HAD). Les patients ont été divisés en 3 groupes selon les définitions de Santé Publique France : cas confirmés (virus identifié et symptômes typiques : code U07.10 ou U07.14), probables (symptômes cliniques U07.11) et possibles (autres symptômes U07.15). L'évaluation et la valorisation des coûts directs ont été effectuées selon la tarification à l'activité et les suppléments applicables de l'assurance maladie.

Résultats

Les données du PMSI ont permis d'identifier 271 728 séjours pour 210 635 patients hospitalisés avec un lien avec le COVID-19 dont 185 111 cas confirmés, 23 416 probables et 2 108 possibles. Les résultats suivants correspondent aux cas confirmés. La majorité des patients (85 %, N = 157 758) ont été pris en charge initialement par un séjour en MCO, 10 % (N = 18 375) en SSR et 5 % (N = 8 978) en HAD. La durée moyenne de séjour était de 17,8 ± 22 jours au total, 12,7 ± 13 jours en MCO, 26,4 ± 26 jours en SSR et 15,5 ± 19 jours en HAD. Parmi les séjours, 23 % ont impliqués les soins critiques (réanimation, unité de soins intensifs et/ou surveillance continue). La moitié des cas était des hommes, dont 56 % hospitalisés en MCO (N = 88 310), 39 % en SSR (N = 7 189) et 31 % en HAD (N = 2801). Au moins une comorbidité était enregistrée chez 79 % des patients (N = 146 457) : hypertension (54 %), diabète (27 %), troubles cardiovasculaires (24 %), insuffisance cardiaque (19 %), obésité (22 %), insuffisance rénale (16 %) et cancer (18 %).

Le coût total des hospitalisations et des SSR liés aux cas confirmés de COVID-19 est estimé à 1,672 milliards € représentant une moyenne de 7 044 €/séjour. Pour les passages en soins critiques, on estime à 339 millions € pour le passage en réanimation, 21,5 millions € en soins intensifs et 28,3 millions € en surveillance continue (respectivement 12 761 €, 2 356 € et 2 248 € en moyenne par séjour). Enfin, 11,5 millions € étaient attribuables à des traitements et/ou dispositifs inscrits sur la liste en sus.

Conclusion

Ces données quantifient le coût de la prise en charge hospitalière du COVID-19 en France en 2020, notamment à travers la durée de séjour et le recours aux soins intensifs pour un quart des patients. Cette surcharge économique devrait être réduite avec la mise en place de la couverture vaccinale en 2021.

Liens d'intérêts déclarés

Pr Sébastien Gallien : membre du comité scientifique de cette étude, qui est financée par Janssen-cilag France

Cost-effectiveness of dolutegravir/abacavir/lamivudine in HIV-1 treatment-Naive (TN) patients in France

BACKGROUND

To evaluate the cost-effectiveness of an integrase inhibitor (INI), dolutegravir (DTG), in combination with abacavir (ABC)/lamivudine (3TC) in France, in treatment-naive (TN) HIV adult patients.

METHODS

The ARAMIS microsimulation Markov model, evaluates costs and effects of DTG vs. first-line ARVs options including INIs (raltegravir, elvitegravir/c), protease inhibitors (PIs) (darunavir/r, atazanavir/r, lopinavir/r), non-nucleoside reverse transcriptase inhibitors (efavirenz and rilpivirine). Efficacy and safety data were derived from phase III studies and network meta-analysis. Treatment algorithms were based on French guidelines and experts opinion. Costs included routine HIV and opportunistic infection care, and death.

RESULTS

The model showed the fixed-dose combination DTG/ABC/3TC was more effective than all other recommended regimens: patients stayed longer on first-line, and lived longer and healthier. With the exception of EFV, DTG/ABC/3TC was more efficacious and less costly compared to all strategies. The cost per QALY gained (ICER) for DTG compared to EFV was €6,939. DTG/ABC/3TC was more efficacious and less costly compared to INIs and PIs in all deterministic sensitivity analyses.

CONCLUSION

DTG/ABC/3TC was cost-effective in the management of HIV TN patients in France. These results are mainly explained by its lower price compared to other INIs and PIs, DTG's superior efficacy and high barrier to resistance.

The use of Zostavax in Spain: the economic case for vaccination of individuals aged 50 years and older

Background Population aging brings up a number of health issues, one of which is an increased incidence of herpes zoster (HZ) and its complication, post-herpetic neuralgia (PHN). Zostavax vaccine has recently become available to prevent HZ and PHN. This study evaluates the cost-effectiveness of vaccination against HZ in Spain considering a vaccination of the population aged 50 years and older and comparing this to the current situation where no vaccination is being administered. Methods An existing, validated, and published economic model was adapted to Spain using relevant local input parameters and costs from 2013. Results Vaccinating 30% of the Spanish population aged 50 years and older resulted in €16,577/QALY gained, €2025/HZ case avoided, and €5594/PHN case avoided under the third-party payer perspective. From a societal perspective, the ICERs increased by 6%, due to the higher price of the vaccine. The number needed to vaccinate to prevent one case was 20 for HZ, and 63 for PHN3. Sensitivity analyses showed that the model was most sensitive to the HZ and PHN epidemiological data, the health state utilities values, and vaccine price used. Conclusion Considering an acceptable range of cost-effectiveness of €30,000-€50,000 per QALY gained, vaccination of the 50+ population in Spain against HZ with a new vaccine, Zostavax, is cost-effective and makes good use of the valuable healthcare budget.

Hemodynamic and biochemical monitoring during major liver resection with use of hepatic vascular exclusion

Twenty-four resections under hepatic vascular exclusion (HVE) have been performed in patients with massive liver tumors. The procedure of HVE was used to minimize blood loss and the chance of gas embolism; it included clamping of the portal triad and occlusion of the inferior vena cava above and below the liver. In 12 of these patients the HVE was associated with clamping of the abdominal aorta above the celiac axis (AoC). During the "anhepatic" phase, which lasted 24 to 65 minutes (mean 39 minutes), neither venous shunt nor refrigeration was used. When HVE was associated with AoC, the circulation to the lower part of the body was completely excluded so that the systemic circulation was reduced to a small upper compartment in which the mean arterial pressure increased by 33% while the cardiac index decreased by 40%. The diastolic pulmonary arterial pressure remained unchanged. When HVE was not associated with AoC, the body was divided into an upper vascular compartment with normal venous resistance and a lower vascular compartment with increased resistance to the venous return and increased blood volume. The cardiac index, which was distributed to these two compartments, decreased by 40% to 50% but the mean arterial pressure decreased by only 14%. The good hemodynamic tolerance to HVE without AoC that was observed in these patients confirms the efficiency of collateral venous channels in the circumstances reported. AoC appears to be unnecessary in most patients if accurate fluid volume loading has been achieved before HVE. The study of acid-base balance demonstrates the ability of the human body to correct spontaneously the acidosis that follows the release of the clamps, provided a stable hemodynamic state is maintained. Only minor disorders of coagulation, without abnormal bleeding, were observed, and no prophylactic treatment was necessary. There were no deaths during operation, but a 25% postoperative mortality rate was observed mainly related to the underlying disease and the status of the remnant liver parenchyma. Despite its apparent sophistication, HVE is a simple and safe procedure for performing otherwise hazardous liver resections for tumors of large size or that are located close to the inferior vena cava and the suprahepatic veins. Its hemodynamic and metabolic consequences appear to be moderate.

[Acid-base equilibrium and vascular exclusion of the liver: study of 30 extensive hepatectomies]

The acid-base disorders after hepatic vascular exclusion (HVE) were studied in 30 major liver resections. HVE included portal triad clamping and occlusion of the inferior vena cava below and above the liver, without venous shunt nor cooling. Clamping of the supra-coeliac abdominal aorta (AoC) was associated with HVE in 12 patients. HVE lasted 18 to 65 min (mean 37 min). Liver ischemia and splanchnic blood pooling resulted in metabolic acidosis and hyperlactatemia. In order to prevent his acidosis, prophylactic administration of NaHCO23 was used during the first 19 cases. This induced significant metabolic alkalosis during HVE and the early postoperative period; increasing experience made us reduce the amount of NaHCO3. After the release of the clamps, Paco2 increased 25% following HVE without AoC (p less than 0.001) and 53% following HVE with AoC (p less than 0.001). In an attempt to distinguish between the effects of the metabolic acidosis and the rise of Paco2 in the fall of pH which occurred after removal of the clamps, NAaHCO3 was deliberately not given in the last 11 patients. Acidosis appeared to be greater with AoC than without and mainly related to the rise of Paco2. A fall of Paco2 to its initial value was always followed by the return of pH to the normal range. This study demonstrated the human ability to correct spontaneously the acidosis which followed HVE. The need for NaHCO3 after HVE reflected a poor hemodynamic state after major liver resection rather than a metabolic consequence of hepatic ischaemia.

[Pseudo-tumoral haematoma of the iliac fossa in haemophiliacs (author's transl)]

Pseudo-tumoral blood collections in haemophiliacs are uncommon but must be borne in mind because of their severity and of the need for timely and appropriate treatment. Surgical excision appears to be required as soon as the tendency towards enlargement is recognized and before the volume and complications of the tumour increase the difficulties, particularly in the iliac fossa. Other treatments, especially puncture-aspiration, seem to be ineffective and/or dangerous. A better knowledge of the pathogenic processes involved might lead to new therapeutic approaches.

[Effects of postoperative decurarization with neostigmine on digestive anastomoses]

A prospective study was undertaken to assess the influence of neostigmine, a reversal agent for curarimimetic myorelaxants, on the incidence of postoperative disruption of anastomotic sites. Over a period of one year, 400 patients had surgery, including anastomosis, on the digestive tract for a variety of surgical conditions (Table II). At the end of anaesthesia, 200 patients received doses of atropine and neostigmine, usually 1 mg and 2.5 mg of each, as indicated on clinical basis and neuromuscular stimulation. The other patients did not recieve these drugs and were ventilated till the myorelaxation vanished spontaneously. During the postoperative period of incidence of anastomotic breakdown was assessed by the surgeon, unaware of the use or the omission of neostigmine in his patients. Anastomotic leakage was classified in four groups, namely: proved, absent, likely and unlikely. In this series and according to these clinical criteria, both groups had an incidence of anastomotic breakdown which was not significantly different (Table III). Neostigmine as used in this work does not seem to compromise the normal healing of anastomotic sites on the digestive tract.

[Place of anti-inflammatory agents in the prevention of deep phlebitis]

The inflammatory reaction includes, after an initial tissue lesion, a catabolic phase with proteolysis, an exudative reaction phase, and finally an anabolic phase with the formation of an inflammatory granuloma. The reaction should be considered, however, as an initial inflammation, rapid and limited to the affected tissues, and a secondary inflammation induced at a distance by a humoral mechanism with the appearance of pathological globulins. Only certain anti-inflammatory agents act at these two levels : steroids and non-steroids. Corticosteroids can be used effectively in small doses. Courses of salicylates are difficult to manage and are not standardized. Fenamates and indometacine lead to psychiatric disorders. The only useful drugs are phenylbutazone and hydroxyphenylbutazone. These two drugs can be used alone, or in combination, or eventually being superseded by anti-coagulants. As they are derived from pyrazolidine, they are above all preventive. Their absorption in the digestive tract is rapid and almost complete ; the maximum plasma concentration occurs 2-4 h. after injection. Delayed accidents occur 7-15 days after the last dose. Suppotanderil and suppophenylbutazone are used at the dose of 250ml, 2 or 3 times a day. They may be combined with AVK depending on the clinical signs and the prothrombin and Howell's time. These drugs are contraindicated in patients with ulcers, with haematological diseases, and with severe cirrhosis. They should always be replaced straight away by anti-coagulants in patients with valve prostheses or with severe rhythm disorders.