[Inequalities to the access of renal transplantation for French patients living in the overseas French territories]

This study explored the access to the French national renal transplantation waiting list and the waiting time before transplantation for the patients with ESRD on dialysis living in the FOT. Overseas health authorities gave data on ESRD incidence and prevalence. Data on patients registered between 1997 and 2000 were extracted from the French national waiting list (390 patients from the FOT and 9378 from continental France). Registered prevalence of ESRD in FOT (726 to 1418 per million population (pmp)) were higher than continental France (580 pmp). The yearly incidence of registration on the national French waiting list was 36 pmp. The same figure was observed in the FAT (French Guyana and Caribbean's islands: 36.8 to 43 pmp), very low in New Caledonia and Tahiti (7.7 and 18.1 pmp), and very high in the Reunion Island, where a renal transplantation unit is available (77.5 pmp). Median waiting times before transplantation varied significantly, FAT: 35.4 months, Reunion Island: 9.9 months, Pacific Territories: 8.8 months and the Metropolitan territory: 12.2 months. After adjustment on risk factors known to be associated with the waiting times before transplantation, we still observed a longer waiting time for patients from FAT (RR = 1,4, p < 0.05) and a lower waiting time for patients from Reunion Island (RR = 0.6, p < 0.001) compared to waiting time observed in patients from continental France. Consequently, transplantation teams in FAT must be developed.

[Geographic variations in access to heart transplantation in France]

This study was undertaken to determine whether there were regional variations in the access to the national waiting list for cardiac transplantation and in access to cardiac transplantation itself in France. The incidence of inscription on the waiting list for transplantation was calculated for new candidates living in each region between 1998 and 2000, indicating the level of access to the waiting list. The average interval before transplantation between 1995 and 2000 was calculated by the Kaplan-Meier method. The regional lack of transplant organs was estimated by the ratio of the difference between patients inscribed on the waiting list and those operated, over the number of patients operated. The overall national incidence of inscription of the waiting list for cardiac transplantation was 8 new patients per year per million inhabitants with a range of 1.7 in Corsica to 12.1 in Lorraine. The regional incidence was lower than the national reference in 5 regions in higher in 4 regions. There was a strong attraction of patients to the Ile-de-France, Pays de la Loire and Rhone-Alpes regions. The average waiting time for transplantation in France was 3.7 months and ranged from 1.2 months in Brittany to 15.4 months in Aquitaine (p < 0.001). The degree of regional lack of transplant organs was significantly and positively correlated with the average waiting time for transplantation. The results of this study show that there are regional differences in the incidence of inscription on the waiting list for cardiac transplantation in France and a significant variation in waiting times for cardiac transplantation, and therefore, in access to cardiac transplantation.

[Trends and estimates of regional differences of cornea donation and transplantation in France (1991-1998)]

PURPOSE

To evaluate national trends of corneal procurement and transplantation, and to estimate regional disparities between the rates of transplantation and patients registered on local waiting lists.

METHODS

A questionnaire was sent, every year since 1994, to all the heads of ophthalmology departments in public and private hospitals.

RESULTS

After a dramatic decrease in 1992, donations and transplantations then increased to reach 4549 and 4053 in 1998. This increase was mainly observed for cornea retrieval from non heart beating donors in public hospitals. Since 1997, the number of imported corneas has increased, 1016 corneas were imported in 1998 (25% of the corneas transplanted). The estimate of the number of patients registered on local waiting lists decreased to 7400 at the end of 1998. Regional agreement, using the ratio of the number of patients registered on waiting list at the end of 1998 and the number of cornea harvested in 1998 was low for several French regions: Aquitaine, Champagne-Ardenne, Nord-Pas-de-Calais, Picardie, Ile-de-France, Rhône-Alpes, Antilles.

CONCLUSION

Careful thought and regional efforts pointed at non-heart beating donors should be applied to increase the level of corneal harvesting, and to reduce waiting lists in France to levels similar to those in other European countries. Recent issue of legal authorization of cornea banking and creation in october 1999 of a national waiting list should facilitate these efforts.

[Evaluation of the results of organ transplantation in France: is there a center effect?]

The evaluation of the results of organ allografts for each type of organ and for each center is one of the prioritary missions of the Etablissement français des Greffes (EfG). The objectives, the methodology and the results of this evaluation have been defined and discussed with all the organ transplantation teams, after a preliminary work of the Conseil Médical et Scientifique of the Etablissement. This paper describes the evaluation experiment conducted by the EfG between 1995 and 1998. The main objectives of this first phase of the evaluation project are the identification of centers with outside of the norm results and the study of the relationship between the number of transplants performed by each center and the quality of their results. The chosen quality indicators are the excess in the patients mortality rate, computed one year after the first transplantation, for vital organs, and in the one year kidney graft loss rate for kidney transplantation. The excess of mortality is defined as the difference between observed and expected mortality rates. The expected mortality rate is estimated, for each program, by a statistical model based on a set of patient specific risk factors. All the vital organ transplantation teams who have performed more than 10 transplants between 1991 and 1995, and all the kidney transplantation teams who have performed more than 15 transplants between 1991 and 1996 have been included in the study. The main results of this evaluation experiment are the following ones: even if the intercenter variability of the results was statistically significant, it remained of low magnitude, particularly for heart, liver and kidney transplantation. None of the evaluated centers presented results outside of the norm. The results were positively correlated to the number of transplants for liver and lung transplantation. This was not the case for heart and kidney transplantation; this relationship is difficult to analyze for heart-lung transplantation, due to the small number of centers included. Thanks to the data base constituted since 1959 by all the organ transplantation teams, and in spite of the partially retrospective nature of this study, which explains its limits, this evaluation experiment, opens a perspective of extension to other domains of public health. In the future, however, this kind of evaluation should be prospective; a project aimed to developing the evaluation of the results of organ transplant actions in real time was defined and is currently on-going.

[Screening of patients at risk for hepatitis C virus infection in general medicine]

OBJECTIVES

The French consensus conference recommended targeted screening for hepatitis C virus infection in patients with a past history of intravenous drug use or transfusion of blood products before 1991. The aim of this study was to determine the feasibility and results of targeted screening by general practitioners.

METHODS

For 2 weeks, 58 general practitioners systematically asked all their patients about a past (or current) history of intravenous drug use or transfusion of blood products before 1991. In patients who responded affirmatively, hepatitis C virus screening was proposed if it had not been performed previously.

RESULTS

8,292 patients were included. Blood transfusion and intravenous drug use were present in 383 (4.6%) and 116 (1.4%) patients respectively. Positive hepatitis C virus serology had been identified before the study, in 16 and 63 patients in these groups respectively. Tests were performed in 77% and 50% of patients with a history of blood transfusion and intravenous drug use. Systematic screening showed a positive hepatitis C virus serology in 7 and 4 patients with a history of blood transfusion and intravenous drug use (representing 2% and 15% of the tests performed during the study). Globally, 79 (88%) of the 90 patients with a positive serology had been identified before this systematic screening.

CONCLUSIONS

Systematic targeted screening of hepatitis C virus infection only results in a diagnosis in a few cases. In the patients who consulted a general practitioner, 70% and 94% of cases of hepatitis C in patients with a history of blood transfusion or intravenous drug use respectively, were known before systematic screening.