[Misconstructions about health economics applied to prenatal screening].
Explore the source record for details and available documents.
Cost-Benefit Analysis↗
Biomedical subjects
I Durand-Zaleski
Publications and source records attributed to I Durand-Zaleski.
[Role of referral and practical evaluation in medical decisions].
Explore the source record for details and available documents.
Decision Making↗
[Economic burden of COPD: the SCOPE study].
INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a major health problem. Few data about COPD economic burden are available. METHODS: SCOPE was an observational economical retrospective and prospective study conducted in France in 2001, by 114 general practitioners (GPs) and 57 lung specialists. The aim was to describe the burden of COPD patients and to estimate the annual cost according to severity stages. Health resource utilization was collected by questionnaires over a 12-month period for 285 patients. RESULTS: It was a cost-of-illness analysis. COPD patients followed by a lung specialist were more severe than patients followed by a GP and had a higher level of medical resource consumption. The COPD disease and its complications explained 66% of the total cost. The main cost drivers were inpatient care (35%, or 1509,9 euros/year/patient) and prescription medications (31%, or 1340,6 euros/year/patient). The direct total cost varied according to COPD severity on account of inpatient care and respiratory assistance. DISCUSSION: This study confirmed the economic burden of COPD in France. Actions allowed to slow down the disease's evolution and to anticipate the exacerbation could reduce the cost.
Aged↗
Do minitransplants have minicosts? A cost comparison between myeloablative and nonmyeloablative allogeneic stem cell transplant in patients with acute myeloid leukemia.
Allogeneic hematopoietic stem cell transplantation (SCT) is a widely used, cost-intensive procedure. Although pretransplant nonmyeloablative (NMA) or reduced-intensity conditioning regimens appear very promising, prospective studies comparing this approach with the conventional myeloablative (MA) approach in specific hematologic diseases are necessary, especially in patients in whom the conventional approach is not contraindicated. Cost may be an important factor in the decision-making process. We compared the costs of MA and NMA transplants in patients with acute myeloid leukemia (AML). We estimated 1-year resource utilization in 12 consecutive MA patients (median age: 39 years) and in 11 consecutive NMA patients (median age: 58 years) who underwent HLA-identical sibling SCT for AML. Resources care expenses were valued using the average daily rate for personnel costs, supplies, and room costs. Other data were directly collected from the patients' charts. Despite a trend for lower costs in NMA patients during the first 6 months, costs during the 6-12-month period were significantly higher after NMA due to late complications and readmissions (P=0.03). Finally, mean 1-year costs were not different in MA and NMA patients (P=0.75). Prospective studies comparing conventional and NMA approaches in homogeneous populations should include economic items.
Adult↗
[An organizational and economic approach in France to the ambulatory treatment of febrile neutropenia].
A NEW OBJECTIVE: Keeping neutropenic patients with fever in their homes helps to preserve their quality of life and reduces the costs. However, it is important to specify the conditions and the means necessary for the organisation so that home treatment can be applied safely because of the high risk of morbidity due to infection. THE FUNDAMENTAL CONDITIONS FOR ITS MANAGEMENT: The patients who could potentially benefit from an outpatient treatment strategy when presenting with neutropenia and fever must not have a tumour progressing and must not exhibit signs of co-morbidity and be affected by neutropenia and fever at home. Moreover, full information and the patient's and relatives' consent, a hospital nearby, the permanent presence of someone with the patient, the possibility of a telephone contact, the patient's full compliance, prior consent and excellent communication and excellent patient-physician relationship are all essential conditions. THE PARTICIPANTS AT HOME: The patient is essentially followed-up by the treating physician. Private nurses can intervene at the patient's home. Hospitalisation at home is presently the only alternative medical structure to classical hospitalisation. The development of nursing networks ensure the continuity between the hospital and the town and the good coordination of the health workers caring for the patient. The steps to be taken during an episode of fever are debated: complete discharge from hospital for some, initial outpatient controls in the hospital for several hours for others and the initial hospitalisation for 24 to 72 hours for some others. Whatever the case, haemocultures must be performed before the initiation of any antibiotherapy. SURVEILLANCE: The optimal clinical surveillance is ensured daily by a private nurse and the treating physician. An assessment every 2 to 3 days in a hospital unit is recommended. CARE NETWORKS: Their development should increase and hence create the continuity between the hospital and the town. The outpatient management of neutropenia with fever is a major source of economy; it allows the patients to be kept at home whilst ensuring the quality and security of their treatment.
Administration, Oral↗
[Medical practice analysis in internal medicine: a national descriptive study].
PURPOSE: This descriptive and epidemiological study was conducted in Mars 2002 in Internal Medicine in order to (1) participate in elaborating a White Book about the speciality, (2) analyse the post-university formation needs of the specialists in Internal Medicine. METHODS: A questionnaire was sent to all specialists in Internal Medicine listed on the ADELI file (n = 2155). For the first three patients seen in consultation and during hospital stay, questioned specialists had to mention the age, sex, origin, motive of the visit, nature of symptoms, complexity of the problem and the nature of the required abilities. They also had to precise the main diagnosis of all patients seen in the same day. RESULTS: Three hundred and sixty answers have been received. Three hundred and thirty two were exploitable. Five thousand six hundred and eleven main diagnosis were listed. Fifteen percent of the questioned specialists did practise in other specialities than Internal Medicine. Orphaned diseases were the most common pathologies carried out in consultation (17%). Patients seen during their hospital stay suffered more frequently from infectious, haematological and malignant diseases. In 55% of the cases, patients were seen in second or third line after a visit to a general practitioner or another specialist. The abilities of the Internal Medicine specialist alone were sufficient in 70% of the cases to solve the problem. Complexity of the problem was evaluated by the specialists themselves at about 45/100 on an analogical scale. CONCLUSIONS: This study inform the medical community about the type of patients treated by the specialists in Internal Medicine, precise the exact nature of their professional exercise and their real need in medical post-university formation.
France↗
Improving glycaemic control of patients with Type 2 diabetes in a primary care setting: a French application of the Staged Diabetes Management programme.
AIMS: To assess the impact of a French adaptation of the Staged Diabetes Management (SDM) programme on glycaemic control of people with Type 2 diabetes in primary care. Secondary endpoints were blood pressure, blood lipids, healthcare costs and quality of life. METHODS: Prospective, randomized controlled study, of 1 years' duration. General practitioners (GPs) were recruited in four separate districts of a French region. They enrolled consecutive patients with Type 2 diabetes. GPs in the intervention group were educated in the SDM programme. GPs in the control group were asked to provide usual care. Healthcare costs were collected by medical departments of the Health Insurance systems. Quality of life was assessed with the Duke Health Profile. RESULTS: Three hundred and forty patients enrolled by 57 GPs completed the study, 192 in the intervention group and 148 in the control group. Patients in the intervention group were managed more adequately in accordance with the guidelines (P < 0.05 for nine out of 10 items). HbA(1c) decreased by 0.31% in the intervention group and increased by 0.56% in the control group, resulting in a difference of 0.87% by the end of the study (P = 0.001). Blood pressure and blood lipids did not differ between groups. Occurrence of major complications was low and identical in both groups. Incremental costs during the study in the intervention group were 35 euros per patient per month, and this was not significantly different in comparison with the control group. Quality of life was not affected by the intervention. CONCLUSIONS: Educating GPs in the French adaptation of the SDM programme improves glycaemic control in a primary care setting, without significantly increasing healthcare costs.
Blood Glucose↗
Reducing the number of T3 orders in the Paris hospital network: towards better appropriatness of thyroid function test prescription.
In vitro thyroid function tests are among the most frequently prescribed laboratory procedures. Serum triiodothyronine (T3) tests are seldom necessary as a first-level measurement. Our objectives were to measure the proportion of T3 measurements relative to all in vitro thyroid function tests in a large hospital network and to investigate the contributions of various interventions to change prescribers'behavior. We performed two cross-sectional surveys in 1995 and 1998 in the 50 Paris University hospitals. Questionnaires were mailed to the heads of the 30 laboratories performing thyroid function tests. One-month orders of free and total thyroxine, free and total T3 and thyrotropin were recorded; changes in T3 measurement orders between the two periods were estimated and association with interventions were expressed as odds ratios and 95% confidence intervals. Twenty-five heads of laboratory responded to both surveys. In 1995, T3 measurements constituted 21% of in vitro thyroid function test ordering, which seems to us exceedingly high. The decrease in T3 measurement ordering observed in 1998 (15% of thyroid function test ordering) was independently associated with multiple behavioral changes: educational interventions, structured test form use and year of prescription.
Humans↗
A clinical approach to the management of a patient with suspected renovascular disease who presents with leg ischemia.
Atherosclerotic renal artery stenosis (ARAS) may cause hypertension, progressive renal failure, and recurrent pulmonary edema. It typically occurs in high risk patients with coexistent vascular disease elsewhere. Most patients with ARAS are likely to die from coronary heart disease or stroke before end-stage renal failure occurs. Recent controlled trials have shown that most patients undergoing angioplasty to treat renovascular hypertension still need antihypertensive agents 6 or 12 months after the procedure. Nevertheless, the number of antihypertensive agents required to control blood pressure adequately is lower following angioplasty than for medication alone. Trials assessing the value of revascularization for preserving renal function or preventing clinical events are only in the early recruitment phase. Revascularization should be undertaken in patients with ARAS and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or with an increase in plasma creatinine levels during angiotensin-converting enzyme inhibition. With or without revascularization, medical therapy using antihypertensive, hypolipidemic and antiplatelet agents is necessary in almost all cases.
Humans↗
A tale of two countries: costs and financial incentives for provisional stenting during percutaneous coronary intervention in France and the United States.
Provisional stenting is associated with longer physician time but the use of fewer stents. This randomized controlled trial in tertiary care in French hospitals compared strategies of systematic and provisional stenting. We estimated the costs and financial incentives associated with each strategy, based on individual data on 12-month resource use drawn from a 251-patient database. Resources were evaluated using French costs; data on costs in the United States were drawn from the literature and interviews with hospital administrators in one center. In France 1-year costs were 8,267+/-528 dollars for provisional stenting and 7,973+/-553 dollars for systematic stenting, compared to 18,715 dollars and 18,632 dollars in the United States. Given the uncertainty of longterm results, the choice between stenting strategies might be guided by financial incentives. In the United States financial incentives favor systematic stenting, while in France public hospitals and physicians are neutral.
Clinical Trial↗
Down's syndrome screening with nuchal translucency at 12(+0)-14(+0) weeks and maternal serum markers at 14(+1)-17(+0) weeks: a prospective study.
BACKGROUND: Sonographic and biochemical methods for Down's syndrome screening have developed simultaneously, but independently. As a consequence, the rate of invasive procedures for fetal karyotyping has dramatically increased and become an important public health issue which needs to be controlled. One approach is to combine sonographic and biochemical results into a single risk assessment. METHODS: In a multicentre interventional study, nuchal translucency (NT) was measured between 12(+0) and 14(+0) weeks of gestation. Maternal serum markers (MSM) were measured between 14(+1) and 17(+0) weeks of gestation. Karyotyping was advised when: (i) NT was > or =3 mm; or (ii) the MSM-related risk was > or =1 in 250 at term. Karyotyping was delayed until after a maternal blood sample had been taken. NT and MSM were expressed as multiples of the medians (MoMs), and risks were calculated and tailored to the study population. A combined risk for NT and MSM was estimated retrospectively. Costs per case diagnosed, and the cost per case averted were calculated for the three screening strategies. RESULTS: A total of 9444 women was screened. Twenty-one fetuses (0.22%) had Down's syndrome, whilst 326 women (3.4%) were lost to follow-up. Among 9118 women followed up, 5506 had both NT and MSM, 821 had only NT, and 2791 had only MSM. Median maternal age was 30.5 years. False-positive rates for NT, MSM and NT combined with MSM were 3.0, 5.8 and 0.23% respectively. The false-positive rate generated by a sequential two-stage screening was 8.6%. Detection rates of Down's syndrome were 62 and 55% for NT and MSM respectively. Seven cases with Down's syndrome (35%) had raised NT and MSM, and 17 (81%) had either raised NT, MSM, or both. For a 5% false-positive rate, detection rates were 55 and 80% for NT alone and for combined NT and MSM respectively. Ultrasound alone appears to be more cost-effective ( pound50 per case diagnosed) than both tests ( pound61 per case diagnosed). CONCLUSIONS: The study results suggest a 25% increase in the detection rate of Down's syndrome using a combination of NT measurement at 12(+0)-14(+0) weeks and MSM at 14(+1)-17(+0) weeks for a 5% false-positive rate, with modest increase in cost.
Biomarkers↗
Including polymerase chain reaction in screening for hepatitis C virus RNA in blood donations is not cost-effective.
BACKGROUND AND OBJECTIVES: To assess the cost and effectiveness of adding a system of polymerase chain reaction (PCR) testing to the current enzyme-linked immunosorbent assay (ELISA) screening for hepatitis C virus (HCV) in blood donations. MATERIALS AND METHODS: We performed a cost-effectiveness analysis comparing three HCV screening strategies in French blood donors: detection of antibodies against HCV by an ELISA on blood donations (the current policy) vs. ELISA and PCR either on each blood donation or on blood pools. We combined national surveillance data on HCV antibody-positive blood donors with a literature review in a Markov model for natural history of HCV disease and its treatment. RESULTS: PCR testing performed in parallel with ELISA will potentially add less than 1 year of life for all French recipients compared to ELISA screening alone. The incremental costs per life year saved were, respectively, epsilon84.6 million with ELISA and PCR testing of blood pools, and epsilon891.1 million with testing of individual blood donations. CONCLUSION: PCR testing performed in parallel with antibody screening, either on pools or on single donations is not currently a cost-effective option for the detection of HCV RNA virus in blood donors.
Blood Donors↗
SOR Project: the French context.
Explore the source record for details and available documents.
France↗
Induction of labour with a viable infant: a randomised clinical trial comparing intravaginal misoprostol and intravaginal dinoprostone.
OBJECTIVE: To compare the efficacy and safety of vaginal misoprostol (50 microg) with vaginal dinoprostone. DESIGN: Double-blind randomised trial. SETTING: Obstetrics Department, Poissy Hospital, France. PARTICIPANTS: 370 patients with medical indications for induction of labour. OUTCOME MEASURES: Vaginal deliveries within 24 hours, as well as time to vaginal deliveries, caesarean rates, costs, and fetal, neonatal and maternal condition. RESULTS: Compared with vaginal dinoprostone, vaginal misoprostol resulted in greater efficacy in several areas: vaginal delivery within 24 hours; time to vaginal delivery; and vaginal delivery within 12 hours. There was a non-significant increase in the caesarean section rate for fetal distress in the misoprostol group, but fewer caesarean sections for failed induction. Fetal tolerance was similar in the two groups, although significantly more neonates had a cord pH <7.20 and (non-significantly) none had meconium stained amniotic fluid in the misoprostol group. The incidence of poor neonatal outcome was similar in both groups. Subgroup analysis by indication for induction showed that the higher rates of arterial cord pH <7.20 and of meconium-stained amniotic fluid with misoprostol persisted only in possible fetal compromise. Poor neonatal outcome was less frequent in the misoprostol group in cases of induction for non-fetal indications. CONCLUSIONS: Vaginal misoprostol resulted in successful and earlier induction of labour more often than dinoprostone, but the safety of misoprostol raises some concern in potentially compromised infants. Misoprostol should be preferred to dinoprostone in cases of induction for non-fetal indications.
Administration, Intravaginal↗
Economic evaluation of drug resistance genotyping for the adaptation of treatment in HIV-infected patients in the VIRADAPT study.
BACKGROUND: Costs of antiretroviral therapy for HIV-infected patients have increased at a time when most countries are attempting to contain health care costs. Part of this increase results from HIV drug resistance associated with virologic failure and a subsequent shift to more complex and costly therapies. Genotypic guided treatment is associated with better virologic outcome. However, it is not yet known whether it will be cost effective. METHODS: We present here an economic evaluation based on the results from the VIRADAPT study, a prospective, open-label, randomized trial comparing patients assigned to standard of care (n = 43), versus genotypic guided treatment (n = 64) for 6 months. Total follow-up for the extended trial was 1 year. Costs were computed from the viewpoint of the health care system. Hospitalization data were retrieved from the VIRADAPT study case report forms, costs were estimated from the cost of the corresponding diagnosis-related groups derived from the French national cost data base: these were actual costs and not charges. Data on the volume of tests prescribed, drugs, and clinic visits were retrieved from the VIRADAPT study database. The unit costs of tests and clinic visits were determined using the French national Social Security reimbursement price; costing of drugs used were based upon purchase price by either retail pharmacies or hospitals. Genotyping using TruGene HIV-1 assay was estimated at $500 per test from manufacturer's data (all figures in this paper are expressed in U.S. dollars). RESULTS: Total mean (standard deviation) yearly costs per patients were $20,412 (+/-$10, 129) in the standard of care group and $18,484 (+/-$9,652) in the genotyping group (p =.35). Drug costs represented 55% of total costs. There was a trend toward a decrease in drug costs in the genotyping arm (p =.07), the greatest reduction being in the decreased use of protease inhibitors in the genotyping arm. The additional expense of genotyping appeared to be offset by the savings obtained in drug costs. CONCLUSION: In our study, the cost of drug resistance testing is offset by a reduced use of protease inhibitors and their attendant costs. Although not reaching statistical significance, this trend in the reduction of drug costs and drug use presents a great interest for future trials.
Adult↗
[Evaluation of diagnostic or screening procedures. Validity of tests, sensitivity, specificity, predictive values. Definition and indications for mass screening].
Explore the source record for details and available documents.
Algorithms↗
[Prevention of venous thromboembolism in a non-surgical medical ward. Proposed indications for low molecular weight heparin].
OBJECTIVE: The efficiency of venous thromboembolism prophylaxis with low molecular weight heparins (LMWH) has not been established in non surgical patients, so their official preventive use has been limited in France since 1995 to surgery. However, a survey conducted in 5 university hospitals in non surgical patients showed that 21-29% of patients still received a LMWH prescription. It seemed necessary to define the medical conditions for which the practical use of these heparins would be justified. We contacted external experts to obtain a consensus by using the Delphi method. METHODS: The Delphi method, created by the "Rand Corporation" in the USA and used in medicine since the nineteen seventies, is based on a light logistic, with questionnaires been sent by mail with a feed-back report A total of 48 experts were chosen by local staff teams in the 5 hospitals. For the 3 rounds, from March to October 1998, questions were devised by a multicentred staff team. RESULTS: Among the 48 experts contacted, 32 completed the 3 questionnaires, 7 of them did for 2, and 43 did for at least one questionnaire. The experts first defined a list of 12 risk or high risk situations and 11 aggravating factors. For any high risk situation, prescription is justified. For other cases, 2 risk situations are required, or one risk situation with at least 2 aggravating factors, to justify a prescription. If no risk situation is present, prescription is, according to experts, usually not justified. CONCLUSION: The maximal agreement defines the situations in which one use of low molecular weight heparins is proposed to prevent deep venous thrombosis in non surgical inpatients, in most current hospital situations and for more than 24 hours of hospitalization. Clinical trials are needed, to validate their effectiveness and define the optimal dose in these indications. To date, epidemiological studies should be conducted to evaluate the experts proposals by estimating risk factors for deep venous thrombosis.
Double-Blind Method↗