Biomedical subjects

Jean-Paul Moatti

Publications and source records attributed to Jean-Paul Moatti.

11 recordsLinked to original sources

PubMed2003

Health-related quality of life after 1 year of highly active antiretroviral therapy.

OBJECTIVE: We investigated the impact of the first year of highly active antiretroviral therapy (HAART) on health-related quality of life (HRQL). METHODS: Medical data for patients in the French APROCO cohort were collected at enrollment (M0) and month 12 (M12). A self-administered questionnaire gathered information about HRQL (Medical Outcome Study 36-Item Short Form Health Survey) and toxicity-related symptoms. Using the twenty-fifth percentile of HRQL scales in the French population as a threshold, patients with normal values in at least three mental and three physical scales were considered to have a "normal HRQL." RESULTS. Of the 1053 patients followed through M12, HRQL data at M0 and M12 were available for 654. Among the 233 patients with a normal baseline HRQL, 63 (27.0%) experienced a deterioration of HRQL at M12. Among the 421 patients with a low baseline HRQL, 121 achieved a normal HRQL at M12. Logistic regression showed that factors independently associated with a normal HRQL at M12 were normal baseline HRQL, baseline CD4 count <500 cells/mm, time since HIV diagnosis <8 years, undetectable HIV-RNA at M12, and lower number of self-reported symptoms at M12. CONCLUSION: An assessment of HRQL should be integrated to efficacy outcomes to evaluate and compare long-term strategies properly and to optimize the durability of response to antiretroviral therapy.

Adult↗

PubMed2003

Eliciting several willingness to pay in a single contingent valuation survey: application to health care.

The usual implementation of contingent valuation (CV), in the context of priorities setting for allocation of public funds in health care, is to develop as many surveys as there are programmes, i.e. to perform separate evaluations (SE). In the EuroWill project, three health programmes (for heart disease, breast cancer and a service of helicopter ambulance) were however simultaneously evaluated, i.e. a joint evaluation (JE) was performed. The paper examines the issue of the econometric techniques that should be used to estimate WTP values obtained in the context of JE by comparing the application of independent OLS regressions for each programme versus simultaneous estimations using seemingly unrelated regressions (SUR) on data of the French EuroWill survey. It shows that separate estimations may lead to misspecifications because they cannot take into account that JE exogenously provides a reference structure to the respondent which affects the estimates of WTP for each programme. Therefore, the potential advantage of JE versus SE as an elicitation technique in CV studies applied to health care (to better control the referents used by respondents for evaluating different programmes) only holds if simultaneous rather than independent techniques are used in the estimation of WTPs.

Air Ambulances↗

PubMed2003

Impact of gene patents on the cost-effective delivery of care: the case of BRCA1 genetic testing.

BACKGROUND: In 1994/95, two genes, BRCA1/2, associated with a predisposition to breast or ovarian cancer were identified. Genetic testing of deleterious BRCA1/2 mutations consequently can be proposed to individuals with a family history of breast or ovarian cancer to identify who is at risk. The granting of U.S. patents on BRCA1/2 to a privately owned company has led to the monopoly use of a unique technique (Direct Sequencing of the gene, DS) for BRCA1/2 testing in this country. Alternative strategies using prescreening techniques, however, have been experienced worldwide. METHODS: On the basis of data collected at three laboratories of French public hospitals, we carried out a cost-effectiveness study comparing DS to 19 alternative strategies with the number of deleterious BRCA1 mutations detected as the outcome. RESULTS: Results show that the DS strategy presents the highest average cost per mutation detected (9,882.5 Euro) and that there exist strategies using prescreening techniques that can reach similar effectiveness while reducing total costs. Moreover, other strategies can obtain a four- to sevenfold reduction in the average cost per mutation detected as soon as some rates of false negatives (2% to 13%) are deemed to be acceptable. CONCLUSIONS: Results suggest that gene patents with a very broad scope, covering all potential medical applications, may prevent health care systems from identifying and adopting the most efficient genetic testing strategies due to the monopoly granted for the exploitation of the gene. Policy implications for regulatory authorities, in the current context of the extension of BRCA1/2 patents in other countries, are discussed.

Breast Neoplasms↗

PubMed2003

Can sequential administration minimise the cost of high dose chemotherapy? An economic assessment in inflammatory breast cancer.

OBJECTIVE: To evaluate the potential cost savings of using sequential high dose chemotherapy (HDC), with granulocyte colony-stimulating factor (filgrastim) and stem cell support, rather than single course administration of HDC with bone marrow transplantation (BMT) or peripheral blood stem cell transplantation (PBSCT). PERSPECTIVE: French public hospital perspective. METHODS: Direct medical costs of sequential treatment, estimated on the basis of physical quantities of resources consumed by 95 patients with inflammatory breast cancer (IBC) included in a French pilot multicentric trial (PEGASE 02), were compared with those of historical control groups of patients treated with single course HDC, either with BMT (n = 27) or PBSCT (n = 14). Costs were evaluated in 1998 French francs (1 Euro = 6.55957 French francs). RESULTS: The total cost of sequential HDC was significantly lower than that for single course HDC both with BMT (-29%; 22,755 Euros vs 32,284 Euros; p < 0.001) or PBSCT (-16%; 22,755 Euros vs 27,209 Euros; p = 0.026). This was mainly due to a reduction in the length of hospitalisation in transplantation units. CONCLUSION: According to our results, economic arguments cannot be used against the widespread use of sequential HDC for patients with IBC. However, further economic evaluations based on overall and disease-free survivals alongside a randomised clinical trial are still needed to definitively establish the cost effectiveness of sequential administration of HDC.

Adolescent↗

PubMed2002

Nonadherence among HIV-infected injecting drug users: the impact of social instability.

The authors tested the impact of social instability on adherence to highly active antiretroviral therapy (HAART) among patients infected with HIV through injection drug use (IDU; MANIF2000 cohort). In the study, they analyzed sociodemographic baseline characteristics to develop an indicator of social instability. Information concerning adherence to HAART was collected through questionnaires during a 2-year follow-up period. Factors associated with nonadherence were studied in two different groups: 1) patients who had stopped injection drug use (ex-IDUs) and who were not in drug maintenance programs (DMT) during the entire follow-up period, and 2) those who were still opiate dependent. Among the 210 eligible patients, 114 were classified as ex-IDUs and 96 as opiate dependent. Ex-IDUs reported nonadherence behaviors in 96 of 384 visits (25.0%), while opiate-dependent patients were nonadherent in 111 of 308 visits (36.0%; p = .02). Among ex-IDUs, the only factor associated with nonadherence was social instability, while among opiate-dependent patients, injection behavior was the only determinant of nonadherence behavior. For opiate-dependent patients, DMT may enhance adherence to HAART, but only if it is successful in reducing abuse of injection practices. For ex-IDUs, it is very important that the management of social difficulties be taken into account to increase adherence to HAART.

Adult↗

PubMed2002

[The appropriateness of the indications and diagnostic efficiency of colonoscopy. Results of a survey conducted in all the hospital centers of the Provence-Alpes-Côte d'Azur area].

OBJECTIVE: To evaluate the appropriateness of indications and the diagnostic efficiency of colonoscopy taking into account available guidelines. METHODS: This was a retrospective study conducted by the Union Régionale des Caisses d'Assurance Maladie de Provence-Alpes-Côte d'Azur (URCAM-Paca) aimed at assessing the appropriateness of the indications and diagnostic efficiency of colonoscopy. Anonymous data concerning near totality of the colonoscopies carried out during one week in all the establishments (public and private) of the area, were collected by consulting the medical records. RESULTS: The indications for colonoscopy were first analyzed with regard to the guidelines for good clinical practices (références médicales opposables and consensus conference) according to two scales of reading (literal interpretation and broad interpretation). We noted that the available guidelines do not cover the totality of the colonoscopies performed, that their formulation does not make them all controllable, and that the colonoscopies, which respect them, range from 27.5% (strict reading) to 74.1% (broad reading). When taking into account not only the quality of the preparation, but also the result of the examination after re-classification into benign, pathological or normal examinations, the differences in efficiency appear only when one retains the broad interpretation of the reference guidelines. The efficiency analysis makes it possible to highlight a defect of predictability of the recommendations with regard to the pathologies considered as serious. It also appears that approximately 10% of the colonoscopies are, at the same time, out of the reference and have a normal result, and thus can be considered as absolutely not justified. CONCLUSION: Better compliance of the practitioners to colonoscopy recommendations would initially be generated by improvement in the predictability and the legibility of the current reference guidelines.

Colonoscopy↗

PubMed2002

Predictors of virological rebound in HIV-1-infected patients initiating a protease inhibitor-containing regimen.

OBJECTIVE: To study the predictors of virological rebound in patients having early virological response to protease inhibitor (PI)-containing regimen. DESIGN AND METHODS: APROCO cohort study prospectively enrolled 1283 HIV-infected patients starting a PI-containing regimen in 1997-1999. Adherence to therapy was measured with self-administered questionnaires after 4 months of therapy (M4). Virological rebound was defined as a viral load (VL) > 500 copies/ml in patients having early virological response, defined as a VL < 500 copies/ml at M4. Predictors of time to virological rebound were studied with multivariate proportional hazards model. RESULTS: During a median follow-up of 20 months, virological rebound was observed in 32% of the 830 patients with early virological response. Virological rebound was more frequent when patients had received previous antiretroviral treatment [adjusted hazards ratio (HR) = 2.4; P < 0.0001], were younger (HR = 1.4 per each 10 years younger; P < 0.0001), had baseline CD4 cell count < 500 x 106/l (HR = 2.3; P < 0.001), had higher baseline VL (HR = 1.4 per each log10 copies/ml higher; P < 0.001), reported low adherence to therapy at M4 (HR = 2.1; P < 0.001) or had stopped PI at M4 (HR = 1.7; P = 0.04). CONCLUSION: Initiation of treatment at a stage of preserved immunity is associated with a more durable virological response under protease inhibitor. Every effort should be made to monitor and strengthen adherence to therapy, even in patients having early virological response.

Adult↗

PubMed2002

Adherence to highly active antiretroviral therapies (HAART) in HIV-infected patients: from a predictive to a dynamic approach.

To-date, most socio-behavioural research about HTV-infected patients' adherence to highly active antiretroviral therapies (HAART) has been based on cross-sectional studies. The French APROCO cohort gave us the opportunity to conjointly analyse the relationships between short-term adherence to HAART and HIV-infected patients' characteristics before initiation of treatment on the one hand, factors related to patients' subjective experience with HAART on the other hand. At the fourth-month follow-up visit (M4) after first prescription of HAART (M0), 26.7% of our sample of 445 patients self-reported non-adherence behaviour. Some patients' characteristics at M0 (younger age, poor housing conditions, lack of social support, and problems of adherence with previous antiretroviral regimens) were related to non-adherence at M4 in multivariate analysis. Non-adherence at M4 was, however, also related to the evolutions that affected a number of factors between M0 and M4: levels of depression, symptoms associated with treatment side effects, perception of individual state of health, beliefs towards effectiveness and toxicity of HAART. increases in alcohol and tobacco consumption, as well as contacts with other physicians than hospital HAART prescribers. Our prospective study brings additional evidence that even short-term non-adherence cannot be reliably predicted on the sole basis of a few a priori patient characteristics that clinicians could easily identify before initiation of HAART. It suggests that a dynamic approach to adherence, continuously monitoring the impact of experience with HAART on patients' daily lives, is needed for improving management of HIV/AIDS care.

Adult↗

PubMed2002

Testing for BRCA1 mutations: a cost-effectiveness analysis.

Breast carcinoma is the most common type of cancer affecting women in the Western world. The hereditary forms, which amount from 5 to 10% of all the cases of breast cancer, mainly involve BRCA1 or BRCA2 mutations. Due to the diagnostic strategy used by the patent owner, Direct DNA sequencing (DS) may become the only BRCA1/2 test procedure available, although there exist several alternative strategies. A cost-effectiveness study was carried out using BRCA1 testing as a model. The main techniques available for performing mutation searches were assessed: DS, denaturing high performance liquid chromatography (DHPLC), single-strand conformation polymorphism (SSCP), denaturing gradient gel electrophoresis (DGGE), heteroduplex analysis (HA), fluorescent assisted mismatch analysis (FAMA) and the protein truncation test (PTT). Twenty strategies involving the use of one or more techniques were then devised for performing the complete genetic analysis. DS was adopted as the 'gold standard' for effectiveness. All the strategies except for DS involved a two-step procedure. The first step consisted of pre-screening the 22 coding exons of BRCA1. The second step consisted of performing DS only on the variations detected in the coding sequence. The cost of the strategies tested, including a pre-screening stage, turned out to be 30 to 90% lower than that of DS, whatever annual use was made of the equipment. The most cost-effective strategy, ie, that corresponding to the lowest cost per mutation detected, was found to be a combination between PTT on exon 11 (60% of the coding sequence) and HA on the remaining 21 exons (PTT(11)+ HA(21)). However, since a high false negative rate is associated with this strategy, at least four other strategies are worth mentioning: PTT(11)+ DHPLC(21), DHPLC alone, FAMA(11)+ DHPLC(21) and FAMA alone. Our results on genetic testing for breast cancer show that DS is not the most cost-effective method available. The monopolist approach of the firm which owns the patents on the BRCA1/2 genes, may, therefore limit the use of the most cost-effective strategies.

Cost-Benefit Analysis↗

PubMed2002

[Factors related to screening of hepatitis C virus in general medicine].

UNLABELLED: Despite the high prevalence of hepatitis C in France ( approximately 1.2%), a large proportion of people infected with hepatitis C virus (HCV) are not known aware of their status. The objective of this study was to investigate the factors related to screening in general medicine. MATERIAL AND METHODS: Three hundred and one general practitioners were interviewed by phone in South-Eastern France about their HCV screening practices, knowledge of the epidemic, of the natural course of the disease, and opinions about health care for people infected with HCV. RESULTS: While general practitioners often offered HCV screening to intravenous drug users, screening for people who had received blood transfusion, and identification of risk factors among patients were not satisfactory. Multivariate analysis showed that certain characteristics in general practitioners were negatively and independently related to the frequency of HCV screening, especially: general practitioners older than 40 (odds-ratio: 3.12), general practitioners who did not care for intravenous drug users (odds-ratio: 2.24) and did not prescribe human immunodeficiency virus tests (odds-ratio: 5.55). Other characteristics such as awareness of the course of hepatitis C and health care were also associated with HCV screening. Conversely knowledge of the size of the epidemic was not related to better HCV screening practices. CONCLUSION: Our study shows that knowledge about the size of the epidemic and the natural history of hepatitis C, HCV screening practices and investigation of risk factors among patients are not satisfactory among South-eastern French general practitioners. Although HCV screening and health care must be improved among intravenous drug users, hepatitis C should not be considered as a disease of injecting drug users only by general practitioners and the population. Efforts should be made so that hepatitis C is recognized as a global public health issue, and training of general practitioners should be improved to investigate risk factors and offer HCV screening instead of merely dramatizing the situation.

Adult↗

PubMedDate not supplied

Efficacy of an educational and counseling intervention on adherence to highly active antiretroviral therapy: French prospective controlled study.

PURPOSE: The objective was to evaluate the impact of an intervention for improving adherence to antiretroviral therapies (HAART) in HIV-infected patients. METHOD: We designed a prospective, controlled, randomized trial to assess the impact of an educational and counseling intervention in addition to standard of care. At M0, the study enrolled 244 HAART-treated patients who attended a medical consultation between September and December 1999 who were not included in another protocol. Patients in the intervention group (IG) were offered three individual sessions by trained nurses. The proportions of adherent patients at 6 months followup (M6) and the change in HIV RNA between M0 and M6 were measured. RESULTS: Between M0 and M6, HIV RNA significantly decreased in the 123 patients of the IG (mean difference = -0.22 log [+/-0.86], p =.013), while it increased (+0.12 log [+/-0.90], p =.14) in the 121 patients of the control group. However, the proportion of patients with HIV RNA <40 copies/mL remained similar in both groups. In an intent-to-treat analysis, the only significant predictor of 100% adherence at M6 was the intervention group (p =.05) after adjustment for baseline adherence (p =.001). Among the 202 patients with available data on adherence, the proportion of adherent patients was similar in both groups at M0 (58% vs. 63%, p =.59) but became higher in the IG at M6 (75% vs. 61%, p =.04). CONCLUSION: The educational and counseling intervention was efficient for increasing adherence to HAART and could be implemented in most clinical settings.

Adult↗