Résumé
French balneotherapy is highly dependent on public regulations and finance. State and public bodies have a major say on cares delivered, in both nature and number, on required qualifications of therapists, on a fixed 3-week’s duration, on hygiene and safety. At the same time, public financing of cares is by far more important than the contribution of complementary private health insurances and out-of-pocket payments by the patient. Some 10 years ago, the National Health Insurance Fund openly stated that hypothesized health benefits of spa therapy were no longer good enough to keep the subsidizing of thermal treatments. Clinical research with flawless methodology had to be organized to prove thermalism has a true medical interest. Years later the challenge has been met and fewer opponents question any longer the virtues of hydrotherapy. The actual medical benefit of spa treatments is now well established in such fields as generalized anxiety disorders, knee osteoarthritis, obesity and overweight, post-breast cancer rehabilitation, healthy ageing, ... This financial effort of more than 10 million euros proved to be fruitful as the National Health Insurance Fund recently renewed the subsidyzing of thermal treatments. However, in the wake of spiralling health costs putting a strain on public spending, a new requirement is set on spa center operators. Nowadays, they also have to prove that balneotherapy is cost-efficient in comparison with other therapies. The yet to be proved economic relevance of spa therapy as well as new expectations are set to bring about a dramatic shake-up by which alongside the traditional treatment of chronic diseases, spa companies will have to address new fields of competences, such as prevention, rehabilitation, quitting of addictions, postponing of age-associated loss of autonomy, etc.
Résumé
In France, several public and or private scientific investigation bodies are involved in medical balneological scientific investigation (academic or university-linked institutes in Paris, Nancy, Bordeaux, Grenoble, Clermont-Ferrand; private structures in Paris, Aix les Bains, Saujon). However, these last 10 years, the important development in medical balneology investigation could be related to the French Association for Balneotherapy Research (AFRETH). The Afreth has been created in 2004 by the French Union of SPA Contractors, the Union of the mayors of spa resorts and the French branch of the FEMTEC. The AFRETH provides every year a budget of 1 M€ for scientific investigation in balneology. The founders’ representatives, who constitute the association’s administrative committee, take the decision of supporting financially the scientifically validated projects. The scientific validity is pronounced by the scientific committee (12 independent and acknowledged doctors and scientists) on the basis of external independent experts’ advices (methodological, clinical and biological sciences from French academic institutions). 10 calls for projects have been launched and fully implemented. They concerned mainly the actual medical benefit (cf. Table below). A global budget of 11 M€ has been engaged. Regarding the medical benefit have been implemented and published: STOP-TAG (treatment of generalised anxiety, 237 patients); Thermarthrose (knee osteo-arthritis, 462 patients); Maathermes (obesity and overweight, 257 patients); Pacthe (treated breast cancer patients, 250 patients) Thermes & veines (chronic venous insufficiency, 425 patients). These different randomised controlled trials have demonstrated significant results in favour of balneotherapy. Publication is in progress for Rotatherm (a RCT concerning shoulder cuff tendinitis, 186 patients). Are in progress a RCT on COPD (BPCeaux), a RCT on subacute lumbar pain (ITILO). Pilot investigations have been implemented concerning the metabolic syndrome, Alzheimer’s disease and other ageing problems, psychotropic drugs withdrawal, therapeutic education of patients with chronic venous insufficiency. So scientific investigation has to come with usual balneotherapy but also with the development of new trends which have to be scientifically assessed from their initiation. From our experience, we have to emphasize the difficulties related to the patients’ enrolment and the need of new methodological designs, alternative to usual RCT to investigate such a complex therapeutic intervention.