A Hexagonal Aim as a Driver of Change for Health Care and Health Insurance Systems.

Policy Points Improving health systems requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers - Quadruple Aim -. Reinforcing the recently defined Fifth Aim as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. Adding a Sixth Aim to take into account the increased health risks due to climate change. CONTEXT: Improving health systems, such as the U.S. or French, requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers, including clinicians and staff - Quadruple Aim -. While these aims are already ambitious, they may be insufficient when considering the economic, social and environmental challenges to the health of our communities in the near and long term. METHODS: A conceptual framework to provide additional ethical guardrails for health systems. RESULTS: Recently, authors have articulated a Fifth Aim and we propose to add a Sixth Aim to the Quadruple Aim model. These additional aims are meant to account for our growing knowledge around the determinants of health and the challenging processes and structures of governance across a wide range of sectors in society including healthcare. We are strengthening the Fifth Aim defined as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. The Sixth Aim is to account for the increase in risk to population health due to climate change as well as the impact our health systems have on the environment. CONCLUSIONS: As social tension and environmental changes seem to continue to impact the structure of our society this "Hexagonal Aim" taken together might provide additional ethical guiderails as we set our healthcare goals.

Représentations des acteurs de la mise en œuvre du projet régional de santé dans deux régions.

BACKGROUND: The Regional Health Project (RHP) is an important lever to build a health producing system. The RHP serves as the reference for health policies in the French regions. It is developed in three main stages, preparation, diagnosis and priorities. Different institutional actors are involved: managers, administrators, leaders for democracy and medico-social services as well as primary care professionals. How have all of these actors been involved in the three main stages of preparation of the RHP? AIM: The aim of this article is to analyze the implementation of the RHP in two French regions and how the actors in those regions perceived that implementation. METHOD: The analysis of the implementation of the RHP focused on the definition of the implementation process, the diagnosis and the identification of the problems. This later one included the development of the priorities and the objectives while taking into account the resources and the evaluation. This analysis was conducted in two medium-sized regions in France between 2011 and 2015. RESULTS: The formulation of the problems in the RHP is rather general. Priorities and objectives are poorly justified. Resources and evaluation are not taken into account. We attribute these weaknesses to the difficulty of crossing the administrative, managerial and democratic representations with care practices in the regions. CONCLUSIONS: A method and process that integrates the two public policy representations should be specified in a detailed document established prior to formally engaging the planning process. Therefore, the harmonization of methodology and terms is first needed as well as the development of training and research.

[Benefits of integrated care delivery system for heart failure: A case study of Intermountain Healthcare (USA)]. / Bénéfices de la prise en charge intégrée de l'insuffisance cardiaque : l'exemple d'Intermountain Healthcare (États-Unis).

BACKGROUND: Among chronic diseases, heart failure is a top public health priority both in France and in the United States. If progress is possible in France, the experience from Intermountain Healthcare (IH), in the United States can be a source of significant experimentations. AIM: To identify the teaching of the clinical integration of the specialists in the field of heart failure with the primary care sector which could be useful in France. METHODS: This research is based on the qualitative analysis of data resulting from the work between experts, of bibliographical research, and of some groupings by item corresponding to the objectives of the Triple Aim from the Institute for Healthcare Improvement (IHI). RESULTS: The program of the integrated care delivery system for heart failure of Intermountain Healthcare reaches the objectives of the Triple Aim from the IHI, that is to say, the enhancement of the health of the population, improving quality of care and the satisfaction of the user, and the reduction of the cost of care. This program also enhances the Chronic Care Model by integrating a team of specialists in the field of heart failure, building up a pluridisciplinary team focused on the need of both the patients and their families. This creates a multidisciplinary care delivery system for heart failure which is global, protocolized, stratified, planned and followed. The prevention and the ambulatory care integrating the specialized care of second stage to the care of first stage are developed. The users and their families are co-responsible for their health. The systematic evaluation is based on the specific indicators. DISCUSSION: This program improves the effectiveness of care while improving organizational efficiency resulting in savings for IH Health Plan (SelectHealth). It also enhances the equality of access to better healthcare and health for the entire population.

[Integrated care delivery system for mental illness: A case study of Intermountain Healthcare (USA)]. / Prise en charge intégrée des maladies mentales: l'exemple d'Intermountain Healthcare (USA).

BACKGROUND: Mental health is a public health priority among chronic diseases in France and the United States. Although there is room for progress in France, the experience of Intermountain Healthcare (IH), Utah, in the United States can provide convincing experimental data. AIM: To identify the lessons learned from IH clinical integration of mental health specialists in primary care practices called "Mental Health Integration" (MHI) which might be useful in France. METHODS: This research is based on qualitative analysis of data derived from collaborative work with IH experts, literature searches, and item queries on the 3 objectives of the Triple Aim of the Institute for Healthcare Improvement (IHI). RESULTS: The MHI programme was developed to achieve IHI T riple AIM: improving user satisfaction; improving access of care and the health of the population; reducing health care costs per capita. By integrating mental health specialists within a multidisciplinary team headed by primary care physicians and working under the same roof with care managers and support staff, the MHI model enhances the process of the Chronic Care Model. Furthermore MHI has become the foundation for team-based care centered on the patient and theirfamily over the continuum of care by offering a global and structured evidenced-based care process. Prevention and integration of specialized care have been developed. Users and their families are co-responsible for their health. Discussion: Evaluation is systematic and based on specific indicators. The efficiency and clinical and organizational effectiveness created generate savings for health insurance as well as improved access to care and health equality.

[Health priorities, regions, areas and citizens: the case of Franche-Comté]. / Priorités de santé, région, territoires de santé et citoyens : l'exemple Franc-Comtois.

How can users' associations promote direct citizen involvement in the debate over health priorities throughout a region and within local health areas? A survey was conducted by user representatives with the support of a group of researchers and academics, based on a questionnaire outlining 42 key priorities and a 43rd priority inviting an open response. The questionnaire was published between April 12 and April 18 2010 in 14 local and regional newspapers throughout Franche-Comté. In total, 962 responses were collected, though only 928 responses were included in the analysis as having originated from the Franche-Comté region. In decreasing order of importance, the five major priorities identified by respondents are: a decent home, a healthy diet, sufficient income, drinking water, and improved cancer prevention and control. Views from the different health areas within the region were found to reflect the views of the region as a whole, while emphasizing access to education. Health determinants were the most common priority emphasized by respondents, though a number of area-specific characteristics were also found. Public surveys may help regional health agencies and authorities to define or validate local and regional health priorities in addition to national priorities, with a view (in particular) to reducing health inequalities throughout the region and within the different health areas.

Predictive factors of advanced interventional procedures in a multicentre severe postpartum haemorrhage study.

PURPOSE: Severe postpartum haemorrhage (SPPH) is the leading cause of peripartum hysterectomy and maternal death. There are no easily measurable parameters that indicate the failure of medical therapy and the need for an advanced interventional procedure (AIP) to stop genital tract bleeding. The aim of the study was to define factors predictive of the need for an AIP in the management of emergent PPH. METHODS: The study included two phases: (1) an initial retrospective study of 257 consecutive patients with SPPH, allowing the determination of independent predictors of AIP, which were subsequently grouped in a predictive score, followed by (2) a multicentre study of 239 patients admitted during 2007, designed to validate the score. The main outcome measure was the need for an AIP, defined as uterine artery embolization, intraabdominal packing, arterial ligation or hysterectomy. RESULTS: Abnormalities of placental implantation, prothrombin time <50% (or an International Normalized Ratio >1.64), fibrinogen <2 g/l, troponin detectable, and heart rate >115 bpm were independently predictive of the need for an AIP. The SPPH score included each of the five predictive factors with a value of 0 or 1. The greater the SPPH score, the greater the percentage of patients needing an AIP (11% for SPPH 0, to 75% for SPPH ≥2). The AUC of the ROC curve of the SPPH score was 0.80. CONCLUSIONS: We identified five independent predictors of the need for an AIP in patients with SPPH and persistent bleeding. Using these predictors in a single score could be a reliable screening tool in patients at risk of persistent genital tract bleeding and needing an AIP.

[Representatives of consumer associations and the "hôpital, patients, santé et territoires" law: an outline of the issues and twelve proposals]. / Représentants d'associations d'usagers et Loi << Hôpital, patients, santé et territoires >> : enjeux et douze propositions.

Since 1996, consumers have been able to become involved in the development and implementation of national, regional and local healthcare policies, thereby demonstrating the possibility of establishing a model of democratic institution in healthcare at all levels of decision-making and policy implementation. Despite this 13-year political ambition, it is open to question whether the bill on the reform of the hospital will serve to extend the same dynamic for patients, healthcare institutions and local authorities. On 15 November 2008 and 18 April 2009, fifty-four consumer association representatives in the Franche-Comté region convened to conduct an audit of their commitments with a view to making proposals to adapt the bill aimed at reforming hospitals for the benefit of patients, healthcare and territories (HPST) before the bill is debated in Parliament (National Assembly and Senate). Despite significant investments since 1996 and some notable successes, for these representatives of consumer healthcare associations, the results are distinctly mixed. This is because they sometimes feel instrumentalized in healthcare facilities and believe that their opportunities for participation have declined since 2002. Their view is that this may diminish the power they wield at a time when the economy may be seen as becoming a substitute for public healthcare and participatory democracy. In a context of inequality in healthcare and at a time of economic crisis, this paradigm shift has tended to mobilize representatives of consumer associations. In their view, a strong counter-power is required to ensure fair and equal access to healthcare for all. They suggest twelve proposals concerning organization and professionalism at both territorial and national levels, articulated around the following principle : a representative of a consumers' association can become a regional reference in the management of the agency's regional healthcare system and may be given the means to coordinate the work of other representatives of consumer associations for each of the regional healthcare plans.

[Elderly people, precariousness, social handicap and length of stay: pilot study at the Lariboisière-Fernand Widal Hospital Group in Paris]. / Personnes âgées, précarité, handicap social et durée de séjour: étude pilote au groupe hospitalier Lariboisière-Fernand Widal de Paris.

OBJECTIVES: To administer a social handicap questionnaire associated with French DRGs (PMSI) to determine the social handicaps of a population hospitalized in a public health establishment and to measure the cost implications for the establishment due to increased length of stay (DMS). METHOD: A prospective pilot study has been carried out in the Lariboisière-Fernand Widal Hospital Group in Paris targeting users 50 or more years old hospitalized for short stays in medicine, surgery and obstetrics. Data of the PMSI and answers to the questionnaire for hospitalisations longer than 24 hours have been exploited. RESULTS: Two hundred twenty-two stays from 8 to 23 November 2005 have been analyzed: 140 pertained to patients aged 50-69 years (27.8%) and 82 to patients aged 70 or more years (16.3%). Three-fourths of the persons aged 50-69 and 70 or over presented a social handicap: 45% showed a strong handicap and a third an average handicap. The three indicators "renter/owner", "interior comfort" and "family relations" were the major determinants of social handicap for those aged 70 or more, 50-69 and 50 or more years. For the patients 70 years and over and those 50-69 years, with an average handicap, the indicator was "income" with the domain "patrimony." For strong handicaps, it was the indicator "scolarisation" for the 70 or more years and the indicator "income" for the 50-69 years old. When all classes and populations were pooled, the DMS was significantly lower than that of the ENC (p<0.001 for the 70 years and over; p<0.05 for the 50-69 years). With again all classes and populations pooled, patients 70 and over stayed in hospital 6.50 days less on average compared to data published by the ENC; those 50-69 years stayed 3.57 days less. Persons aged 50 and over with a social handicap remained hospitalized on average more than 2.5 days: 2.2 days for the 70 and over and 3.1 days for the 50-69 years group. In terms of hospital days that produces an increase of 18%, corresponding to a supplementary expenditure attributable to social handicap of approximately 5.9 million euros. CONCLUSION: This pilot study with a questionnaire disability social PMSI proposing specific aid, but also reducing the DMS, provides several promising information but also indicates the limits of our approach. Among these, we note in particular: (a) its regular feasibility requires constant supervision, wider and well-trained, (b) that the measurement of our tool can only be affirmed after its use in many patients, and (c) the classification of disability in social class could even be discussed again. We still wanted to explore whether through this initiative without much logistical, markers of interest had emerged, which seems to be the case.

[Health system reforms, economic constraints and ethical and legal values]. / Réformes du système de santé, contraintes économiques et valeurs éthiques, déontologiques et juridiques.

Health system and hospital reforms have led to important and on-going legislative, structural and organizational changes. Is there any logic at work within the health system and hospitals that could call into question the principle of solidarity, the secular values of ethics that govern the texts of law and ethics? In order to respond, we compared our experiences to a review of the professional and scientific literature from 1992 to 2010. Over the course of the past eighteen years, health system organization was subjected to variations and significant tensions. These variations are witnesses to a paradigm shift: although a step towards the regionalization of the health system integrating the choice of public health priorities, consultation and participatory democracy has been implemented, nevertheless the system was then re-oriented towards the trend of returning to centralization on the basis of uniting economics, technical modernization and contracting. This change of doctrine may undermine the social mission of hospitals and the principle of solidarity. Progress, the aging population and financial constraints would force policy-makers to steer the health system towards more centralized control. Hospitals, health professionals and users may feel torn within a system that tends to simplify and minimize what is becoming increasingly complex and global. Benchmarks on values, ethics and law for the hospitals, healthcare professionals and users are questioned. These are important elements to consider when the law on the reform of hospitals, patients, health care and territories and regional health agencies is implemented.

[Hospital governance: between crisis management and implementation of public health policy]. / Des pôtes d'activités hospitaliers entre gestion de la crise et mise en oeuvre d'une politique de santé publique.

The implementation of the recent act to amend the law on hospitals, patient health and territories (HPST Law) completes the reform of the organization and governance of health facilities, which was announced in 2002 by the "Hospital 2007" plan. What kind of assessments and perspectives can be considered and envisaged for these Hospital Activity Poles? We compared our experience with a review of the professional and scientific literature in order to stimulate answers to these questions for advocacy purposes prior to the Act's implementation. The hospital's cluster of activities should reinforce--not call into question the core activities and the financial stability of the facility, while respecting the contract on agreed objectives and the necessary means and resources to meet the health needs of the catchment population as well as national priorities. Although significant, but limited, successes exist, five obstacles to hospital reorganization can be identified. These include, for example: lack of delegation of management and centralization of decisions, the heterogeneity of numerous Hospital Activity Poles or problems related to timing. These obstacles may cause strain, or put the Hospital Activity Poles and the health facilities in a difficult situation with respect to their dynamics. This may show that the State and social health insurance should steer and direct public health policy and that the delegation of management roles and responsibilities to the Hospital Activity Poles should be addressed.

[Analysis of fourteen French national programmes on physical activity and sports as determinants of health from 2001 to 2006]. / Analyse de quatorze actions nationales pour le déterminant de santé activités physiques et sportives en France de 2001 à 2006.

Physical activity and sports are considered as one of the determinants of health. The aim of this study is to review the rationale for the formulation of this public health issue and its integration in national action plans. The study shows that fourteen national programmes were drafted and implemented between 2001 and 2006 by seven institutions. The research methodology was based on crossing data obtained from semi-directed interviews and documents regarding the design, implementation and follow-up of these programmes. For the conditions of the success, the fourteen actions scored an average of 175.0 +/- 66.9 out of 300%. Public health actors and professionals must be given more opportunities to involve themselves and engage in developing stronger relationships and linkages, in particular with the institutional and community settings. In general, the most invested parts of a programme are the structural and operational aspects of activities. Six significant points surfaced from the study: consideration of drug use as an addictive behaviour; recognition of the psychological stress of professional athletes; acknowledgment of youth as being at high risk for doping behaviour; integration of the concept that physical activity and sports must take the benefit/risk perspective into account; and the necessity to promote health. Through the exchange of numerous local and regional experiences, an optimisation of their synergistic connections was made possible on a continuum extending from "health promotion through physical activity and sports" to "prevention of drug-use and doping behaviours". Professionals have been able to develop actions in the above-mentioned domains across this continuum that have, to date, remained isolated. Proposals are made to strengthen these dynamics. Other health determinants and public health priorities could be investigated with the same methodology.

[Social disability and public hospitals: towards a model of resource allocation]. / Handicap social et hôpitaux publics : pour un modèle d'allocation de ressources dans le cadre d'une politique de santé publique.

A recent study to measure social disability used the results of a questionnaire administered to 696 patients between March 14th and April 7th 2007 which showed that three-quarters of the population surveyed have a social disability. Major determinants of social disadvantage are found using three specific indicators: income, assets and home-interior comfort. A greater deterioration of poor health status was not particularly noted within the most socially disadvantage group of patients, and social disability did not lead to actual over-consumption of medical products or services. People with social disabilities remained hospitalised more than 1.5 days over the average length of hospital stay which accounts for an inferred additional costs to hospital budgets equivalent to 10.3 million ?. The article proposes a model for measuring social disability that can be used routinely upon patient admission to identify socially disadvantaged cases in order to offer those patients specific and tailored assistance and reduce the length of their stay. This model may also support public health policy monitoring.

[Biological procedures, civil and military health facilities, and recommendations of good practice and hospital reform: the example of diabetes management]. / Actes de biologie, établissements de santé civils et militaires, recommandations de bonnes pratiques et réformes hospitalières: exemple de la prise en charge du diabète.

In the context of implementing hospital reforms, the objective of this work was to compare practice in relation to evidence-based guidelines and recommendations for good practice in diabetes screening and management. Laboratory test consumption was determined for patients hospitalized for diabetes in 2005 in three public hospitals (one civilian, two military) taking care of diabetic patients and performing related biological tests. For the 395 admissions in these three hospitals during 2005 [Diagnosis-related group (DRG) 10M02V "Diabetes, age 36 to 69 years without co-morbidity"], the average length of stay and the number of biological acts ["B"] performed were lower than those given by the French national health cost study scale and by the Montpellier University Hospital database. In terms of qualitative coherence between the guidelines for treatment and the recommendations, the total number of biological acts ["B"] is higher than if one were to strictly apply the good practice suggested by the French Health Authority. These three hospitals have and apply different guidelines for practice in the area of diabetes management. The implementation of reforms such as DRG-based payment scales may be an additional leverage to ensure that the recommendations of best practices are effective. Improved methods and tools for data collection and monitoring are essential, especially for estimating revenue and expenditure.

[What prevention programmes and which organizations are needed to support healthy ageing?]. / Quelles actions de prévention et quelles organisations pour un vieillissement réussi?

Physical activity and exercise are recognized as one of the determinants of health. This study aims to produce a review of the logical foundations at work that support the identification of a public health problem for this determinant and how to address it through national action. The research is based on cross-analysis of data from semi-directed interviews and data extracted from documents on the development, implementation and follow-up of such actions and programmes. The study shows that fourteen national programmes were created and implemented by seven different agencies. These fourteen activities scored an average of 175 +/- 66.9 out of 300%. Actors and professionals in the field must be given more capacity to be implicated and involved while simultaneously encouraging the strengthening of relationships with their environment, in particular the institutional and organizational settings as well as the community components. In general, the structural and operational aspects of action are those which receive the most investment in such activities. Six main points arose as important: doping considered as a addictive mechanism, acknowledgement of the psychological suffering of professional athletes, youth at high risk of doping, and that the concepts of physical activity and sports should take into account a risk/ benefit analysis and the necessity to first and foremost promote health. The act of sharing and exchanging a number of experiences, at the local and regional level, resulted in the identification of synergies between these experiences on a continuum from "health promotion through physical activity and sports" to "prevention of doping". Within this framework, professionals were able to develop activities in the aforementioned domains, which until now had remained isolated and marginal. Recommendations were made to reinforce and strengthen this dynamic. Other determinants of health and public health priorities could be explored using the same methodology.

[Equity and planning: a critical analysis of a third generation regional healthcare management program]. / Equité et planification: analyse critique d'un schéma régional d'organisation sanitaire de troisième génération "perinatalité".

The third generation of the regional healthcare organization plan (Sros III) proposes to develop the organisation of healthcare and its management according to evolution of its activities and the populations concerned. At the time of a strategic analysis of SROS III (what we refer to as its perinatal period), the question is whether promoters can move from an approach based on accessibility (egalitarian equity) to a needs-based approach (differential equity), which although more complicated in to apply and implement, was found be much better adapted to healthcare users. The research is derived from an analysis of documents from November 2004 to November 2006. A university public hospital developed the data which supported a proposal to shift from level I to level II. This proposition was retained in the territory's medical plan authorized by the regional health authorities. Health professionals and the architects of the healthcare plan have the capacity to new organizations responsible for taking into account the activities and healthcare needs of the population in order to initiate and establish differential equity.

[Medical education in France and Canada: is there a best system?]. / Formation médicale en France et au Canada. L'un des deux systèmes est-il meilleur que l'autre?

We have compared the conception and organization of medical education systems in France and Canada, taking into consideration key means and processes including the organization of curriculum, the selection of students, certification and licensure. The major objective of this comparison is to illustrate the degree to which the organization of medical education is influenced by the specific history and culture of each country. This is particularly important in an era of increasing internationalization in medical education. In Canada, a federalist orientation means a great deal of freedom for each province to determine its own criteria for medical licensure, and for each faculty of medicine to determine its own selection criteria and curriculum organization. Meanwhile, the evaluation of graduates of medical schools and later of specialties is organized at a national level. France, on the other hand, is much more centrist, and controls the "input" of students to medical schools and the nature of their curriculum. However, France allows each faculty of medicine to deliver a diploma that authorizes physician graduates to practice, without an evaluation of student performance at a national level. We show how the selection and evaluation of students in France are influenced by the French Revolutionary principles of "liberté" and the education of a national "elite", while in Canada the goals of "equity" and the guarantee of a level of "minimum competence" under pin a very different system. In conclusion, we highlight the important of taking into consideration these factors before undertaking reform of educational systems or transferring methods from one country to another.