[Qualitative and quantitative comparisons of three individual deprivation scores for outpatients attending a free hospital care clinic in Paris]. / Caractéristiques métrologiques et comparaison de trois outils de repérage de la précarité sociale dans une permanence d'accès aux soins de santé hospitalière à Paris.

BACKGROUND: Inequality in health care is a growing problem, leading to the development of different tools for the assessment of individual deprivation. In France, three tools are mainly used: Epices (which stands for "score for the evaluation of social deprivation and health inequities among the centers for medical examination"), a score called "Handicap social" and a screening tool built for medical consultations by Pascal et al. at Nantes' hospital. The purpose of this study was to make a metrological assessment of those tools and a quantitative comparison by using them on a single deprived population. METHODS: In order to assess the metrological properties of the three scores, we used the quality criteria published by Terwee et al. which are: content validity, internal consistency, criterion validity, construct validity, reproducibility (agreement and reliability), responsiveness, floor and ceiling effects and interpretability. For the comparison, we used data from the patients who had attended a free hospital outpatient clinic dedicated to socially deprived people in Paris, during one month in 2010. The "Handicap social" survey was first filled in by the 721 outpatients before being recoded to allow the comparison with the other scores. RESULTS: While the population of interest was quite well defined by all three scores, other quality criteria were less satisfactory. For this outpatient population, the "Handicap social" score classed 3.2% as non-deprived (class 1), 32.7% as socially deprived (class 2) and 64.7% as very deprived (class 3). With the Epices score, the rates of deprivation varied from 97.9% to 100% depending on the way the score was estimated. For the Pascal score, rates ranged from 83.4% to 88.1%. On a subgroup level, only the Pascal score showed statistically significant associations with gender, occupation, education and origin. CONCLUSION: These three scores have very different goal and meanings. They are not interchangeable. Users should be aware of their advantages and disadvantages in order to use them wisely. Much remains to be done to fully assess their metrological performances.

Effect of a short-term intermittent exercise-training programme on the pulse wave velocity and arterial pressure: a prospective study among 71 healthy older subjects.

AIMS OF THE STUDY: Stiffening of large arteries has been associated with increased cardiovascular outcomes among older subjects. Endurance exercises might attenuate artery stiffness, but little is known about the effects of intermittent training programme. We evaluate the effect of a short Intermittent Work Exercise Training Program (IWEP) on arterial stiffness estimated by the measure of the pulse wave velocity (PWV). METHODS AND SUBJECTS: Seventy-one healthy volunteers (mean age: 64.6 years) free of symptomatic cardiac and pulmonary disease performed a 9-week IWEP that consisted of a 30-min cycling twice a week over a 9-week period. Each session involved six 5-min bouts of exercise, each of the latter separated into 4-min cycling at the first ventilatory threshold alternated with 1-min cycling at 90% of the pretraining maximal tolerated power. Before and after the IWEP, the following measurements were made: carotid-radial PWV and carotid-femoral PWV with a tonometer and systolic and diastolic blood pressure. RESULTS: Training resulted in a non-significant decrease of the carotid-radial PWV, a significant decrease of the carotid-femoral PWV from 10.2 to 9.6 m/s (p < 0.001) (that was no longer significant after adjustment for mean arterial pressure) and a significant decrease in both systolic and diastolic blood pressure, respectively, from 129.6 ± 14.9 mmHg to 120.1 ± 14.1 mmHg (p < 0.001) and from 77.2 ± 8.8 mmHg to 71.4 ± 10.1 mmHg (p < 0.001). CONCLUSION: The present results support the idea that a short-term intermittent aerobic exercise programme may be an effective lifestyle intervention for reducing rapidly blood pressure and probably central arterial stiffness among older healthy subjects.

[Precarious parturients and readmission: pilot study at the Lariboisière-Fernand-Widal Hospital Group in Paris]. / Parturientes précaires et réhospitalisation : étude pilote au groupe hospitalier Lariboisière-Fernand-Widal de Paris.

OBJECTIVES: We wondered whether pregnant women with social handicap benefited from readmissions which could have been prevented, and if there was a selection of patients? PATIENTS AND METHOD: This is a retrospective study of 127 pregnant women with social handicap having given natural childbirth in a public health establishment. The research was based on analysis of data from DRG's (PMSI), legislation and other documents. RESULTS: Between mid March 2007 and mid June 2009, 27 of the 127 pregnant women with social handicap have benefited from 35 readmissions. There were 171.5 ± 255.1 days between readmissions. There was no second readmission on the same day for the same patient. According to the criteria of the Appropriateness Evaluation Protocol (AEPf), none of the readmissions were considered avoidable. No parturient was readmitted for non-medical reasons. Readmitted patients presented low to severe social handicaps and had 79.6 % more coded diagnosis compared to their first hospitalization. This service plays its public service role to fight against social exclusion. DISCUSSION AND CONCLUSION: This pilot study provides encouraging results but also underlines the limits of our approach. We nevertheless wished to explore whether this low resource intensive initiative could make interesting indicators emerge, which seems to be the case.

[Impact of precariousness on quality of prenatal detection: Lariboisière hospital experience in Paris]. / Impact de la précarité sur la qualité du dépistage anténatal : expérience de l'hôpital Lariboisière à Paris.

CONTEXT: The objective of our study was to estimate the impact of the precariousness on the quality of the care in antenatal diagnosis of the patients followed to Lariboisière (Parisian service of gynaecology obstetrics situated in a district of the capital discriminated socially) over a period of 3 months. PATIENTS: All the patients undergoing a prenatal diagnosis consultation in Lariboisière Hospital between February and April 2008. Patients were split in two groups according to their precariousness (economic or psychosocial) or not. Criteria studied were: initial purpose of the prenatal consultation, quality of the first trimester ultrasound exam, access to the integral calculus in Down Syndrome detection, lateness of care between the diagnosis and the prenatal consultation. The second part of this analysis was to evaluate if precariousness was associated with organizational problem in prenatal diagnosis. RESULTS: Fifty-nine patients were included: 29 (49%) were identified as being in a precariousness situation. The initial purpose of the consultation was the same in the two groups. Precariousness was associated to organizational problems for the prenatal diagnosis consultation (72 vs. 47%, P=0.004). Thirty-five patients (59%) have met organizational problems for the prenatal diagnosis consultation. Were associated to organizational problems: precariousness (60% vs. 33%, P=0.04), low education level (86 vs. 54%, P=0.007) and single mother (23% vs. 0%, P=0.001). CONCLUSION: This work shows the negative impact of precariousness on the prenatal diagnosis. Prevention may improve the information and the quality of care given to these patients.

Effects of a short-term personalized Intermittent Work Exercise Program (IWEP) on maximal cardio-respiratory function and endurance parameters among healthy young and older seniors.

OBJECTIVE: The aim of this study was to evaluate the efficiency of a short-term Intermittent Work Exercise Program (IWEP) among healthy elderly subjects. STUDY DESIGN AND SETTING: This longitudinal prospective study took place at the Strasbourg University Hospital geriatric department. STUDY PARTICIPANTS: One hundred and fifty older volunteers, previously determined as being free from cardiac and pulmonary disease, were separated into two age groups: the "young senior" (60.2 ± 3.1 yr) and the "older senior" groups (70.8 ± 5.2 yr). These groups were then subdivided by gender into the "young female senior", "young male senior" "older female senior" and "older male senior" groups. INTERVENTION: Before and after the IWEP, all subjects were asked to perform an incremental cycle exercise to obtain their first ventilatory threshold (VT1), maximal tolerated power (MTP), peak oxygen uptake (VO2peak) and maximal minute ventilation (MMV). The IWEP consisted of a 30-min cycling exercise which took place twice a week, and was divided into six 5-min stages consisting of 4 min at VT1 intensity and 1 min at 90% MTP. MEASUREMENTS: An assessment was made of the effects of the IWEP on maximal cardio-respiratory function (MTP, VO2peak, MMV) and endurance parameters (VT1, heart rate [HR] measured at pretraining VT1 and lactate concentrations at pre-training MTP). RESULTS: This short-term training program resulted in a significant increase of MTP (from 13.2% to 20.6%), VO2peak (from 8.9% to 16.6%) and MMV (from 11.1% to 21.8%) in all groups (p<0.05). VT1 improved from 21% at pretraining to 27%, while HR at pre-training VT1 as well as lactate concentrations at pre-training MTP decreased significantly in all groups (p<0.05). The post-training values for VO2peak and MMV of the "older seniors" were not significantly different (p>0.05) from the "young seniors" pre-training values for the same parameters. CONCLUSION: The most striking finding in this study is that after only 9 weeks, our short-term "individually-tailored" IWEP significantly improved both maximal cardio-respiratory function and endurance parameters in healthy, previously untrained seniors.

[Precariousness, DRG's and health planning: pilot study at the Lariboisière hospital in Paris]. / Précarité, tarification à l'activité et planification sanitaire et sociale: étude pilote à l'hôpital Lariboisière de Paris.

OBJECTIVES: This paper considers the specific administrative procedures set up by managers of public healthcare establishments and those responsible for health and welfare policies to care for low-income pregnant women for whom 100% of the "price per act" (T2A) is refunded. What are the limitations and what improvements can be suggested? PATIENTS AND METHOD: The results are based on an analysis of data from semi-structured interviews, legislation and documents. RESULTS: The State, health insurance systems, public health establishments, local authorities, charities and outpatient services are involved in handling low-income parturients in different services and different establishments, both locally and regionally. A health and welfare policy comprising specific, coordinated actions and measures has been developed. The T2A "price per act" system may threaten its survival: the limited number of front-line facilities is often saturated and demand is increasing, treatment is often reduced to reactive management leading to unwanted readmissions, ethics are sometimes called into question and there is a risk of patient selection. DISCUSSION AND CONCLUSION: This pilot study provided some encouraging information but also indicated the limitations of the approach adopted. However, it was still of interest to see whether it was possible to use this approach, which did not require considerable resources, to reveal useful markers. This appeared to be the case. Regional Health Agencies (ARS) and local authorities could support the system. Additional funding is needed.

Impact of short-term aerobic interval training on maximal exercise in sedentary aged subjects.

BACKGROUND: Ageing is known to be associated with a decrease in peak oxygen consumption (VO2peak) and maximal tolerated power (MTP). Regular physical exercise is the most appropriate to improve aerobic capacity, but its effect still remained discussed in old people. DESIGN: The aim of this study was to determine whether a short interval training session would be associated with improvements in exercise efficiency in aged subjects in both genders. METHODS: In all, 19 women and 16 men (65.4 +/- 4.9 years) performed a cycle incremental exercise test before and after a 9-week period of aerobic interval training (twice a week, 30 min session where 6 x 4-min at the first ventilatory threshold alternated with 1-min at the second ventilatory threshold) with cycle ergometer. Minute ventilation (MV), O(2) uptake (VO(2)) and CO(2) output (VCO(2)) were measured breath-by-breath and by an open-circuit metabolic cart. RESULTS: Before training, maximal values of MV (MMV), VO2peak, heart rate, systolic blood pressure, MTP, blood lactate at MTP recovery and the power at the first (pVT(1)) and second ventilatory thresholds (pVT(2)) were higher in men compared with women. Nine weeks of interval training induced a significant increase in MMV, VO2peak, MTP, pVT(1) and pVT(2) and decrease in systolic blood pressure in the same way in men than in women, without any significant effect on their maximal heart rate values. CONCLUSIONS: These findings suggest that the age-related declines in aerobic index are attenuated by a short exercise interval training sessions in women and men.

[Parturients vaginal childbirth, social handicap and length of stay: pilot study at the Lariboisière Fernand-Widal Hospital Group in Paris]. / Parturientes accouchant par voie basse, handicaps sociaux et durée de séjour : étude pilote au groupe hospitalier Lariboisière-Fernand-Widal de Paris.

OBJECTIVES: Would a social handicap questionnaire with French DRG (PMSI) make it possible to know social disability parturients vaginal childbirth in a public health loss of revenue by increasing the average length of stay during the hospitalization of patients precarious? PATIENTS AND METHODS: The questionnaire of the social handicap consisted of 14 indicators associated to classify at the admission each patient in three categories of social handicap. RESULTS: The administration of a questionnaire of social handicap was carried out for 127 women giving birth by low way. Three quarters of the studied population have a strong social handicap and 18% present a means of it. The more social handicapped patients do not represent an additional cost for the establishment in terms of supplementary day of hospitalization. CONCLUSION: French DRG (PMSI) and indicators of precariousness can be used to locate the patient having social handicap. The consistency of the public action between the medical one and the social one are questioned.

Health benefits of physical activity in older patients: a review.

As the number of elderly persons in our country increases, more attention is being given to geriatric healthcare needs and successful ageing is becoming an important topic in medical literature. Concept of successful ageing is in first line on a preventive approach of care for older people. Promotion of regular physical activity is one of the main non-pharmaceutical measures proposed to older subjects as low rate of physical activity is frequently noticed in this age group. Moderate but regular physical activity is associated with a reduction in total mortality among older people, a positive effect on primary prevention of coronary heart disease and a significant benefit on the lipid profile. Improving body composition with a reduction in fat mass, reducing blood pressure and prevention of stroke, as well as type 2 diabetes, are also well established. Prevention of some cancers (especially that of breast and colon), increasing bone density and prevention of falls are also reported. Moreover, some longitudinal studies suggest that physical activity is linked to a reduced risk of developing dementia and Alzheimer's disease in particular.

[Construction-cost assessment of a program designed to promote physical and sports activities and prevent doping behaviors: PN-APSD - on 2002-2007]. / Coûts de construction du programme de "promotion de la santé par les activités physiques et sportives et de prévention des conduites dopantes : PN-APSD - 2002-2007".

BACKGROUND: According to the framework legislation promulgated as part of the reform of finance laws in France, quality is a mandatory feature of all governmental actions. In this context, this work was conducted to assess the construction cost of a national health program designed to promote physical and sports activities and prevent doping behaviors. This program was considered to have the characteristic features of a successful governmental health intervention. METHODS: Four cost categories were evaluated: cost of the activity itself, transportation costs, communication costs and promotion costs. RESULTS: It was found that the program costs for 2002-2007 were 100,000 euro, with 15% of the costs in the communication category. CONCLUSION: Economic elements could be associated with factors of successful health service interventions in order to help decision makers responsible for the public interest and the consistency of public health actions.

[Complete cost of surgery for postpartum haemorrhage]. / Coût total des actes chirurgicaux dans la prise en charge des hémorragies de la délivrance.

OBJECTIVE: Reduction of maternal mortality is a major priority in the public health domain. One of the main causes of maternal mortality is postpartum haemorrhage. Because economic pressures favour the use of less expensive strategies, it is becoming now critical to know exactly the cost of the surgical procedures involved in the treatment of postpartum haemorrhage, in order to provide future guidelines in Implementing reforms in hospital. MATERIALS AND METHODS: Evaluation was made on multiple data collected in the Gynecology-Obstetrics and Central Sterile Supplies departments of a tertiary care Hospital. Analysis of the production costs was made based on the actual costs. The receipts were figured on the basis of applicable reimbursement in France in 2005, taking into account the financial decisions of the producers. RESULTS: From January 2004 to December 2005, 262 patients were treated for postpartum hemorrhage and patients files were available for review in 255 cases. Of these, surgery was performed in 52 cases. The costs of surgery in the postpartum care ranged from 275.04 euro per manual exploration of the uterine cavity (n=8), 302.48 euro per exploration with valve (n=26), 601.55 euro per vascular ligation (n=3), 725.53 euro per vaginal packing or unpacking (n=10) to 875.06 euro per hysterectomy (n=5). Cleaning and sterilizing of surgical instruments represented a substantial burden, ranging from 7.5% to 11.4% of the total cost of surgery. DISCUSSION AND CONCLUSION: The costs of surgery for postpartum haemorrhage have been calculated to provide future guidelines for the directions and follow-up of these activities in light of the T2A-EPRD and poles of activity. The actual costs could be used to determine the bases of one or more French DRGs (PMSI) "postpartum hemorrhage" evolution.

[Consumers and health policies: reports and perspectives]. / Usagers et politiques de santé: bilans et perspectives.

The French public power-base imagined that the involvement and participation of consumers in decision-making could render the debates on health policies more transparent when faced with the opposing professional and techno-administrative logics. One could also ask oneself what is the true reality of this participation. The research strategy is based on the intersection and overlap of data resulting from the analysis of minutes reported from semi-guided interviews with regional and national referential persons, consumers and from documents concerning the construction and implementation of national, regional and local health policies. This study demonstrates that, from 1996 to 2002, consumers were associated with and implicated in the development and implementation of national, regional and local health policies. Exemplary success stories exist which testify to the possibility of anchoring a democratic consultation model in health institutions irrespective of the level of decision-making, application or operationalisation. Recommendations are proposed in order to strengthen these dynamic forces and relationships.

[Payment by activity and financing of innovative hospital procedures: does the new payment system cover endovascular treatment for cerebral aneurysms?]. / Financement des traitements endovasculaires des anévrysmes cérébraux. La tarification à l'activité permet-elle aux établissements de santé de financer la prise en charge des patients?

METHOD: We have calculated all hospital expenses related to treated intracerebral aneurysms for 2005. Catheters, microcatheters, and guidewires as well as coils were included. We have compared these expenses to the payment by activity and fee per service collected for providing these services. RESULTS: Payments received covered only a third of the expenses for the supplies used. Three types of expenses are not reimbursed: the guiding material, the coils used but not released, and the latest generation of coils not yet added to the national list of covered devices. These expenses are also not covered by the payment received for the hospital admission. DISCUSSION: Endovascular management of intracranial aneurysms has become the treatment of choice over the recent years. This treatment is virtually only available in university hospitals. With the current mode of reimbursement, such treatment generates losses to the hospital. CONCLUSION: This example raises the question of financial support for innovative treatments and procedures.

[Patients and clients integrated in the process of constructing the regional health organisation plans]. / Les usagers dans la construction des schémas régionaux d'organisation sanitaire.

The government orders of April 1996 were devoted to the second generation Regional Health Organisation Plans (SROS II) as health planning levers. One of the main issues at stake in their development was the need to favour an overall management of the regional public health priorities and to involve the system's clients in them. In order to better understand the opinions of the clients themselves and the opinions of the health planning professionals on the participation of the clients in SROS II, a national sample was selected in order to take into account the diversity of regional experiences, the different institutional linkages and the unity of both the place and the problem at hand. Two series of 42 interviews conducted at 6 month intervals were recorded and a thematic analysis according to a validated interview grid was carried out by the Analytical Laboratory for Social and Health Policy (LAPSS) at the National School of Public Health (ENSP). This survey shows that the first attempt to include the participation of the system's clients in the health planning efforts by the SROS II was appreciated and recognised as legitimate and useful, yet suffered from a lack of legibility and of a clear definition of its role. Other participation mechanisms remain to be investigated and explored as they could be enlarged in the next plan, in which the clients could become a separate entity of actors as an entirely independent group.

[Apprenticeships carried out by "health planning craftsmen" during the construction of regional health organisation sketches]. / Les apprentissages réalisés par les "artisans de la planification sanitaire" pendant la construction des schémas régionaux d'organisation sanitaire.

The decree of April 1996 established the second generation Regional Health Organisation Plans (SROS II) as a lever for health planning. One of the major issues at stake in their development is to promote the overall coverage of regional health priorities. This resulted in the need for apprenticeships on the part of "health planning designers". In order to better comprehend their opinion, a nationally selected sample was gathered to take into account the diversity in regional experiences, the differences in institutional partnership and the unity within the given place of the problem. Two series of 42 interviews at six month intervals were recorded and a thematic analysis was carried out according to a validated interview grid by the Social and Health Policies Analysis Laboratory (LAPSS) at the National School of Public Health (ENSP). This study demonstrates that the actors involved in health planning, who are few, should nevertheless develop skills centred on their multiple functions and tasks in order to adopt to new reforms within the context of an environment of significant economic and legal pressures. These professionals performed collective and organisational, and even cultural, apprenticeships which allowed for the mobalisation of initiatives, the integration of diversity in individual projects towards a capacity for responsible collective action and quality, all of which advocates for the modernisation of public action.

Influence of immersion on respiratory requirements during 30-min cycling exercise.

Immersion is considered to facilitate exercise-based rehabilitation. However, the drag effect of moving limbs in water, likely to increase the respiratory requirements at exercise, is not mentioned in many reports. The energetic and ventilatory requirements of 30 min steady state cycling exercise performed by healthy male subjects in air and during immersion up to the xiphoid in 33 degrees C water were compared. In the first experimental series nine subjects exercised at the same 60% maximal oxygen consumption (V'O2,max) in air and water. In the two ambient conditions, ventilatory variables had similar values, but the ergometric setting had to be reduced during water immersion so that the workload rated only 69+/-20 W (mean+/-SD) in water versus 121+/-32 W (p<0.001) in air. In the second experimental series, the same ergometric work load (122 W) was achieved by nine subjects with an average V'O2 of 2,210+/-300 mL x min(-1) in air versus 2,868+/-268 mL x min(-1) in water (p<0.001). Resting water immersion caused a marked trend for decreasing vital capacity (p=0.06), but no modification of other ventilatory variables. During exercise at similar V'O2, the average values of minute ventilation (V'E), tidal volume (VT), respiratory frequency (fR), tidal inspiratory time (VT/tI) were not different between water and air. However, at similar ergometric workload, V'E, VT, fR, VT/tI and plasma lactate levels were significantly higher in water than in air. Such consequences of the drag effect of water upon limb movements have not been reported in previous studies relying on shorter exercise bouts. Thus, maintaining steady exercise levels in water either led to a decrease in the workload or required a 25% higher oxygen consumption than in air. These findings may be relevant to the prescription of water immersion rehabilitation programmes.

Hemodynamic responses to 30-min cycling exercise at 70% VO2 max both in ambiant air and during chest-immersion.

The aim of this study was to examine the influence of water immersion to the chest on cardio-vascular adaptation to exercise. Upright or sitting immersion causes an increase in central blood volume, but it remains controversial whether central blood volume remains elevated during dynamic exercise in water and facilitates cardiac adaptation, depending particularly on the intensity of exercise which can be matched for O2 consumption (metabolic range) or for mechanical intensity (work load). We have compared hemodynamic variables measured during two cycling exercises at the same mechanical intensity, performed both in ambiant air and during immersion up to the chest.