Geriatric Choosing Wisely choice of recommendations in France: a pragmatic approach based on clinical audits.

BACKGROUND: The international Choosing Wisely campaign seeks to improve the appropriateness of care, notably through large campaigns among physicians and users designed to raise awareness of the risks inherent in overmedication. METHODS: In deploying the Choosing Wisely campaign, the French Society of Geriatrics and Gerontology chose early operationalization via a tool for clinical audit over a limited area before progressive dissemination. This enabled validation of four consensual recommendations concerning the management of urinary tract infections, the prolonged use of anxiolytics, the use of neuroleptics in dementia syndromes, and the use of statins in primary prevention. The fifth recommendation concerns the importance of a dialogue on the level of care. It was written by patient representatives directly involved in the campaign. RESULTS: The first cross-regional campaign in France involved 5337 chart screenings in 43 health facilities. Analysis of the results showed an important variability in practices between institutions and significant percentage of inappropriate prescriptions, notably of psychotropic medication. DISCUSSION: The high rate of participation of target institutions shows that geriatrics professionals are interested in the evaluation and optimization of professional practices. Frequent overuse of psychotropic medication highlights the need of campaigns to raise awareness and encourage deprescribing.

[The COMPAQH project: researches on quality indicators in hospitals]. / COMPAQH : recherches sur le développement des indicateurs qualité hospitaliers.

After three years, the coordination de la mesure de la performance pour l'amélioration de la qualité hospitalière (COMPAQH) project can deliver its first findings and consider new perspectives of development. Which indicators are diffused? Under which criteria are they assessed? Which interhospital variability is observed? How to consider their application into hospitals? Which balance can we define between internal and external use? And finally, which consideration can we give to this program of quality measurement? This article addresses these different questions, giving a state of the development of this program.

[Developing quality indicators in hospitals: the COMPAQH project]. / Développement d'indicateurs de qualité au sein des établissements de santé: le projet COMPAQH.

BACKGROUND: To select a set of quality indicators (QI) in order to test them in a panel of 36 French hospitals METHODS: The COMPAQH (COordination for Measuring Performance and Assuring Quality in Hospitals) project is coordinated by the French National Institute for Medical Research and supported by the French Ministry of Health and the French National Evaluation and Accreditation Agency. This project has four objectives: (1) to select a set of QI -2003- (2) to implement them in 2004-2005 in a volunteer panel of hospitals (3) to compare the hospitals anonymously (4) to explore quality management implications. QI were selected with a four-step process: (1) Establishment of a list of national priorities for Quality Improvement in relation with the Ministry of Health. (2) setting up a potential list of QI regarding these priorities. The COMPAQH staff determined a preliminary set of 81 QI, based on data in the literature and evidence about the scientific soundness of quality measures and the effectiveness of methods for improving quality. (3) Evaluation of the preliminary list. Each QI was presented in a pamphlet describing its operational definition, rationale, methodology, workload and responsibility of data collection The hospital panel (representatives) ranked the 81 QI with a validated evaluation tool which contained four dimensions: Importance, Scientific acceptability, Feasibility, and Usability. (4) Development of a consensus on a final selection. Based on a structured voting process (Delphi method, two rounds), the hospital panel selected a comprehensive set of 42 QI among the 81. RESULTS: (1) Eight national priorities were defined: pain management, continuity of care, management of nutritional disorders, Iatrogenic risks (including nosocomial infections), patient satisfaction, follow-up of practice guidelines, management of human resources, accessibility. (2) A set of 42 QI were selected: a set of 6 core QI and 7 to 18 specific QI according to the hospital type. CONCLUSION: Such a set of QI provides a foundation for developing a quality measurement system in French hospitals. It requires a pragmatic view for implementing them and a coherence between the different objectives of use (internal and external use).

[Medico-economic assessment of two methods for implementing thyroid testing guidelines]. / Evaluation médico-économique de la mise en oeuvre de recommandations de prescription des examens biologiques explorant la fonction thyroïdienne.

BACKGROUND: To compare independent and combined effectiveness and cost-effectiveness of two implementation interventions of guidelines for ordering thyroid function tests. The two implementation interventions were a Memorandum Pocket Card (MPC) and a Test Request Form (TRF). Intervention groups were wards. METHODS: The study used an experimental 2*2 factorial design with matching hospitals according to size and activity and wards according to pre-intervention appropriateness for test ordering. Four ward groups were established: the dual intervention group, the order form group, the pocket card group and the control group. Physicians in all groups received guidelines and were invited to a local information meeting. The main outcome measure of effectiveness was the Guideline Conformity Rate (GCR). The cost-effectiveness ratio was the cost difference between the tested intervention and the control intervention upon effectiveness difference between the tested intervention and the control intervention. RESULTS: Six hospitals participated in the study (two middle-sized hospitals, two small-sized hospitals and two psychiatric hospitals). A total of 1412 orders for thyroid function tests were collected. GCR was 78% in the dual intervention group, 83% in the order form group, 73% in the pocket card group and 62% in the control group. The interaction between TRF and MPC was not significant (B=-0.70, p=0.21). Compared to simple information, TRF was effective in increasing GCR (OR=2.65, 95% Confidence Interval [CI]: 1.52-4.62), unlike MPC (OR=1.28, CI: 0.75-2.19). TRF was the less expensive and the most effective intervention. CONCLUSION: Using a robust design, our study shows a greater effectiveness of TRF than MPC and their association in implementing thyroid function test guidelines. The development of clinical practice improvement projects through the second procedure of accreditation in France is a good opportunity to develop a guidelines implementation research project.

[Access to medical records: who asks and why?]. / Accès au dossier médical: caractéristiques et motifs des demandeurs.

OBJECTIVE: The aim of the survey was to study the characteristics of patients who (or whose families) request access to their medical records, their satisfaction with the handling of their requests, and the reasons for them. METHODS: This prospective study analyzed all the requests for access to medical records sent to two hospitals and collected data from the hospitals at that time (characteristics of the requester, patient and hospitalization) and from the requesters afterwards (opinion survey). RESULTS: The study reviewed 94 requests for medical records. Delays in providing the records exceeded the statutory periods. Most requests were intended to allow continuity of care, to provide information the patient did not receive during hospitalization, or because the patient needed to transmit it to a third party (new doctor, insurance, attorney, worker compensation). The hospitals mailed records to patients by regular mail in 90% of cases. One third of the patients were not satisfied by the handling of their request, complaining about the following difficulties: length of wait for records, complexity of the request procedure, its expense, absence of some documents, and difficulty in understanding the files without medical assistance. CONCLUSION: Improvements are needed, both to decrease the number of requests and to improve the requesters' satisfaction. Specific improvements are suggested.

[Use of the critical incident technique in the development of a measurement tool for satisfaction in psychiatry]. / Utilisation de la méthode des incidents critiques dans la construction d'un outil de mesure de la satisfaction en psychiatrie.

BACKGROUND: Health care centers will have to set up a regular survey of their patients' satisfaction, in addition to the discharge questionnaire. Few instruments for measuring satisfaction are at present available. A working group associating 10 psychiatric hospitals in Aquitaine conducted a study on the specificity of this measure in psychiatry. AIMS OF THE STUDY: To record the patient's perception on the stay in order to identify areas of satisfaction and dissatisfaction as perceived and reported by himself, using a qualitative approach. METHODS: The critical incident technique was used in 3 volunteer hospitals, in patients hospitalised in psychiatric wards selected by their doctor. Interview using a semi-structured questionnaire were conducted by an investigator external to the departments. Data were analysed in a qualitative way. RESULTS: 32 interviews could be analysed, and 215 events were extracted. These events were classified in 12 themes. CONCLUSION: The events identified from these interviews have allowed identification of new areas of patient satisfaction, which could be used to build additional items centered on patients' preoccupations.

Lipodystrophy, metabolic disorders, and human immunodeficiency virus infection: Aquitaine Cohort, France, 1999. Groupe d'Epidémiologie Clinique du Syndrome d'Immunodéficience Acquise en Aquitaine.

The objective of this study was to estimate the prevalence of and risk factors for clinical lipodystrophy (LD) and metabolic disorders in human immunodeficiency virus (HIV) type 1-infected patients. A cross-sectional survey of the Aquitaine Cohort was performed in January 1999. The clinical diagnosis of LD was categorized as fat wasting (FW), peripheral fat accumulation (FA), and mixed syndromes (MS). Of the 581 patients studied, 61% were treated with protease inhibitors. The overall prevalence of LD was 38% (95% confidence interval [CI], 32-42): prevalence of FW was 16% (95% CI, 13-18); of FA, 12% (95% CI, 10-15); and of MS, 10% (95% CI, 8-13). The prevalences of metabolic abnormalities were 49% (95% CI, 44-53) for lipid disorders and 20% (95% CI, 17-23), for glucose disorders. Factors associated with LD were age (for FW and MS), male sex (for FW), AIDS stage (for MS), body mass index (for FW and FA), waist-to-hip ratio (for FA and MS), and duration of antiretroviral treatment (for FW).

Severe hepatic cytolysis: incidence and risk factors in patients treated by antiretroviral combinations. Aquitaine Cohort, France, 1996-1998. Groupe dEpidémiologie Clinique de Sida en Aquitaine (GECSA).

OBJECTIVE: To study hepatic cytolysis in patients treated by highly active antiretroviral therapy (HAART) with protease inhibitor or with two nucleoside reverse transcriptase inhibitors (NRTIs). METHODS: We selected patients of the Aquitaine Cohort who initiated HAART or two NRTIs before 1 January 1998, had alanine amino-transferase (ALT) < or = 200 IU/I at baseline and at least one follow-up measure. Cox model was used to study the association between occurrence of severe hepatic cytolysis (ALT>200 IU/l) and age, gender, HIV transmission group, baseline CD4 and CD8 cell count, history of hepatic cytolysis, antiretroviral drug, baseline liver enzymes (WHO classification level 0: < or = 50 IU/l, level 1: 51 to 100, level 2: 101 to 200), hepatitis B and C co-infection. RESULTS: Sixty-four of 748 (8.5%) patients treated with HAART and 71 of 1249 (5.7%) treated with two NRTIs developed cytolysis. The probability of occurrence was 7.9% after 1 year [95% confidence interval (CI), 5.9-10.4] for patients treated with HAART and 4.8% (95% CI, 3.6-6.4) for patients treated with two NRTIs (log-rank test, P = 0.01). The median time to occurrence was 164 days for HAART-treated patients and 252 days for those treated with two NRTIs. In multivariate analysis, the history of cytolysis [hazard ratio (HR) = 2.3; 95% CI, 1.2-4.4], baseline value of ALT (HR = 2.4; 95% CI, 1.2-4.8 and HR = 3.3; 95% CI, 1.4-7.4 for levels 1 and 2, respectively), hepatitis B (HR = 3.0; 95% CI, 1.4-6.2) and C co-infections (HR = 3.2; 95% CI, 1.7-6.2) remained significantly associated with the occurrence of severe hepatic cytolysis among HAART-treated patients. History of cytolysis, hepatitis B and C were associated with cytolysis in patients treated with two NRTIs (HR = 14.8, 2.6 and 2.7, respectively). CONCLUSION: Hepatic cytolysis is more frequent among patients treated with HAART than with two NRTIs. Hepatitis B and C are the major risk factors after initiation of HAART or treatment with NRTIs. Co-infections with hepatitis B virus or hepatitis C virus may modify the management of HIV-infected patients treated by HAART.

[Survey on cases of primary tuberculosis in the department of Gironde]. / Enquête sur les cas de primo-infection tuberculeuse dans le département de la Gironde.

French official statistics do not mention primary tuberculosis and data on its prevalence are rare, despite the fact that the annual number of cases of primary tuberculosis is a clear indicator of the progression or regression of what remains an endemic disease in Europe. In order to collate information on the subject, a questionnaire was sent to 132 doctors practising in Gironde. These included pulmonologists, pediatricians and child health doctors. One hundred and one questionnaires were returned, listing a total of 18 cases of primary tuberculosis for the first half of 1997. Children were more often affected by the disease and presented a latent form. In 61% of cases, patients infected had not previously received BCG vaccination and in 56% of cases the infectious patient was identified. Furthermore, 4 of the non-vaccinated patients had been in close contact with an infectious patient and 3 patients among these should have been vaccinated since they were living in community structures. The 2 symptomatic cases reported occurred in non-vaccinated adults. This study was of limited-scope and duration but provides interesting information on the population affected by primary tuberculosis. These results underline the necessity of maintaining a high level of BCG vaccination amongst children and adults in community structures if we wish to lower the prevalence of the disease in France.

[Guidelines on difficult intubation in anesthesia: evaluation of 2 information diffusion methods]. / Les recommandations dans l'intubation difficile en anesthésie: évaluation de deux modalités d'information.

BACKGROUND: In 1996, experts from the Société Française d'Anesthésie et de Réanimation published guidelines about difficult intubation. We aimed to assess the effectiveness of two diffusion methods of these guidelines, media versus direct mailing plus media diffusion, and the relation between reading of the guidelines and practice behavior and training willingness. METHODS: Data were collected in two different samples of 300 anesthetists from three regions for pre and post-intervention surveys (E1 and E2 samples). Half of the anesthetists from E2, randomly chosen, received a direct mailing of the guidelines (E2a sample). The remaining constituted the E2b sample. Three assessment criteria were used, two concerning practice behavior and one training willingness. Relationship between these criteria and diffusion methods and reading was tested using logistic regression. RESULTS: The response rates were respectively 91%, 80% and 78% in the E1, E2a and E2b samples. The socio-professional features were not statistically different between the three samples. There was no relationship between the criteria and the diffusion methods. The direct mailing did not increase the reading rate (81% and 82% respectively in the E2a and E2b samples). The rate of anesthetists who routinely screened for predictive signs of difficult intubation (one of the practice criteria) was higher in E2a than in E2b (28% and 12% respectively). In the multivariate analysis, the difference only appeared among the sub-group of anesthetists who did not receive the direct mailing. The private practice was associated with a lower rate of routine screening. CONCLUSION: No impact of the diffusion methods on practice behavior and training willingness was found. Reading was inconstantly associated with practice behavior.

[Procedures use by French anesthetists in cases of difficult intubation and the impact of a conference of experts]. / Procédures utilisées par les anesthésistes-réanimateurs français en cas d'intubation difficile et impact de la conférence d'experts.

OBJECTIVE: To analyse the management of difficult intubation (DI) by French anaesthetists and the impact of the French experts' conference (EC) on this topic. STUDY DESIGN: Prospective, comparative, before/after study by questionnaire carried out in Aquitaine, Provence-Alpes-Côte d'Azur and Alsace-Lorraine. MATERIAL AND METHODS: A questionnaire on demographical data, detection of DI, management techniques and desiderata for continuing education on DI, was sent three months before the publication of the EC to 100 randomly selected anaesthetists, in each region (group PRE). Three months after the diffusion of the EC, the questionnaire completed by a survey on the impact of the EC was sent to 100 other randomly selected anaesthetists in each region (group POST). In the latter group, anaesthetists who considered the EC were compared to those who did not. RESULTS: The participation rate was 91% for the group PRE and 79% for the group POST respectively. Both groups were not significantly different for age, gender, position and seniority. Most used techniques that included blind nasal intubation (84%), intubation through laryngeal mask (82%), and intubation with fibrescope (53%). Demands for additional training were for translaryngeal ventilation (68%), intubation with fibrescope (64%), retrograde intubation (52%), and intubation through a laryngeal mask (46%). The EC was known by 71% of anaesthetists. In this group, the EC improved the assessment rate of the three recommended predictive criteria for DI from 12 to 28% (P < 0.02), but neither the management policy, nor the desiderata for additional training. CONCLUSION: Currently, the search of predictive indicators for DI is not systematically applied. The EC has only slightly modified the practice patterns. The need for additional training is important.

[Comparison of cases of isolated pulmonary tuberculosis with cases of other localizations of tuberculosis in the course of an active surveillance (Gironde, 1995-1996)]. / Comparaison des cas de tuberculose pulmonaire isolée aux cas de tuberculose d'autre localisation dans un système de surveillance active (Gironde, 1995-1996).

PURPOSE: Data collected during the years 1995 and 1996 in the course of an epidemiological survey of tuberculosis in Gironde allowed comparison of pulmonary tuberculosis with extrapulmonary localizations, evaluation of the importance of each localization and highlighting of potential risk factors. METHODS: Patients living in Gironde who had evidence of either clinical, radiological or bacteriological expression of tuberculosis were included in the survey. Statistical comparisons were done using either Pearson's Chi 2 or Fisher's exact test. RESULTS: The survey included 292 cases subdivided into 183 cases of pulmonary tuberculosis (63%) and 109 cases in which another localization had been diagnosed (37%). Extrapulmonary localizations that were the most often encountered either alone or in association with pulmonary localization were the following: lymphadenopathy (32%), pleural (28%), genito-urinary (12%) and osteo-articular localizations (7%). The survey showed that patients in whom tuberculosis localization was extra-pulmonary were more frequently under 20 years of age or over 60 years of age (P < 0.04). These patients also presented more often with HIV-infection (P < 0.02). CONCLUSION: Extrapulmonary localizations of tuberculosis should be systematically investigated in young and elderly patients as well as in HIV-infected patients.

p53 protein expression in grade II astrocytomas: immunohistochemical study of 100 cases with long-term follow-up.

p53 protein expression was evaluated by immunohistochemistry in a homogeneous series of 100 supratentorial grade II astrocytomas with long-term follow-up. The staining was positive in 72 cases. The proportion of p53 positive tumors was slightly higher in younger patients. The tumor regrowths which derived from p53 positive tumors were themselves p53 positive, and this p53 immunopositivity was often stronger than in the initial tumors. All of the 10 gemistocytic astrocytomas included in our series were p53 positive, and age more than histological type appeared decisive in prognosis. p53 protein expression did not quite reach statistical significance as an independent predictive variable in multivariate analysis, whereas survival was related with age, mass effect, surgery and tumor location. Only a tendency to a longer survival was observed on the curves in younger patients with mildly positive tumors.