[The participation of primary care physicians in integrated health services network: United States experiences]. / Participation des médecins généralistes dans les réseaux de santé : expériences en Amérique du Nord.

BACKGROUND: Reforms of care and services have affected primary care physicians, but very little attention has been devoted to their actual participation in Integrated Health Services Network (IHSN). METHODS: From a literature review of articles published from January 1985 to December 2006, we selected 24 studies on physicians' participation in IHSN and their perceptions on practices. RESULTS: This literature review suggests that physicians' perceptions of IHSN are linked to their actual level of participation. Physicians who participated fully perceived improvements in all practice dimensions. Physicians who participated partially were dissatisfied with physician-patient relationships, perceived a loss of professional autonomy and increased gate-keeping constraints. They had however a positive perception of the overall quality of care. When physicians received capitation payments, they were overall dissatisfied. CONCLUSIONS: In order to improve primary care physicians' participation in IHSN, quality of care should be reinforced, capitation payment avoided and gate-keeping should be transformed into coordination of care.

Risk adjustment of quality indicators in French long term care facilities for elderly people. A preliminary study.

BACKGROUND: In France, the funding reform for long term care facilities mandates quality improvement efforts and the measurement of quality of care indicators. In the United States, the Center for Health Systems Research and Analysis (CHSRA) has proposed 24 indicators, which measure practices and outcomes ("events") in long term care facilities. The objective of this preliminary study was to propose risk adjustments on the CHSRA indicators for future use in France. METHODS: The unit of analysis was residents assessments (558) in eight French facilities wich voluntarily participated to the experimentation of the Resident Assessment Instrument (RAI) from January 1996 to June 1999. This preliminary study focused on nine of the CHSRA's indicators: "prevalence of falls", "use of nine or more different medications", "prevalence of bladder or bowel incontinence", "prevalence of occasional or frequent bladder or bowel incontinence without a toileting plan", "prevalence of urinary tract infections", "prevalence of dehydration", "prevalence of bedfast residents", "prevalence of little or no activity" and "prevalence of stage 1-4 pressure ulcers". A working group selected residents'characteristics for risk adjustment based on the literature, risk adjustments selected by CHSRA, and their own propositions. For each event, candidate independent characteristics were screened using univariate analyses and, when significant, were entered into a stepwise selection analysis to obtain the final model. The proposed indicator was the ratio between observed and expected numbers of events. RESULTS: Six indicators were left unadjusted. For the event "prevalence of occasional or frequent bladder or bowel incontinence without a toileting plan", we proposed a stratification on "dementia - neurological diseases" (p<0.001). We proposed two models of prediction: for the event "prevalence of bladder or bowel incontinence" we adjusted on "severe cognitive impairment" (OR=4.00), "dementia- neurological diseases" (OR=1.75) and "total dependence in mobility" (OR=9.30); for the event "prevalence of stage 1-4 pressure ulcers" we adjusted on "dependence for bed mobility" (OR=4.97), "leaves 25% or more food uneaten at most meals" (OR=1.82) and "diabetes mellitus" (OR=3.45). CONCLUSION: This preliminary study underlines the importance of considering risk-adjustment for quality indicators in elderly care facilities.

[Behavior regarding therapeutic drugs and self concept of elderly persons with chronic diseases]. / Comportements vis à vis des medicaments et representations de soi chez des personnes agées souffrant de maladies chroniques.

This research on a sample of 133 persons older than 60 years and suffering from chronic diseases, concerns their practices towards medicines. Various practices displayed can be grouped in three different ways according to the regularity and the order of medicine taking, forgetting, self-medication, etc.; they seem to be linked neither to sex or age of subjects nor to variables directly or indirectly affected by the disease (number and type of medicines, gravity of the disease, subjective health). The understanding of these differential practices is improved if we consider the self-concept of subjects, that is to say their different positions in an organized whole of personality traits; this position reflects traits that they recognize as being more or less constitutive of their identity, that which motivates and gives sense to the totality of their life conduct.

Nursing homes in 10 nations: a comparison between countries and settings.

AIM: to illustrate demographic differences and recent trends in the provision and structure of long-term care systems in the 10 countries participating in the Resident Assessment Instrument studies (Denmark, France, Iceland, Italy, Japan, The Netherlands, Sweden, Switzerland, the UK and the USA). METHOD: data were assembled from government documents, statistical yearbooks and articles from journals; supplemental data on long-term care and nursing homes were solicited from colleagues. RESULTS: All 10 countries are developed nations with high life-expectancies. Sweden has the oldest and Iceland the youngest population in this study, with Japan showing the highest ageing rates over the next three decades. Between 2 and 5% of elderly people reside in nursing homes. Interestingly, Iceland, as the 'youngest country' in this study, has the highest rate of institutionalization (living in residential or nursing homes), while the 'oldest country' (Sweden) has a low rate of institutionalization. In all countries the support ratio (number of elderly people per 100 younger adults) is high and increasing rapidly. CONCLUSIONS: no relation appears to exist between the ageing status of a country and the number of nursing home beds. Institutionalization rates among the nations studied differ even more, due at least in part to differences in the organization and financing of long-term care services, in the amount of responsibility assumed in the care for disabled elderly people by each sector and the availability of long-term care beds. Facing a rapid ageing of their population, many countries are in the process of health and social care reforms.

Cultural problems of ageing especially regarding gender and intergenerational equity.

The absence of old age as a specific social group in some cultures raises the question of ageing as a cultural construction. In this paper we will consider only problems of cultural ageing in industrial Western society and especially in some OECD countries. There, demographic changes have been characterised by ageing of populations, visible since the fifties, by feminization of later life and modifications of social network. Ageing of population including the oldest generations have made definitions of later life more politicized and have gone together with new attitudes towards ageing and elderly people giving rise to different patterns of ageism. Examination of incomes, health status, social support of the elderly shows that until today there have been persistent inequalities related to age, gender and social class in terms of resources, access to informal and formal care and value accorded to later life. These inequalities are due to differences in status and resources of elderly and trajectories of ageing, always conditioned by social locations: position in labour market and in domestic division of labour with resulting social relations. The differences vary also between countries according to their welfare regime and their social policy. In the future, the proportion of those over 65 of age and among them of those ever 80 will be greater raises the questions of health status of the oldest generations, income distribution among generations and genders, of access to informal and formal care and adequacy of the later for the frail elderly. To cope with those issues ageing and later life should be considered in a life-span perspective. Better sharing of jobs and of economic wealth, development of meaningful activities other than work may be solutions to answer to the questions addressed by an ageing population and the problems of later life.

[Epidemiological research in rheumatology: current status and prospects]. / La recherche épidémiologique en rhumatologie: situation actuelle et perspectives.

Rheumatic diseases are very common and their consequences on both the individuals (leading cause of activity limitation between the age of the 18 and 64 years) and on society (socio-economic costs) are considerable. However, the epidemiology of these diseases remains poorly known. In this paper, a review of the epidemiological data for the most frequent rheumatic diseases (including recent advances) is followed by an analysis of the specific obstacles to epidemiological research in the rheumatology field and by a proposal of possible developments.

The effects of system characteristics on policy implementation and functioning of care for the elderly in France.

In the early 1960s, old age in France was replaced by the notion of "troisième âge," a new definition stressing the possibility of pursuing social and leisure activities and greater independence. Old age itself was postponed to a later age, and acquired a purely negative image and one confused with that of incurable illness. As a result, a living-at-home policy was elaborated, and also a program of adapting institutions to the problems of those now defined as being in the "quatrième âge." This dual-faceted medicosocial policy was originally intended to be comprehensive and coordinated. Analysis of the structural characteristics of the care providers and of the agencies responsible for organization and financing of services shows fragmentation at the levels of service delivery and policy development. This prevents the coordination of service provision, gives rise to a mismatch between people and provision, and leads to a lack of coherent regulation and of adequate financing, in particular with regard to domiciliary care and social services. External factors, such as scarcity of funds related to the economic crisis, reinforce system dysfunctions.

[Blockage of health care pathways]. / Blocage des filières de soins.

The social welfare policy, adopted in the 1970s, of devising ways to help the aged to remain in their homes and adapting institutions to the problems of the very old was instituted without being integrated into the incentive programs of such other sectors as public health and housing. The result has been a patchwork of services and centers whose organization, financing, and allowances are fragmented among a multitude of agencies. In addition, there is an imbalance of resources among the different sectors providing medical care and social welfare assistance. This makes for substantial difficulties in coordinating the activities of service providers and in financing some of the services. Moreover, inflexibility is apparent in adjusting types of services to varied and evolving needs. These problems explain the gaps, disjointed character of care, and faulty guidance in the system of distributing assistance that constitute so many blockages of the pathways used by the elderly. Such blockages cannot be usefully examined by analyzing the overall system, but must be studied at local points of convergence among clients, services and institutions. Such research is presently being conducted by the Concerted Action Committee of the European Community's Health Service Research.

[Disabled and handicapped in the Aquitaine region]. / Incapacités et handicaps dans la région Aquitaine.

An extension of the national survey on health and medical consumption conducted in 1981 on a random sample of the population living at home in Aquitaine used questionnaire on presence of disability and handicap (according to WHO definition). Occupations, mobility, personal care, communication restriction are observed in respectively 10.6, 3.3 and 1.5% of the sample. Because people aged 60 and over are concerned in 60 to more than 80% according disability or handicap dimension, analysis of those was follow up for this only population. Personal and domestic care disabilities are then noted for one out of eight persons, communication disabilities are present among one subject out of twenty. One person out of seven is restricted for mobility and physical independence whereas one out of four was restricted for customary occupations and one out of ten for social relationships. Those aged 75 and over are three of four times more often involved than those aged 60 to 74 with the exception of usual occupations. The 5% of those defined as dependent and nevertheless living alone are the ones that are likely to be institutionalized because of a minor intercurrent health problem.

Disabilities and handicaps in Aquitaine.

An extension of the national survey on health and medical consumption in Aquitaine used a questionnaire on presence of disability and handicap. Communication, personal cares, mobility and occupations were restricted in respectively 1.5, 3.3, 3.2, and 10.6%. People aged 60 and over were mainly concerned. Personal and domestic care disabilities were noted for 1 out of 8, communication disabilities were present among 1 out of 20. One out of 7 was restricted for mobility and physical independence; 1 out of 4 was restricted for customary occupations and 1 out of 10 for social relationships. Those physically dependent living alone were 5%.

Epidemiology of disablement in the elderly.

Two hundred and four people aged 65 and over, living in private households in the 16th arrondissement of Paris, were questioned about the presence of impairments, disabilities, and handicaps, as well as about their living conditions. Personal care activities, mobility, and domestic duties were most notably restricted in women (in 39, 56, and 29% respectively). Social contacts occurred less than once a week in nearly 25 per cent of the sample, recreational and social occupations were restricted in 40 per cent, and economic resources were insufficient in 25 per cent. The oldest women constituted a group at high risk of being institutionalized. Physical activity restrictions interacted with extrinsic factors so as to lead to social activity restriction. Most of the restricted persons were disabled by limitation of their lower limb, trunk, and upper limb functions. Rheumatic disorders, cardiorespiratory conditions, impairments of the special senses, and traumatic disorders were the most frequent underlying conditions reported.

[Study of a health indicator to assess effectiveness of a hospital outpatient department (author's transl)]. / Etude d'un indicateur de santé destiné à l'évaluation de l'efficacité d'une consultation externe hospitalière (application aux consultants de rhumatologie).

Evaluation of medical cares effectiveness needs health indices allowing the description of the severity of the disease and of the capacity of change. Disability seems a concept adapted to both challenges. It represents a disfunctional state continuum of which the levels are measurable, whatever the etiology or the diagnosis are. It also measures the variation of daily activities reduction, consequence of health disorders. From this concept, the authors have built, and applied to rheumatic patients seen at an outpatient department of gerontology, a seven levels scale. 480 consultations affecting 270 patients were carried out. The mean restriction of disability, at the time of the first referral was 2,9. The indice seems to be valid because it allows to classify the patients in 3 groups according to the severity of the involving disorder. The observed changes for 4 typical disorder groups agreed with what was expected. 122 patients were seen twice or more. The average of the difference between the grading of disability at the time of the first and the last consultation was--0,43, showing a significant improvement. After discussion of some shortcomings of their indice, the authors concluded that the scale used seems adapted to assess effectiveness of outpatient medical cares.

[Evaluation of radiologic criteria in rheumatoid arthritis]. / Evaluation des critères radiologiques de l'arthrite rhumatoïde

The authors compared the hand Xrays of 53 patients with rheumatoid arthritis (AR) with those of 53 control subjects matched for age and s. x. Each AR patient conformed to the New York clinical criteria. Assesment was carried out on Xrays of both hands, search being made for erosions, geodes, and joint narrowing, the severity being graduated from 0 to 4, according to data from the international Atlas of Radiology. The sensitivity, sepcificity and severity of each of these abnormalities was studied joint by joint (18 for the hand). Analysis of the results shows that study of all 18 joints in the hand is not useful; account may be taken only of the first three metacarpo-phalangeal joints, the carpo-metacarpal joints and the radio-carpal joint. The proximal interphalangeal joints, contrary to the most commonly held opinion, are more a source of errors than of diagnosis. Erosion is the most specific sign, especially if one is only considering the characteristic sites. With a specificity of the order of 98 per cent, this abnormality has sufficient weight to counteract the very low incidence of the disease in a population in comparison with degenerative disorders. Geodes should be studied more by their severity than by their frequency; this is high in the controls, which diminishes their specificity (45 for the wrist, 62 for the first carpo-metacarpal, and 75 for the first metacarpo-phalangeal joint). Joint narrowing is a difficult sign to read and its value is all at the radiocarpal and carpal joints.

[Rheumatic diseases: a public health problem (author's transl)]. / Les maladies rhumatismales: problème de Santé Publique

This study surveys the main quantitative data of the literature concerning the morbidity and the functional and socio-economic influence of rheumatic diseases. The cost of medical care and the functional and socio-economic repercussions entailed by these diseases represent a heavy burden on the community. In France, epidemiological surveys must be carried out, which will include medical attendance rates, sickness incapacity and statistics on disability. Once the amplitude of this problem is determined, it must be communicated to the general public, using sanitary education techniques, and an influence must be exerted on the authorities to undertake a general campaign against rheumatic diseases.

Rheumatoid arthritis in the Pima Indians of Arizona: an assessment of the clinical components of the New York criteria.

When a prevalence study of Rheumatoid Arthritis (RA) was made in the adult Pima Indian population living on the Gila River Reservation, a high prevalence was found using the New York criteria (5-9 per cent). This was mainly due to the high frequency of limitation of motion which brought in many undesirable subjects. After excluding it as a component of New York criteria we found a prevalence for RA of 3 per cent with a predominance among the females (3-8 as against 2-0 per cent in males). The group so defined fulfilled the requirements of the Rome criteria, showed a higher concordance with serological or radiological evidence of RA, and appeared to identify subjects in whom the experienced clinical rheumatologist would more often agree with the diagnosis.