[Asynchronous Tele-Expertise (ASTE) in obstetrical ultrasound: Is it equivalent to face-to-face consultation?] / La Télé-Expertise asynchrone (TEAS) en échographie obstétricale : est-ce équivalent à la consultation en présentiel ?

INTRODUCTION: The demand for remote advice has expanded since the advent of information and communication technology. This study aims to evaluate the use of asynchronous tele-expertise (ASTE) in providing a quality expert opinion in the field of obstetric ultrasound. MATERIALS AND METHODS: Requests for expert opinions on pregnant patients were considered retrospectively over a 24-month period (01/09/2018 to 01/21/2020). All patients were initially seen in consultation with a midwife sonographer, located in Hyères, 82km from the expert's centre. In the event of unusual images, including one or more malformations on ultrasound screening, a second opinion was necessary. Responses were characterized as follows : possible or impossible to analyse images; ASTE alone or combined with a face-to-face consultation; and absence or presence of unusual images. Unusual images were classified as normal variants or recognised malformations. We analysed the outcomes of these pregnancies and assessed concordance between prenatal advice and postnatal outcome. RESULTS: During the study period, we identified 174 referrals from 141 patients. Requests for advice were made by 3/174 (1.7%), 69/174 (39.7%), and 102/174 (58.6%) in the first, second, and third trimester of pregnancy, respectively. Overall, 115/141 (81.6%), 21/141 (14.9%), 4/141 (2.8%), and 1/141 (0.7%) patients were provided with one, two, three, and five opinions, respectively. In total, 37/141 (26.2%) patients required a face-to-face consultation, resulting in 38/174 (21.8%) opinions (one patient was seen twice). At least one unusual image was found for 27/141 (19.2%) patients and no unusual images were reported for 114/141 (80.8%) patients. Analysis of the pregnancy outcomes revealed a perfect correlation between prenatal advice and postnatal data, both for cases with unusual images and those without. CONCLUSION: The preliminary results of our study reveal that ASTE is safe in terms of enabling an expert to answer a precise question formulated by a screener when confronted with images deemed to be unusual. Using this mode of communication, a tailored healthcare pathway may be defined for the mother and her foetus. This new type of practice cannot exist without establishing a genuine relationship of trust between the person requesting the opinion and the person who is asked to provide the opinion.

[Standard or specific unit costs: Which criteria for choosing an economic evaluation of health strategies in multicentric studies?] / Coûts unitaires standards ou coûts unitaires spécifiques : quels critères de choix pour l'évaluation économique de stratégies de santé dans les études multicentriques ?

The question of what monetary value should be assigned to consumed resources, that is to say the choice of the unit cost, is a major consideration in terms of impact on the cost analysis results. To date, no agreement has been reached regarding this methodological question. The choices made by methodologists and the subsequent impact on the results of the analysis are only rarely put forward. This work addresses the theoretical framework of health strategy evaluations that can be carried out either in the normative framework of the conventional economic approach of well-being, referred to as welfarist, or in that of an approach referred to as extra-welfarist. It also provides elements that help clarify the choice of the hospital unit costs used to calculate the cost of health strategies, so as to reconcile the use of such studies and improve their comparability. What is preferable, opting for specific per hospital unit costs or applying a standard unit cost to all facilities? How should a standard cost be calculated? Is it appropriate to calculate an average of the unit costs, as recommended by certain guidelines? The advantages and the limitations of the various modes of assessing hospital resources in the setting of multicentric trials are discussed.

Randomized study of early hospital discharge following autologous blood SCT: medical outcomes and hospital costs.

We report the first randomized study comparing early hospital discharge with standard hospital-based follow-up after high-dose chemotherapy (HDCT) and PBSCT. Patients aged 18-65 years, with an indication of PBSCT for non-leukemic malignant diseases were randomly assigned between two arms. Arm A consisted of early hospital discharge (HDCT during hospitalization, discharge at day 0, home stay with a caregiver, outpatient clinic follow-up). In arm B patients were followed up as inpatients. In total 131 patients were analyzed (66 in arm A and 65 in arm B). Patient characteristics and hematological reconstitution were comparable between the two groups. In arm A, 26 patients were actually discharged early. Patients in group A spent fewer days in hospital (11 vs 12 days, P=0.006). This strategy resulted in a 6% mean cost reduction per patient when compared with the conventional hospital-based group. The early discharge approach within the French health system, while safe and feasible, is highly dependent on social criteria (caregiver availability and home to hospital distance). It is almost always associated with conventional hospital readmission during the aplasia phase, and limits cost savings when considering the whole population of patients benefiting from HDCT in routine clinical practice.

Does cancer survivors' health-related quality of life depend on cancer type? Findings from a large French national sample 2 years after cancer diagnosis.

We investigated whether health-related quality of life (HRQL) depends on cancer type, after adjustment for demographic and medical variables. A French national population-based survey was conducted between November and December 2004 to assess surviving cancer patients' HRQL 2 years after diagnosis. HRQL was measured by the 36-Item Short Form Survey scale. The sample included 3900 persons. All cancer diagnoses were entered in the study. We demonstrated that medical and treatment variables have an impact on patients' physical HRQL but not on mental HRQL. Cancer type impacted on physical HRQL, with those suffering from upper aerodigestive tract /lung cancers and haematological malignancies being affected to a greater degree. Disturbing side effects impacted both HRQL domains. Socio-demographic variables had statistically significant effects but not clinically meaningful ones. Socio-economic variables led to potentially clinically meaningful differences for cancer patients' HRQL and represented a socio-economic gradient in HRQL among cancer survivors. From our results, we may assert that cancer survivors, 2 years after cancer diagnosis, share a similar pattern of psychological morbidity, independent of cancer type. Patients disproportionately affected by cancer, such as those with lower educational levels and income, need to be identified and targeted and interventions which address their unique needs and concerns need to be developed.

Cost-effectiveness of adjuvant docetaxel for node-positive breast cancer patients: results of the PACS 01 economic study.

BACKGROUND: Using data from the PACS 01 randomized trial, we evaluated the cost-effectiveness of anthracyclines plus docetaxel (Taxotere; FEC-D) versus anthracyclines alone (FEC100) in patients with node-positive breast cancer. PATIENTS AND METHODS: Costs and outcomes were assessed in 1996 patients and the incremental cost-effectiveness ratios (ICERs) were estimated, using quality-adjusted life years (QALYs) as outcome. To deal with uncertainty due to sampling fluctuations, confidence regions around the ICERs were calculated and cost-effectiveness acceptability curves were drawn up. Sensitivity analyses were also carried out to assess the robustness of conclusions. RESULTS: The mean cost of treatment was 33% higher with strategy FEC-D, but this difference decreased to 18% at a 5-year horizon. The ICER of FEC-D versus FEC100 was estimated to be 9665euro per QALY gained (95% confidence interval euro2372-euro55 515). The estimated probability that FEC-D was cost-effective reached >96% for a threshold of euro50 000 per QALY gained. If the price of taxane decreased slightly, the ICER would reach some very reasonable levels and this strategy would therefore be much more cost-effective. CONCLUSION: The sequential use of FEC100 followed by docetaxel appears to be a cost-effective alternative, even when uncertainty is taken into account.