The cost of child abuse and neglect in France: The case of children in placement before their fourth birthday.

BACKGROUND: Despite the high prevalence of child abuse and neglect and its consequences on health, very few studies have evaluated the trajectories of children in placement in France, and there are no cost studies available. OBJECTIVE: To estimate the cost of abuse and neglect in children in placement before their 4th birthday in France. PARTICIPANTS AND SETTING: A cohort of children in placement before their 4th birthday in a single nursery between February 1994 and June 2001 was followed from birth until they left care. METHODS: Child protective services (CPS), health, health and social, and judiciary services utilization was derived from a qualitative analysis of the children's files and valued with their unit costs in 2013 euros from the societal perspective. Total costs and mean annual cost per child followed by CPS were calculated overall, by cost category, and by status at admission to the nursery. RESULTS: 129 children were included. Mean age at first admission was 1.9 years (SD = 1.3). The mean length of follow-up by CPS was 14.3 years (SD = 5.0). Mean annual cost per child was estimated at €53,265 (SD = 42,077), with CPS costs representing 78% of costs. 80% of health care costs were due to psychiatric care. Children with no identified psychosocial risk factors had significantly higher psychiatric care costs and health and social care costs than pre-term children and children with identified psychosocial risk factors. CONCLUSION: More research should be carried out to address early and comprehensively the multiple needs of children followed by CPS in the short- and long-term.

Global mean diffusivity: A radiomarker discriminating good outcome long term after traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) is a chronic pathology responsible for cognitive disorders impacting outcome. Global clinical outcome several years after TBI may be associated with anatomical sequelae. Anatomical lesions are not well described because characterizing diffuse axonal injury and brain atrophy require using specific MRI sequences with quantitative measures. The best radiologic parameter to describe the lesions long term after TBI is not known. OBJECTIVE: We aimed to first, assess the global volumetric and diffusion parameters related to long-term outcome after TBI and second, define the most discriminating parameter. METHODS: In this observational study, we included 96 patients with severe TBI and 22 healthy volunteers. The mean delay after TBI was 63.2 months [range 31-119]. The Glasgow Outcome Scale Extended (GOS-E) was used to assess the global long-term clinical outcome. All patients underwent multimodal MRI with measures of brain volume, ventricle volume, global fractional anisotropy (FA) and global mean diffusivity (MD). RESULTS: All 96 participants had significant impairment in global FA, global MD, brain volume and ventricle volume as compared with the 22 controls (P<0.01). Only global MD significantly differed between the "good recovery" group (GOS-E score 7-8) and the other two groups: GOS-E scores 3-4 and 5-6. Brain volume significantly differed between the GOS-E 7-8 and 3-4 groups. Global MD was the most discriminating radiological parameter for the "good recovery" group versus other patients, long term after TBI. FA appeared less relevant at this time. Global atrophy was higher in patients than controls but lacked reliability to discriminate groups of patients. CONCLUSION: Global mean diffusivity seems a more promising radiomarker than global FA for discriminating good outcome long term after TBI. Further work is needed to understand the evolution of these long-term radiological parameters after TBI.

Right ventricular failure in septic shock: characterization, incidence and impact on fluid responsiveness.

OBJECTIVE: Incidence of right ventricular (RV) failure in septic shock patients is not well known, and tricuspid annular plane systolic excursion (TAPSE) could be of limited value. We report the incidence of RV failure in patients with septic shock, its potential impact on the response to fluids, as well as TAPSE values. DESIGN: Ancillary study of the HEMOPRED prospective multicenter study includes patients under mechanical ventilation with circulatory failure. SETTING: This is a multicenter intensive care unit study PATIENTS: Two hundred and eighty-two patients with septic shock were analyzed. Patients were classified in three groups based on central venous pressure (CVP) and RV size (RV/LV end-diastolic area, EDA). In group 1, patients had no RV dilatation (RV/LVEDA < 0.6). In group 2, patients had RV dilatation (RV/LVEDA ≥ 0.6) with a CVP < 8 mmHg (no venous congestion). RV failure was defined in group 3 by RV dilatation and a CVP ≥ 8 mmHg. Pulse pressure variation (PPV) was systematically recorded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 41% of patients were in group 1, 17% in group 2 and 42% in group 3. A correlation between RV size and CVP was only observed in group 3. Higher RV size was associated with a lower response to passive leg raising for a given PPV. A large overlap of TAPSE values was observed between the 3 groups. 63.5% of patients with RV failure had a normal TAPSE. CONCLUSIONS: RV failure, defined by critical care echocardiography (RV dilatation) and a surrogate of venous congestion (CVP ≥ 8 mmHg), was frequently observed in septic shock patients and negatively associated with response to a fluid challenge despite significant PPV. TAPSE was unable to discriminate patients with or without RV failure.

Factors associated with direct health care costs in schizophrenia: Results from the FACE-SZ French dataset.

INTRODUCTION: There is a lack of data on health care consumption of patients suffering from schizophrenia, as well as on the related health care costs. Factors associated with health care costs have not been widely studied, whereas knowledge on this topic would allow identifying risk factors and delineating strategies to improve patients' health and follow-up, likely to also decrease health care costs. The aim of this study was to estimate the average direct health care cost of patients with schizophrenia in France and to identify the factors associated with this cost. METHODS: The study population included patients with schizophrenia enrolled in the FondaMental Advanced Centers of Expertise for Schizophrenia cohort. We accounted for the costs directly related to the treatment of schizophrenia. They included the costs of hospitalizations (full- and part-time), psychiatric ambulatory consultations and medications. We studied three categories of factors potentially associated with direct health care costs: demographic, socioeconomic and clinical characteristics. RESULTS: Three hundred and ninety five patients with schizophrenia were included. The mean (median) annual direct health care cost per patient amounted to €14,995 (€3,435). A lower level of functioning and being single were associated with a higher cost. A significant association between the expert center of inclusion and the direct health care cost of schizophrenia was also highlighted. CONCLUSION: Our results highlighted the significant cost of schizophrenia and suggest that improvement in patient care, based on well-validated targeted therapeutic interventions such as psycho-education and cognitive rehabilitation, could reduce worsening in symptom severity and therefore decrease health care costs.

The REFINEMENT Glossary of Terms: An International Terminology for Mental Health Systems Assessment.

Comparing mental health systems across countries is difficult because of the lack of an agreed upon terminology covering services and related financing issues. Within the European Union project REFINEMENT, international mental health care experts applied an innovative mixed "top-down" and "bottom-up" approach following a multistep design thinking strategy to compile a glossary on mental health systems, using local services as pilots. The final REFINEMENT glossary consisted of 432 terms related to service provision, service utilisation, quality of care and financing. The aim of this study was to describe the iterative process and methodology of developing this glossary.

Socio-demographic, clinical characteristics and utilization of mental health care services associated with SF-6D utility scores in patients with mental disorders: contributions of the quantile regression.

PURPOSE: Health-related quality of life (HRQoL) is a widely used concept in the assessment of health care. Some generic HRQoL instruments, based on specific algorithms, can generate utility scores which reflect the preferences of the general population for the different health states described by the instrument. This study aimed to investigate the relationships between utility scores and potentially associated factors in patients with mental disorders followed in inpatient and/or outpatient care settings using two statistical methods. METHODS: Patients were recruited in four psychiatric sectors in France. Patient responses to the SF-36 generic HRQoL instrument were used to calculate SF-6D utility scores. The relationships between utility scores and patient socio-demographic, clinical characteristics, and mental health care utilization, considered as potentially associated factors, were studied using OLS and quantile regressions. RESULTS: One hundred and seventy six patients were included. Women, severely ill patients and those hospitalized full-time tended to report lower utility scores, whereas psychotic disorders (as opposed to mood disorders) and part-time care were associated with higher scores. The quantile regression highlighted that the size of the associations between the utility scores and some patient characteristics varied along with the utility score distribution, and provided more accurate estimated values than OLS regression. CONCLUSIONS: The quantile regression may constitute a relevant complement for the analysis of factors associated with utility scores. For policy decision-making, the association of full-time hospitalization with lower utility scores while part-time care was associated with higher scores supports the further development of alternatives to full-time hospitalizations.

The effect of treatment as usual on major depressive disorder: A meta-analysis.

BACKGROUND: Health-economic models are used to evaluate the long-term cost-effectiveness of an intervention and typically include treatment as usual (TAU) as comparator. Part of the data used for these models are acquired from the literature and thus valid information is needed on the effects of TAU on depression. The aim of the current meta-analysis was to examine positive and negative outcomes of major depression for patients receiving TAU. METHODS: We conducted a systematic literature search in PubMed, EMBASE, PsycInfo, and the Cochrane Central Register of Controlled Trials. Eligible studies were randomized controlled trials including a TAU group for depression. The quality of the included studies was assessed using the criteria described in the "Risk of bias assessment tool". Four separate meta-analyses were performed to estimate remission, response, reliable change and deterioration rates at short-term (≤6 months from baseline). RESULTS: Thirty-eight studies including 2099 patients in the TAU were identified. Nine studies (24%) met five or six quality criteria, 17 studies (44%) met three or four quality criteria and 12 studies (32%) met one or two quality criteria. After adjusting for publication bias, the first meta-analysis (n=33) showed that 33% of the patients remitted from depression. The second meta-analysis (n=13) demonstrated that 27% of the patients responded to treatment, meaning that their depressive symptom decreased at least 50% from baseline to follow-up measurement. The third meta-analysis (n=7) indicated that 31% of the patients showed a reliable change, meaning that their depressive symptoms improved more than expected by random variation alone. Finally, 12% of the patients deteriorated, meaning that their depressive symptoms became more severe. LIMITATIONS: Statistical heterogeneity was substantial in most analyses and was not fully explained by subgroup analyses. The quality of the included studies was moderate. This may result in overestimation of the true effects. CONCLUSIONS: The treatments labelled as TAU for depression were clinically and statistically heterogeneous. We demonstrated that a few patients benefited from TAU and a small number of patients suffered from worsened depressive symptoms at the short term. The results can be included in health-economic models that compare depression treatments to TAU.

Evolution of public and non-profit funding for mental health research in France between 2007 and 2011.

Since 2007, actions have been undertaken in France to foster mental health research. Our objective was to assess their utility by estimating the evolution of public and non-profit funding for mental health research between 2007 and 2011, both in terms of total funding and the share of health research budgets. Public and non-profit funding was considered. Core funding from public research institutions was determined through a top-down approach by multiplying their total budget by the ratio of the number of psychiatry-related publications to the total number of publications focusing on health issues. A bottom-up method was used to estimate the amount of project-based grants and funding by non-profit organizations, which were directly contacted to obtain this information. Public and non-profit funding for mental health research increased by a factor of 3.4 between 2007 and 2011 reaching €84.8 million, while the share of health research funding allocated to mental health research nearly doubled from 2.2% to 4.1%. Public sources were the main contributors representing 94% of the total funding. Our results have important implications for policy makers, as they suggest that actions specifically aimed at prioritizing mental health research are effective in increasing research funding. There is therefore an urgent need to further undertake such actions as funding in France remains particularly low compared to the United Kingdom and the United States, despite the fact that the epidemiological and economic burden represented by mental disorders is expected to grow rapidly in the coming years.

Health-related quality of life and utility scores in people with mental disorders: a comparison with the non-mentally ill general population.

There is a lack of comparable health-related quality of life (HRQoL) and utility data across all mental disorders and all inpatient and outpatient settings. Our objective was to investigate the HRQoL and utility scores of people with mental disorders in France, treated in outpatient and inpatient settings, and to identify the HRQoL and utility score losses attributable to mental disorders compared to the non-mentally ill general population. A cross-sectional survey was conducted to assess HRQoL (SF-12) and utility scores of patients with mental disorders and followed in four psychiatric sectors in France. Scores were described by demographic and clinical characteristics and were then adjusted on age and gender and compared with those of the non-mentally ill general population. Median HRQoL and utility scores were significantly lower in patients with mental disorders than in the non-mentally ill general population; median differences amounted to 5.4 for the HRQoL physical score, to 11.8 for the HRQoL mental score and to 0.125 for the utility score. Our findings underscore the negative impact of mental disorders on HRQoL in France and provide a baseline to assess the global impact of current and future organizational changes in the mental health care system.

Quality of life instruments used in mental health research: properties and utilization.

Quality of life (QoL) assessment is increasingly used in mental health. Multiple instruments exist, but the conditions for choosing one instrument over another for purposes of a specific study are not clear. We performed a systematic review to identify the QoL instruments used in mental health. The instruments were systematically described regarding their intrinsic properties (e.g., generic v. disease-specific) and their characteristics of utilization in studies (e.g., study objectives). Using cluster analyses, we investigated the existence of similar instruments with respect to each of these sets of characteristics and studied potential links between instruments' intrinsic properties and their characteristics of utilization. We included 149 studies in which 56 distinct instruments were used. Similarities were found among instruments in terms of their intrinsic properties as well as their characteristics of utilization, leading to the construction of four clusters of instruments in each case. However, no relevant links were identified between instruments' intrinsic properties and their characteristics of utilization, suggesting that the choice of QoL instruments did not depend on their properties. A consensus about common QoL instruments must be reached to facilitate the choice of instruments, the comparison of results and thus to have an impact on clinical and policy decision-making.

The cost of mental disorders in France.

AIMS: To provide burden estimates of mental disorders in France and compare the results with findings from other countries and EU in general. METHOD: Stepwise top down approach, consisting of analyses of existing data sets, national surveys and ad hoc surveys. Mental disorder was defined by diagnoses in the chapter 'Mental and behavioural disorders' from the International Classification of Diseases, tenth revision (ICD-10), excluding, dementia and mental retardation. Disease burden was measured by total health care costs, social care costs, lost output and loss of well being, 2007 data was used consistently. RESULTS: The total cost of mental health care was estimated at €13.4 billion, or 8% of total healthcare expenditures. Total cost of health and social services was estimated at €6.3 billion, including €1.3 billion for informal care. Total cost of lost production amounted to €24.4 billion, €20.0 billion for lost output and €4.4 billion for workers' compensation. Mental disorders resulted in a total loss of 2.2 million QALY and a total cost of lost well being of €65.08 billion. The total costs of mental disorders were estimated at €109 billion, 20% of which are actual money spent and 80% the social value of disease consequences. CONCLUSION: In France with a population of 65 million, an estimated 12 million inhabitants currently suffer from one or more mental disorders. The true size and burden of mental disorders in France was significantly underestimated by policy makers in the past.

Does lay media ranking of hospitals reflect lower mortality in treating acute myocardial infarction?

BACKGROUND: Ranking of hospitals by lay media has attracted widespread attention but may not accurately reflect quality. Acute myocardial infarction (AMI) mortality is a straightforward measure of clinical outcome frequently used by ranking algorithms. AIMS: Our aim was to assess whether ranking among top hospitals correlated with lower in-hospital risk-adjusted mortality following admission for AMI. METHODS: Using a hierarchical regression model and the comprehensive nationwide database of hospital AMI admissions from 2004 to 2007 in France, we analysed crude and risk-adjusted hospital mortality rates in the ranked ('best') hospitals versus non-ranked hospitals. We subsequently restricted the comparison to non-ranked hospitals with matching on-site facilities. RESULTS: We analysed 192,372 admissions in 439 hospitals, 43 of which were in the ranked group. Patients admitted to the 396 non-ranked hospitals tended to be older with more comorbidities and underwent fewer revascularization procedures than patients admitted to ranked hospitals. Between hospital differences accounted for 10% of differences in mortality. Crude mortality was lower in ranked versus non-ranked hospitals (7.5% vs. 11.9%; P<0.001). The survival advantage associated with admission to ranked hospitals was reduced after adjustment for age and sex (5.7% vs. 6.4%; P=0.087) and comorbidities (4.9% vs. 5.5%; P=0.102). CONCLUSIONS: Ranked hospitals have similar adjusted AMI mortality rates to those not ranked and patient characteristics rather than hospital differences account for the variation in outcomes.

Public and nonprofit funding for research on mental disorders in France, the United Kingdom, and the United States.

OBJECTIVE: To document the investments made in research on mental disorders by both government and nonprofit nongovernmental organizations in France, the United Kingdom, and the United States. DATA SOURCES: An exhaustive survey was conducted of primary sources of public and nonprofit organization funding for mental health research for the year 2007 in France and the United Kingdom and for fiscal year 2007-2008 in the United States, augmented with an examination of relevant Web sites and publications. In France, all universities and research institutions were identified using the Public Finance Act. In the United Kingdom, we scrutinized Web sites and hand searched annual reports and grant lists for the public sector and nonprofit charitable medical research awarding bodies. In the United States, we included the following sources: the National Institutes of Health, other administrative entities within the Department of Health and Human Services (eg, Centers for Disease Control and Prevention), the Department of Education, the Department of Veterans Affairs, the Department of Defense, and the National Science Foundation and, for nonprofit funding, The Foundation Center. DATA EXTRACTION: We included research on all mental disorders and substance-related disorders using the same keywords. We excluded research on mental retardation and dementia and on the promotion of mental well-being. We used the same algorithm in each country to obtain data for only mental health funding in situations in which funding had a broader scope. RESULTS: France spent $27.6 million (2%) of its health research budget on mental disorders, the United Kingdom spent $172.6 million (7%), and the United States spent $5.2 billion (16%). Nongovernmental funding ranged from 1% of total funding for mental health research in France and the United States to 14% in the United Kingdom. CONCLUSIONS: Funding for research on mental disorders accounts for low proportions of research budgets compared with funding levels for research on other major health problems, whereas the expected return on investment is potentially high.