[Decision-making process and evaluation of public health interventions]. / Démarche décisionnelle et évaluation des interventions de santé publique.

OBJECTIVE: We have designed a methodological framework for experts involved in the support of decision-making in public health interventions. METHODS: The methodological framework consists of four elements: 1) A series of nine questions, formulated in non-technical terms, relevant to assessment of the usefulness of an intervention, at a given time in a given context; 2) Translation of these questions into concepts related to the evaluation of interventions (definition of the intervention, its target and objective, potential and actual effectiveness, safety, efficiency, and equity); 3) Logical organization of the information needed to address and answer the questions; and 4) An algorithm to translate the available information into recommendations on the real usefulness of the intervention in the context in which the questions were raised. RESULTS: Each step is illustrated by questions raised about road safety interventions, screening, blood transfusion and measures proposed during the COVID-19 pandemic. CONCLUSION: Decision-making can be facilitated if experts provide decision-makers with a formal summary of the strengths and weaknesses of existing knowledge, based on an analysis of all facets of an intervention's potential usefulness.

[Evaluation of the effects of a complex intervention]. / Évaluation des effets d'une intervention complexe.

Appraising the effects of a complex intervention is one step in a more broadly based research process, from the construction or modelling of the intervention to its actual deployment. It consists in measuring the effectiveness or impact of the intervention, i.e. analyzing its capacity to produce change. The aim of this article is to obtain unbiased measurement of the average effects of an intervention, based on a panel of predetermined parameters and on the assumption of a causal link between the intervention and the measured result. This article is consequently devoted to evaluation of the effects of a complex intervention and focuses on the methodological challenges of its three key stages : 1) modelling of the intervention and feasibility analysis, essential prerequisites ; 2) the choice of study design and of the effects to be measured, that is to say the methodological premises ; and 3) process analysis, carried out in parallel with the evaluation of effects, leading to an indispensable appraisal of the intervention implementation and of the context into which it is integrated. The article is illustrated by five intervention impact assessment projects. A specific objective when evaluating the effects of a complex intervention consists in (a) moving away from a simple search for causality involving the intervention and its effects and (b) toward understanding of the effectiveness mechanisms, once again taking into account the context and the actual conditions of implementation. The challenge is to embrace rather than limit the complexity of the intervention, this being an essential prerequisite for its successful deployment and eventual generalization.

[Statistical and epidemiological methods used in biomedical research: implications for initial medical education]. / Méthodes biostatistiques et épidémiologiques employées pour la recherche biomédicale : implications pour la formation médicale initiale.

BACKGROUND: The main source of key medical information consists in original articles published in peer-reviewed biomedical journals. Reported studies use increasingly sophisticated statistical and epidemiological approaches that first require a solid understanding of core methods. However, such understanding is not widely shared among physicians. Our aim was to assess whether the basic statistical and epidemiological methods used in original articles published in general biomedical journals are taught during the first years of the medical curriculum in France. METHODS: We selected original articles published in The New England Journal of Medicine, The Lancet, and The Journal of the American Medical Association, over a period of six months in 2007 and in 2008. A standardized statistical content checklist was used to extract the necessary information in the "Abstract", "Methods", "Results", footnotes of tables, and legends of figures. The methods used in the selected articles were compared to the national program and the public health program of biostatistics and epidemiology taught during the first six years of medical school. RESULTS: The 237 analyzed original articles all used at least one statistical or epidemiological method. Descriptive statistics, confidence interval and Chi(2) or Fisher tests, methods used in more than 50% of articles, were repeatedly taught throughout the medicine curriculum. Measures of association, sample size, fit and Kaplan-Meier method, used in 40 to 50% of articles, were specifically taught during training sessions on critical reading methods. Cox model (41% of articles) and logistic regression (24% of articles) were never taught. The most widely used illustrations, contingency tables (92%) and flowcharts (48%), were not included in the national program. CONCLUSION: More teaching of the core methods underlying the understanding of sophisticated methods and illustrations should be included in the early medical curriculum so that physicians can read the scientific literature critically for their medical education.

Cross-cultural adaptation and validation of the knee and hip health-related quality of life (OAKHQoL) in a Moroccan Arabic-speaking population.

The aim of this study was to adapt the knee and hip osteoarthritis quality of life questionnaire (OAKHQoL) into Moroccan Arabic and to determine its psychometric properties. After translation, back-translation and pretesting, the translated version was submitted to an expert committee. The psychometric properties were tested on patients with hip or knee osteoarthritis. Internal consistency was tested using Cronbach's alpha coefficient (α), and the test-retest reliability using intraclass correlation coefficients (ICC). Construct validity was assessed by examining item-convergent and divergent validity and by comparing the average scores between age groups and walk perimeter groups. The study was conducted on 131 patients (115 with osteoarthritis of the knee and 16 with osteoarthritis of the hip). The "physical activities" (α = 0.93), "mental health" (α = 0.84) and "pain" (α = 0.88) dimensions of the Arabic version were internally reliable. The ICC were adequate to good; 0.83 for "physical activities", 0.65 for "mental health" and 0.70 for "pain" dimensions. The instrument demonstrated good construct validity; all items exceeded the 0.4 criterion for convergent validity, except items 13 and 41 and most of the correlations between items and their own scale were significantly higher than their correlations with other scales. A semantically equivalent translation has been developed with cultural adaptation of OAKHQoL. It is quite reliable and a valid measure of the effect of osteoarthritis on the quality of life on Moroccan patients.

[Characteristics of transfusion recipients in Bordeaux University Hospital. A descriptive study using hospital claims and haemovigilance system databases]. / Caractéristiques des patients transfusés au CHU de Bordeaux : étude descriptive à l'aide des données du PMSI et du système d'hémovigilance.

OBJECTIVE: The steady increase of the blood demand since 2001 requires to study the clinical characteristics of blood components recipients. The objective was to describe patients transfused in 2006 in Bordeaux University Hospital, and to identify the diseases which justified the transfusion practice, using French hospital claims database. STUDY DESIGN: Data from haemovigilance system were linked to hospital claims databases in order to describe patients transfused in 2006. To target diseases related to transfusion, a list of diagnoses considered as markers for transfusion was drawn up, and validated by physicians prescribing blood components. RESULTS: Among the 100,004 patients admitted to hospital in 2006, 6275 (6.3%) received blood components; 46,727 blood units were transfused to these patients, including 67% of red blood cell, 13% of platelet concentrates and 20% of fresh-frozen plasma; 69% of blood units were prescribed in medical wards, 30% in surgery wards and 1% in gynaecology and obstetrics. The main diagnoses associated with blood transfusion were circulatory complications after cardiac surgery (80% of patients with this diagnosis were transfused), bone marrow aplasia (76% of patients), anaemia (55%), and gastro-intestinal bleeding (48%). The highest numbers of blood units were transfused to patients with hypovolemic, traumatic or postoperative shock, anaemia, hemopathy, or coagulation disorders. CONCLUSION: This study provided a clinical profile of the transfused patients. Data collected could be used to plan blood collection and to define objectives and resources of healthcare establishments.

Reliability of a classification of fractures of the hand based on the AO comprehensive classification system.

The AO/ASIF Comprehensive Classification of Fractures is a logical system to describe and compare long-bone fractures. We adapted this classification to the hand to classify fractures of the metacarpals and phalanges. The alphanumeric sequence codes the bone involved, the bone segment, and the fracture type. To assess the reliability of this classification, one hundred radiographs of hand fractures were classified by nine observers in four sessions. Using Cohen's kappa coefficient, overall inter-observer agreement was 0.93 for bone identification, 0.80 for bone segment, and 0.44 for fracture type. Corresponding intra-observer agreement was 0.94, 0.92 and 0.62 respectively.

[Consensus methods: review of original methods and their main alternatives used in public health]. / Méthodes de consensus: revue des méthodes originales et de leurs grandes variantes utilisées en santé publique.

BACKGROUND: Consensus-based studies are increasingly used as decision making methods, for they have lower production cost than other methods (observation, experimentation, modelling) and provide results more rapidly. The objective of this paper is to describe the principles and methods of the four main methods, Delphi, nominal group, consensus development conference and RAND/UCLA, their use as it appears in peer-reviewed publications and validation studies published in the healthcare literature. METHODS: A bibliographic search was performed in PubMed/Medline, Banque de données santé publique (BDSP), The Cochrane Library, Pascal and Francis. Keywords, headings and qualifiers corresponding to a list of terms and expressions related to the consensus methods were searched in the thesauri, and used in the literature search. A search with the same terms and expressions was performed on Internet using the website Google Scholar. RESULTS: All methods, precisely described in the literature, are based on common basic principles such as definition of subject, selection of experts, and direct or remote interaction processes. They sometimes use quantitative assessment for ranking items. Numerous variants of these methods have been described. Few validation studies have been implemented. Not implementing these basic principles and failing to describe the methods used to reach the consensus were both frequent reasons contributing to raise suspicion regarding the validity of consensus methods. CONCLUSION: When it is applied to a new domain with important consequences in terms of decision making, a consensus method should be first validated.

Survey of European programmes for the epidemiological surveillance of congenital toxoplasmosis.

The objective of this investigation was to describe systems for the epidemiological surveillance of congenital toxoplasmosis implemented in European countries. In September 2004, a questionnaire, adapted from the evaluation criteria published by the United States Centers for Disease Control and Prevention, was sent to a panel of national correspondents in 35 countries in the European geographical area with knowledge of the epidemiological surveillance systems implemented in their countries. Where necessary, we updated the information until July 2007. Responses were received from 28 countries. Some 16 countries reported routine surveillance for toxoplasmosis. In 12 countries (Bulgaria, Cyprus, Czech Republic, England and Wales, Estonia, Ireland, Latvia, Lithuania, Malta, Poland, Scotland and Slovakia), surveillance was designed to detect only symptomatic toxoplasmosis, whether congenital or not. Four countries reported surveillance of congenital toxoplasmosis, on a regional basis in Italy and on a national basis in Denmark, France and Germany. In conclusion, epidemiological surveillance of congenital toxoplasmosis needs to be improved in order to determine the true burden of disease and to assess the effectiveness of and the need for existing prevention programmes.

[The fate of the abstracts presented to the biannual meetings of the French National Society of Internal Medicine]. / Devenir des travaux publiés sous forme de résumés dans les actes des congrès semestriels de la Société nationale française de médecine interne.

PURPOSE: Medical meetings give the opportunity to present oral communications or posters to the attending participants. However, the peer-reviewed publication of a full article allows to reach a wide readership. KEY POINTS: The survey that was performed on the oral communications and posters presented at the 43rd meeting of the French National Society of Internal Medicine, December 2000, showed that amongst the 303 selected podium presentations and posters, only 82 (27%) were published during the five following years. Podium presentations were more likely to be published than posters (36% versus 22%). CONCLUSION: Many oral communications and posters that are presented in medical meeting are not followed by the publication of a peer-reviewed full article despite the modern means of communication. However, this issue is of paramount importance as beyond the legitimate personal satisfaction of a publication, the scientific and academic recognition are the ground of medical career achievement for many physicians.

The recent dramatic decline in road mortality in France: how drivers' attitudes towards road traffic safety changed between 2001 and 2004 in the GAZEL cohort.

A very significant decline in the number of road casualties has been observed recently in France, concomitantly with a dramatic increase in law enforcement. The aim of this study was (i) to assess changes in attitudes about road traffic accident (RTA) prevention initiatives in France from 2001 to 2004 and (ii) to identify factors associated with an increase in positive attitudes towards RTA prevention initiatives. In 2001 and 2004, 9216 participants reported their attitudes towards traffic safety using the same self-administered Driving Behaviour and Road Safety Questionnaire. Sociodemographic, psychological and behavioural data were also available. The mean change in scores analysis showed that support for relaxing existing regulations decreased significantly during this period, while support for heightened enforcement and stricter regulations showed some decrease but remained high overall, especially concerning blood alcohol content and speed controls. Multivariate analyses suggest that highly educated drivers changed their attitudes towards road safety regulations more than other categories. Our results suggest that increased traffic law enforcement measures led to increasing support for current restrictions. Even if support for additional traffic law enforcement began to wane slightly in 2004, a large part of our population remained in favour of strengthening law enforcement related to speeding and drunk driving.

Reliability of the pulp nail bone (PNB) classification for fingertip injuries.

Evans and Bernardis proposed the 'PNB classification', by which a fingertip injury is classified according to each structure: pulp P, nail N, bone B. The objective of this study was to assess the inter-observer reliability, repeatability and accuracy of PNB. One hundred patients presenting with a fingertip injury were included prospectively, photographed, then classified in randomly chosen orders by nine independent observers. A third were drawn randomly and classified a second time to measure repeatability. A reference classification was also provided by one of the authors of the PNB system. Classifications agreed with the reference in 59% of injuries for P, 55% for N and 54% for B. The Kappa values for inter-observer agreement were 0.520 for P, 0.512 for N, and 0.504 for B; for intra-observer agreement, they were 0.616 for P, 0.658 for N, and 0.577 for B. Although levels of agreement are comparable with results found for other classifications, they are insufficient for use of the PNB classification without improvement.

Metabolic syndrome components in Indian migrants with type 2 diabetes. A matched comparative study.

OBJECTIVE: To study the metabolic syndrome (MS) in Indian subjects with type 2 diabetes (T2D) in comparing them with controls from the Indian community and from the general population. METHOD: An adapted definition of MS by the Third report of the National Cholesterol Education Program's Adult Treatment Panel III was used. We defined three groups matched for sex and age (+/-5 years). Non parametric tests for comparison of matched samples and conditional logistic regression were used. RESULTS: We selected 71 Indians with T2D (group 1) and two control groups with fasting blood glucose<6.1 mmol/L: 71 Indians (group 2) and 213 subjects from the general population (group 3). Patients were 24 to 76 years-old and each group contained 56% men. Globally, MS was identified in 77% of the group 1 when diabetes was taken into account. When diabetes was excluded there were 47% of MS in group 1, 18% in group 2 and 16% in group 3. The clusters of four factors (hypertension, large waist circumference, hypertriglyceridemia and Low HDL-C) were more common in Indians. The most frequent factors were hypertriglyceridemia and large waist circumference in Indians. Indians with T2D had a 5-fold higher risk of MS than the general population group, OR (95% CI): 4.93 (2.71 - 8.97); P<0.001. CONCLUSION: The high frequency of MS and of hypertriglyceridemia in Indians with T2D highlights the need for screening and management of MS in this population facing a high cardiovascular risk.

Lower plasma triglycerides are associated with increased need for insulin requirement in poorly controlled Type 2 diabetic patients.

AIMS: To identify factors associated with insulin requirement in Type 2 diabetic patients, and to examine the significance of a normal plasma triglyceride level. METHODS: One hundred and three poorly controlled (HbA1c = 9.4 +/- 1.9%) Type 2 diabetic patients initially not treated with insulin were followed up for 5 years. Insulin was administered if HbA1c > 8% despite maximal oral anti-diabetic treatment and bodyweight control. Variables were compared between insulin requiring and non-insulin-treated patients using unpaired t-tests. The outcomes of initially normotriglyceridaemic (< 1.7 mmol/l) and hypertriglyceridaemic patients were compared using unpaired t-tests, and a survival analysis (Cox proportional hazards model). RESULTS: Sixty-three patients were transferred to insulin. They were 5 years older (P = 0.004), with a 3-year longer duration of their diabetes (P = 0.03), a 1.2% higher HbA1c (P = 0.002), and 50% lower triglyceride levels (P = 0.02) than the others. The survival analysis showed that a long duration of diabetes, a high HbA1c, and a normal triglyceride level were associated with the need for insulin; the effect of normotriglyceridaemia was significant in the most poorly controlled (HbA1c > 9.5%) patients (relative risk: 2.35, 95% confidence interval: 1.16-5.52, P = 0.016). The 46 normotriglyceridaemic patients were leaner (P = 0.0004) and had lower C-peptide levels (P = 0.0008) than the others. Despite similar diabetes duration and HBA1c, more were transferred to insulin (normotriglyceridaemic: 71%, hypertriglyceridaemic: 52%, P = 0.03). CONCLUSION: A normal triglyceride level is associated with a need for insulin in poorly controlled Type 2 diabetes.

Pathways to care of first-admitted subjects with psychosis in South-Western France.

BACKGROUND: A limited number of studies have assessed the pathways to care of patients with first-episode psychosis. The aim of the study was to describe the pathways to care of subjects with psychosis between onset of psychosis and first admission, and to examine the demographic and clinical factors influencing access to care. METHOD: Number and type of helping contacts since onset of first psychotic symptoms were assessed using multiple sources of information in 86 subjects with psychosis first-admitted in two hospitals of South-Western France. Characteristics independently associated with long delays between onset of symptoms and first helping contact, first treatment and first admission were explored using logistic regressions. RESULTS: Twelve per cent of subjects were first admitted without any previous helping contact. The patients were seen by a median of two helpers (maximum 7). For most patients (70%), the first helping contact was a health care professional, and the same proportion of patients had a first contact with a GP or a psychiatrist. The type of first contact was not predicted by demographic or clinical characteristics. Subjects with poor pre-morbid functioning or at-risk behaviour were more likely to have a delayed access to care. CONCLUSIONS: The delay in access to care may not be totally attributed to inadequate management by health professionals, but may be a characteristic of the disease itself, at least in part independent of the organization of the health system.