[Metabolic testing rates after initiation of antipsychotic treatment in persons initially treated by conventional mood-stabilizers]. / Surveillance métabolique biologique après initiation d'un traitement antipsychotique chez des personnes traitées par lithium ou anticonvulsivants.

OBJECTIVES: To assess the rate of metabolic testing after initiation of second-generation antipsychotics (SGA) prescription in persons initially treated by conventional mood-stabilizers (lithium or anticonvulsants, as a proxy of bipolar disorder diagnosis) and to compare the rates of metabolic testing in these persons with those in persons with initiation of first-generation antipsychotics (FGA) prescription or with no antipsychotic prescription. METHOD: Data were anonymously extracted from the 2004 to 2006 French national health database of the Régime Social des Travailleurs Indépendants (RSI). Patients aged 18 years and over were included in the cohort if they fulfilled the following criteria over a three-month inclusion period: refunding of lithium or anticonvulsant over the 3 months without discontinuation (as a proxy of bipolar disorder diagnosis), no concomitant refunding over the 3months of antipsychotic, and no concomitant refunding over the 3 months of an anti-diabetic drug (as a marker of diabetes) or a lipid-lowering drug (as a marker of hyperlipidemia). Metabolic testing was assessed using information collected in the RSI database on the reimbursement of glucose-specific serum tests (glycaemia) and lipid-specific serum tests (total cholesterol). Serum glucose and lipid testings were assessed at baseline and at 12-week follow-up for the first episode of antipsychotic dispensing. Multivariate analyses were performed to compare the rate of metabolic testing in users of SGA to those of users of FGA and to those of non-users of antipsychotics. RESULTS: Three thousand one hundred and seventy patients were included. Of the 490 (15.4%) persons with a first episode of antipsychotic dispensing after the index date, 138 (4.3%) were dispensed only FGA over the first episode and 352 (11.1%) SGA (including 37 patients with both SGA and FGA dispensing). Metabolic testing at baseline and at 12-week follow-up was performed for 14% of persons with initiation of FGA and 12% with initiation of SGA. Almost no patient had both baseline and follow-up testing. Testing rates were lower for lipid testing than for glucose testing. Compared to persons with no antipsychotic, persons with SGA were significantly more likely to have metabolic testing at baseline and at follow-up, independently from other characteristics (adjusted OR=0.24, 95% CI 0.16 to 0.36). No difference was found between persons with SGA and those with FGA (adjusted OR=1.12, 95%CI 0.62 to 2.0). Regarding the other characteristics associated with likelihood of metabolic testing (irrespective of the treatment group), women were more likely than men to have metabolic testing at baseline but not at follow-up. Elderly persons and persons with low occupational status were more likely to have metabolic testing at follow-up. CONCLUSION: From a public health point of view, such findings indicate that the metabolic risks associated with SGA use in real-life conditions are widely underestimated. Regarding the temporal trends of antipsychotic prescription, with the dramatic rise of SGA use observed in most countries, it is a public health priority to improve metabolic monitoring in SGA users, irrespective of the underlying diagnosis. Since it is more complex to modify pre-existing inadequate practices than to initiate correct ones in new prescribers, great attention should be paid to the need for delivering strong messages regarding the metabolic risks associated with SGA prescription during the initial training of physicians.

Antipsychotic use patterns in persons initially treated with mood stabilizers: a naturalistic study.

INTRODUCTION: Little information is available on the pattern of use of antipsychotics in naturalistic conditions in persons initially treated with "conventional" mood stabilizers (lithium and anticonvulsants). METHODS: Data on community prescriptions were extracted from the 2004-2006 claims database of a French health care insurance fund for self-employed workers. Patients included were those continuously exposed to mood stabilizers without concomitant dispensing of antipsychotics over at least a 3-month period. RESULTS: Of the 3 958 persons included, 17.8% had at least one addition/switch to antipsychotics over the follow-up period. The most frequent pattern was addition of second-generation antipsychotics (SGAPs) (41%) or first-generation antipsychotics (FGAPs) (23%) to the mood stabilizer for a relatively short period of time. A switch from mood stabilizer to SGAPs (20%) or FGAPs (15%) was less frequent. Mood stabilizers alone were prescribed again in most patients with the addition of FGAPs (72%) or SGAPs (61%) to mood stabilizers. Conversely, the majority of patients with a switch from mood stabilizers to FGAPs (55%) or SGAPs (58%) went on with these latter treatments over the follow-up. CONCLUSIONS: SGAPs are preferentially prescribed in combination with mood stabilizers and their pattern of use is similar to that of FGAPs.

[What public health measures could reduce antenatal exposure to smoking and improve the quality of perinatal care? The point of view of a public health physician]. / Quelles sont les mesures de santé publique susceptibles de réduire l'exposition anténatale au tabagisme et d'améliorer les indicateurs de qualité des soins périnatals? Le point de vue du médecin de santé publique.

From the population standpoint of public health, two domains of intervention, healthcare programs and good clinical practices, are concerned by the question of smoking cessation. These two domains imply different targets and methodology to achieve a common objective. To achieve improvement starting from an analysis of the existing situation, it is necessary to elaborate guidelines for good clinical practice and also carefully monitor their application in terms of training, evaluation and certification. Health promotion programs designed to help young women stop or not start smoking necessarily imply the use of recognized criteria of efficacy and predictability.

[What are the conditions for the success of public health interventions?]. / Quelles sont les conditions de réussite des interventions en santé publique?

This article aims to identify the optimal conditions necessary for the implementation of public health interventions. In order to approach this question, the authors relied upon a review of the health promotion literature and on three evaluation reports on the processes undertaken within the framework of French regional health programmes and their British equivalent counter-parts. Based on the synthesis of this work, the article puts forth recommendations for carrying out public health interventions at the national, regional and local level. It concludes by offering some structural proposals for improving health programme implementation.

[Prenatal screening of cytomegalovirus in France: an increasing frequency practices of screening from 2000 to 2003 despite no recommendation in favor]. / Dépistage prénatal du cytomégalovirus en France: une augmentation des pratiques de prescription de 2000 à 2003 malgré l'absence de recommandation favorable.

BACKGROUND: Screening cytomegalovirus infection in pregnant women is still controversial in 2004 in France. In this context, we evaluated the interest of such a screening in 2004 in France. This paper was designed to describe trends in CMV prenatal screening practices in 2000-2003 in France. METHODS: This retrospective study, describes the prescription of CMV screening in HIV-negative pregnant women giving birth in the private care sector, according to their occupational category and geographical area. Data were provided by the "Caisse d'Assurance-maladie des Travailleurs Indépendants" (independent workers health insurance fund). RESULTS: The study included 34.347 women, delivering in 2001-2004 (beginning of pregnancy in 2000-2003). The number of pregnant women screened for CMV increased significantly between 2000 (5.8%, 301/5.177), 2001 (11.1%, 1.130/10.139) and 2002 (22.1%, 2.701/12.223), (p<0.001), then was stable in 2003 (22.0%, 1.496/6.808). The percentage of women screened for CMV, at least once during pregnancy, doubled between 2001 and 2002 (p<0.001) in each occupational category and geographical area. It was significantly different between occupational categories (p<0.01), with a higher percentage of women in the self-employed and commercial agent occupational categories than in the craftsman category. There was also a significant difference between geographical areas (p<0.001), with a higher rate in Paris. CONCLUSION: This study providing baseline information on CMV practices showed: 1- a significant increase in the frequency of CMV screening among pregnant women over the period 2000-2002 with a stabilization in 2003; 2- a similar trend observed in each occupation category and geographical area but with a markedly higher frequency of screening practices in the Paris area and among self-employed women. A study measuring the effect of the 2004 ANAES recommendation suggesting not to screen for CMV during pregnancy should be conducted.

[Oral health screening: evaluation of implementation of a national programme]. / Evaluation de la réalisation du bilan bucco-dentaire (BBD) conventionnel.

BACKGROUND: The first national French oral health screening was implemented in 1998 toward young people aged from 15 to 18 Years. These adolescents were invited every year to a free dental check up performed by their dentist. The aim of this study, carried out for self-employed persons insured by compulsory national health insurance, was to measure the rate of dental checks during years 1998-1999-2000, to estimate the oral health status, to assess the factors related to the dental care consumption in 1998, and the predictive factors for a successive dental check. METHODS: We included seventy four French counties. Every teenager born in 1983 (23.874) was invited. We collected data from both the health insurance databases and the form filled in by the consulted dental surgeons. We selected four variables: gender, residence place, social, and occupational group to study the consumption in 1998. RESULTS: In 1998, 10% (2462) of teenagers have got a dental check up (EXP1). Only 0,7% participated in the three screenings (1998-1999-2000). We noted a higher female consumption and disparities between the main categories of self-employed persons. Participation by boys was higher than girls. The lowest participation rates concerned the Ile of France area and adolescents living with single parents. In 1998 (EXP1), 57% of teenagers had at least one decayed tooth. Only 69% of them received appropriate curative dental treatments in the following six-Months period. However, among teenagers followed during the three years, higher rates of care reaching 90% were observed on the second and third EXP. CONCLUSION: This small participation rate may be related to the recent implementation of screening. It should lead to optimize screening and to associate other partners in particular the state education system. It should also be helpful in focusing the oral health prevention policy toward the population with a high risk of decay.

[Smoking and pregnancy: survey among women enrolled in an independent worker insurance program]. / Tabac et grossesse. Etude de l'Assurance maladie des professions indépendantes en Ile-de-France.

OBJECTIVES: In order to further improve its prevention program entitled "Maternity childhood follow-up", the Paris region health insurance program for independent workers carried out a survey among female participants. The survey was designed to assess women's smoking behavior and evaluate reception of information concerning smoking-related risks and support available to stop smoking. The women's suggestions were also collected. MATERIALS AND METHODS: A questionnaire was sent by the physicians in charge of the Ile de France region to the 3525 women who had reported a pregnancy. RESULTS: 1099 answers were received (31%) The mean age of responders was 34.3 4.7 years. Their educational level was high (76% had a university degree). Before pregnancy, 37% were smokers. At the first trimester of pregnancy, 17% were smokers, 15% at the second trimester and 14% at the third trimester. Two years after childbirth, 20.5% were smokers. The proportion of women who stopped smoking was higher for those with a low Fagerström score. 29% of women said they did not receive any information about the harmful consequences of smoking. To cease smoking during pregnancy, 70% are helped by family and friends, 20% by health professionals; 3.5% took nicotine substitutes. CONCLUSION: This survey emphasises the need for improving information to pregnant women for alerting them to the dangers of smoking and for training the relevant health professionals.

Type 2 diabetes mellitus among beneficiaries of the french national health insurance for self-employed workers (AMPI): comparison of the management of craftsmen or tradesmen with professionals patients.

BACKGROUND: Although the management of diabetes mellitus varies according to non medical factors, the influence of socioprofessional category has been not fully studied. This study compared the management of type 2 diabetes mellitus in craftsmen or tradesmen with professionals categories. METHODS: All claims to the French National Sickness Insurance Fund for self-employed workers (AMPI) from its mainland France beneficiaries in 1998 were retrospectively analysed. Patients were beneficiaries, insured or dependants of craftsmen or tradesmen, or professionals receiving oral hypoglycemic drugs during a 3-month inclusion period. Patients were compared on the proportion of care received in private practice over the preceding 12 months using adjusted odds ratio (OR). RESULTS: Compared to patients in professionals (n=1,456), patients in craftsmen or tradesmen (n=35,703) were statistically more likely to see a general practitioner (OR 3.867, 95% CI=3.048; 4.907), to have blood glucose test (OR 1.530, 95% CI=1.332; 1.757) and serum creatinine assay (OR 1.207, 95% CI=1.052; 1.270). They were statistically less likely to consult or have a specialist procedure (ophthalmologist, OR 0.792, 95% CI=0.698; 0.900; cardiologist, OR 0.749, 95% CI=0.658; 0.852; dentist, OR 0.679, 95% CI=0.596; 0.773; endocrinologist, OR 0.522, 95% CI=0.424; 0.642), microalbuminuria test (OR 0.749, 95% CI=0.622; 0.902) and serum creatinine assay or microalbuminuria test (OR 0.746, 95% CI=0.611; 0.912). The two groups did not differ on HbA1c, blood lipid tests and electrocardiogram. CONCLUSIONS: The management of type 2 diabetes mellitus differed between craftsmen or tradesmen and professionals patients. These results should be confirmed.

Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect.

OBJECTIVE: To compare the cost-effectiveness of surgery and topical steroids as treatments for phimosis (defined as a clinically verifiable, pathological, cicatricial stenosis of the prepuce) and to evaluate the financial basis of these treatments. METHODS: Data on treatment using topical steroids was obtained from published reports and those for circumcision from claims by private hospitals for children < 13 years old registered at the health insurance department of our facility. The estimate of the French national financial cost of the treatments for 1998 was calculated from public and private institutional information. RESULTS: Treatment with topical steroids for 4-8 weeks was successful in approximately 85% of patients (mean age 5 years) and had no side-effects; the remaining 15% were treated by circumcision. Topical steroid therapy costs (in French francs) F 360 per patient. For those primarily treated by circumcision (81 boys, mean age 4.3 years) and diagnosed as having phimosis, the cost was F 3330 per patient in the private sector. The total number of circumcisions performed in France, regardless of sector (public or private) for 1998 was estimated to be 51 080, which represents an annual cost of F 195.7 million. CONCLUSION: As topical pharmacological treatment avoids the disadvantages, trauma and potential complications of penile surgery, including anaesthesia-related risks, the use of topical steroids as a primary treatment appears to be justified in boys with clinically verifiable phimosis. This treatment could reduce costs by 75%, which represents a potential annual saving of approximately F 150 million.

[Motivations and risk factors for tobacco use in new members of non-smoking youth clubs]. / Motivations et facteurs de risque tabagique chez les nouveaux adhérents des clubs de jeunes non fumeurs.

Since 1990, the National League Against Cancer and its departmental committees have put in place non-smoking clubs for youth (Club Pataclope) in order to carry out smoking prevention actions for youth between the ages of 7 and 14 years. The organisation of these actions is the responsibility of each of the different clubs. This study aims to describe the profile of new members, their motivations for joining the Pataclope Clubs, and their risks concerning tobacco consumption. A survey by close-ended self-questionnaire was carried out among new clubs members.

Screening primiparous women and newborns for fetal/neonatal alloimmune thrombocytopenia: a prospective comparison of effectiveness and costs. Immune Thrombocytopenia Working Group.

A prospective study was conducted in three maternity wards to compare the medical outcomes and the costs of two screening strategies for the detection of fetal/neonatal alloimmune thrombocytopenia (FMAIT). A total of 2066 primiparas and 6081 newborns were included. Fifty-two primiparous women with HPA-1b phenotype were found, and 45 were followed during pregnancy. Four women developed antibodies, and two fetuses exhibited FMAIT; therefore, the prevalence of anti-HPA-1a was 2 per 1000, and the prevalence of FMAIT 1 per 1000. Forty-eight thrombocytopenic newborns were found out of a total of 5632 blood samples. Five were HPA-1a children whose mothers were HPA-1b. The cost-effectiveness of screening all primiparous women was $45,000 and of screening all newborns is $18,000-per anti-HPA-1a alloimmunization diagnosed. Costs per fetal death or disability averted were $500,000 for the primiparous strategy and $225,000 for the newborn strategy. In conclusion, screening newborns for neonatal alloimmune thrombocytopenia is more cost-effective than screening primiparous women.

[Medical and social factors in the orientation of patients with AIDS after discharge]. / Facteurs médico-sociaux d'orientation des malades du SIDA après hospitalisation.

The objectives of this cohort survey performed in acute care patients were to identify and to describe HIV patients needing long-term care with or without daily assistance (home care of health care institutions). This exhaustive sample was recruited from among the hospitalized AIDS patients of fifteen departments of Assistance Publique-Hôpitaux de Paris; 24% of them required post-discharge medical care (home care or health care institutions). The effects of different factors were assessed to explain the choice of home care or various health care institutions: medical reasons, type of care required, functional disability, and socio-economic conditions. Home care patients had complex care needs, parenteral treatments mainly related to Cytomegaloviral retinitis, and poor functional status. They had a favourable socio-economic environment and help with household activities. Two groups of patients were sent to health care institutions. The first, comprised patients in very poor functional or/and mental conditions, especially in the terminal stage of central nervous system illness. The second, included patients with acceptable functional status, multiple pathologies, and poor socio-economic conditions. After adjustment, significant factors influencing the possibility of home care were: a previous successful home care experience and a high educational level. The factors limiting the possibility of home care were important neurologic symptoms, drug use, living alone and poor lodgings. The results of this study suggest that it would be necessary to increase the availability of long term care facilities for persons with AIDS and develop earlier medico-social follow-up, in order to anticipate the problems related to bad socio-economic conditions.

[Evaluation of hospital care. An experiment at the Public Assistance Hospitals in Paris]. / L'évaluation des soins à l'hôpital. Une expérience à l'Assistance Publique-Hôpitaux de Paris.

Since 1990 the Assistance Publique--Hôpitaux de Paris (AP-HP) developed a policy of health care assessment in agreement with the implications of the law of July 31, 1991. The department of Evaluation of health care, in close collaboration with the local Committees which operate in most of the hospitals of AP-HP, performed during the last three years about fifty studies dealing with two main topics: professional procedures and quality of care. Through three specific selected studies, the authors emphasize the requirements of an assessment policy to efficiently contribute to the improvement of quality of care.

Economic assessment of magnetic resonance imaging for inpatients: is it still too early?

This economic assessment of the implementation of magnetic resonance imaging (MRI) in a French hospital examines data on the diagnostic resources used in neurology and neurosurgery before and after MRI was available. Given a similar patient population and case mix, there was no change in the resources used other than the addition of MRI. So far, MRI appears to be a complement to, and not a substitute for, other imaging techniques used in neuroradiology. The focus of this work is purely economic; its conclusions do not challenge the major scientific contributions of MRI.

Cost of treating predialysis patients with recombinant human erythropoietin.

Treatment of the anaemia of predialysis patients with recombinant human erythropoietin (rHuEpo) is likely to become a widely accepted practice during the coming years. We estimated the impact on health care expenditures with the example of the French population of end-stage renal disease patients. Using retrospective data, we calculated the percentage of predialysis patients with advanced chronic renal failure who would be eligible for treatment according to two different criteria based on haemoglobin and clinical condition, the total duration of treatment, and the total amount of rHuEpo delivered. We estimate that the total cost of treating French predialysis patients could vary between 2.2 and 6.5 million Swiss francs, or 50,000 to 140,000 Swiss francs per million population, using rHuEpo dosage from 50 to 150 IU/kg week.

Inborn errors of amino acid metabolism. The best strategy for their diagnosis.

We performed a cost-effectiveness analysis to evaluate whether a pediatrician who suspects an inherited disease of amino acid metabolism should refer the child to a specialist in inborn errors of amino acid metabolism or should prescribe the usual screening test, chromatography of amino acids. Actual hospital costs were used to value the referral, the tests, and the complications that occur when the diagnosis is not recognized. The percent of confirmed diagnoses was chosen as a measure of effectiveness. We conclude that it is more cost-effective for a pediatrician to refer the child to a specialist, that the best strategy in the absence of a referral is to prescribe thin-layer chromatography, and that the least cost-effective strategy is to perform ion-exchange chromatography immediately.