[Evaluation of a screening programme for diabetic retinopathy (DODIA study)]. / Dépistage de la rétinopathie diabétique par des photographies do fond d'oeil. Evaluation d'un programme en médecine libérale (étude DODIA).

CONTEXT: In France, 43% to 63% of diabetics have an annual fundoscopy. Do the new screening tools, coupled with teletransmission of the images, allow for satisfying ophthalmological screening? It is an important matter given the foreseeable reduction in the number of French ophthalmologists in the forthcoming years. OBJECTIVES: To measure the quality of screening for diabetic retinopathy (DR), in the framework of a network, by the provision of a retinograph by numeric camera (with teletransmission of the images and centralised interpretation), in a screening centre located in town. METHOD: The study evaluated the quality of screening obtained in two comparable groups of general practitioners, one using the retinograph and the other using the classical method of screening by ophthalmologist. The screening was targeted at diabetics who had not had a fundoscopy in the preceding year, nor had known DR or a treating ophthalmologist (for the retinography group only). RESULTS: 667 patients were sampled in the retinography group (456 included) and 707 in the control group (426 included) between 1/04/02 and 1/11/02; 417 patients were followed until the end of the study in the 2 groups. A screening examination was considered effective if it was performed within the six months following its request, and by the presence of a report in the file of the general practitioner. The percentage of patients thus screened was 74% in the retinography group and 71,5% in the other group (not significant). 16% of diabetics in the retinography group had DR compared with 10% of patients in the control group. The analysis of the level of satisfaction of patients tended to show a preference for the system of screening by fundal photography. CONCLUSION: In the framework of a healthcare network, the availability of a retinograph by numeric camera, with the interpretation of photos by teletransmission of the images, obtained a high level of quality of screening for diabetic retinopathy that was at least as good as that obtained by a healthcare network using the classical ophthalmological screening method.

Cost-effectiveness of drotrecogin alfa (activated) in the treatment of severe sepsis with multiple organ failure.

OBJECTIVES: The aim of this study was to estimate the expected cost and clinical benefits associated with the use of drotrecogin alfa (activated) (Xigris; Eli Lilly and Company; Indianapolis, IN) in the French hospital setting. METHODS: The recombinant human activated PROtein C Worldwide Evaluation in Severe Sepsis (PROWESS) study results (1271 patients with multiple organ failure) were adjusted to 9,948 hospital stays from a database of Parisian area intensive-care units (ICUs)-the CubRea (Intensive Care Database User Group) database. The analysis features a decision tree with a probabilistic sensitivity analysis. RESULTS: The cost per life year gained (LYG) of drotrecogin treatment for severe sepsis with multiple organ failure (European indication) was estimated to be dollars 11,812. At the hospital level, the drug is expected to induce an additional cost of dollars 7545 per treated patient. The incremental cost-effectiveness ratio ranges from dollars 7873 per LYG for patients receiving three organ supports during ICU stay to dollars 17,704 per LYG for patients receiving less than two organ supports. CONCLUSIONS: Drotrecogin alfa (activated) is cost-effective in the treatment of severe sepsis with multiple organ failure when added to best standard care. The cost-effectiveness of the drug increases with baseline disease severity, but it remains cost-effective for all patients when used in compliance with the European approved indication.

The course of depressive illness in general practice.

OBJECTIVE: Depression is reported to be common in primary care settings and to have a high likelihood of relapse during the 4- to 6-month period following initial symptomatic improvement. However, most prospective studies of long-term treatment of depression have been conducted with patients selected for participation in placebo-controlled drug protocols or psychiatric clinics associated with tertiary referral centres. METHOD: We examined the treatment course and outcome of outpatients with major depressive episode treated in a primary care setting. The general practitioners were free to choose the treatment and its duration. Their only obligation was to assess the therapeutic outcome in terms of efficacy and safety and to perform a final evaluation at the end of the 6-month observation period or, if the patient was treated for a shorter period, at the end of the treatment. RESULTS: Of the 476 patients involved, 308 (64.7%) responded to treatment and remained well, 117 (24.6%) showed no response, and 51 (10.7%) had an early relapse after initial improvement. Among the studied demographic, clinical, and therapeutic factors, the history of recurrent depression was the only variable with a significant effect size in predicting the course of the illness. CONCLUSION: Patients with recurrent depression were at higher risk of relapse or nonresponse.