Classification of hospital pathways in the management of cancer: application to lung cancer in the region of burgundy.

CONTEXT: The evaluation of national cancer plans is an important aspect of their implementation. For this evaluation, the principal actors in the field (doctors, nurses, etc.) as well as decision-makers must have access to information that is reliable, synthetic and easy to interpret, and which reflects the implementation process in the field. We propose here a methodology to make this type of information available in the context of reducing inequalities with regard to access to healthcare for patients with lung cancer in the region of Burgundy. METHODS: We used the national medico-administrative DRG-type database, which gathers together all hospital stays. By using this database, it was possible to identify and reconstruct the care management history of these patients. That is, by linking together all attended hospitals, sorted chronologically. Eligible patients were at least 18 years old, whatever the gender and had undergone surgery for their lung cancer. They had to be residents of Burgundy at the time of the first operation between 2006 and 2008. Patient's pathway was defined as the sequence of all attended hospitals (hospital stays) during the year of follow up linked together using an anonymised patient identifier. We then constructed a pathway typology of pathway using an unsupervised clustering method, and conducted a spatial analysis of this typology. RESULTS: Between 2006 and 2008, we selected 495 patients in the 4 administrative departments of the Burgundy region. They accounted for a total of 3821 stays during the year of follow-up. There were 393 men (79%) and the mean age was 64 (95% confidence interval: 63-65) years. We reconstructed 94 pathways (about five per patient). Here, neighbourhood's cares accounted for 41% of them, while 44% included a surgical intervention outside the region of Burgundy. We constructed a pathway typology with five classes. Spatial analysis showed that the vast majority of initial surgeries took place in the major regional centres. CONCLUSION: The construction of a pathway typology leads to better understanding of the reasoning that lies behind the movements of patients. It opens the way for analysis of the collaboration between the different healthcares establishments attended, which should bring to light associations that need to be developed.

[Results of a survey of different types of stroke care in France: from stroke unit to conventional care]. / Caractérisation des différents types de prise en charge des accidents vasculaires cérébraux en France: des unités neuro-vasculaires aux services conventionnels. Résultats d'une enquête par questionnaire.

INTRODUCTION: Stroke is a worldwide problem with high incidence, mortality and disability rates. A Meta analysis by the Stroke Unit Trialist Collaboration showed that stroke units improve outcome for stroke patients. Stroke care should take place in stroke units which consist of a hospital unit or part of a hospital unit that exclusively takes care of stroke patients. European recommendations have been published by the European Stroke Initiative and French recommendations by the Societe Française Neurovasculaire. METHODS: We sent a questionnaire to French stroke physicians in order to establish the different types of stroke care for French inpatients. RESULTS: About half the people surveyed answered (106/193) and we selected 74 responses in order to have only one response for each hospital. Thus, we analysed 74 responses from 74 different French hospitals, coming from the whole country. Of the 74 hospitals, 23 had a stroke unit, 21 had dedicated beds for stroke inpatients, and 30 had no specific care. We identified 5 different types of stroke units: those with intensive acute care and post acute care (8/23), those with intensive acute care that were coordinated with a neurology department (7/23), those with beds in the neurology department (3/23), one with three levels (emergency, acute care and post acute care) and one that shared intensive care with cardiology. Structures of 3 stroke unit couldn't be identified. We studied their conformity to the recommended guidelines and found that, in most cases, they followed them closely. We studied differences between hospitals with stroke units and hospitals without stroke units in terms of technical or human means. We founded only a few differences between these two groups in the advantage of stroke units over hospitals without stroke units. DISCUSSION: We found major differences of organisation between different types of stroke units, but no differences between hospitals with stroke units and other hospitals. These stroke units are generally in conformity with the recommended guidelines.

Choosing where to deliver: decision criteria among women with low-risk pregnancies in France.

As in the rest of Europe, the supply of maternity hospitals has progressively decreased over the past few decades in France. An understanding of user choice criteria is important to help health planners reorganize obstetrical services and to predict changes in utilization patterns in response to supply changes. The objectives were to understand the criteria that women use to select their maternity hospital in France and to analyse the relation to individual and community characteristics. A survey of 536 recently delivered women with low-risk pregnancies explored the factors motivating user choice in three territories with distinct geographical and health service supply characteristics: four districts in Burgundy, two districts in Pays de la Loire, and the district of Seine-Saint-Denis in Ile-de-France. Women were asked to select a principal choice criterion. Their responses were grouped into categories: Accessibility/proximity, reputation of the establishment among users, advice of treating physician, technical quality and cost. Accessibility and proximity were the most selected criteria (33%), followed by the reputation of the maternity (29%), technical quality (15%) and advice of treating physician (13%). Age, parity and education influenced choice criteria. After controlling for individual determinants, region of residence was highly related to choice criteria; women living in Burgundy were more likely to select an establishment based on proximity, in Seine-Saint-Denis women were more likely to follow the advice of their physician, and in Pays de la Loire, more likely to base their decisions on the reputation of the establishment. The association between choice criteria and community characteristics could explain the failure of previous models to predict behaviour in different contexts. It is important to carry out local surveys of user perceptions before restructuring in order to take into consideration women's opinions on their future places of delivery and to refine geographic models.

[Risk factors, diseases and health care acceptance in perinatology: a predictive model of hospital use]. / Facteurs de risque, pathologies et recours au soin en périnatologie: un modèle de prédiction du recours à l'hôpital.

BACKGROUND: The goal of our study was to develop a predictive model of resource use for pregnancy and perinatal care based on the knowledge of the distribution of risk factors in a given population of pregnant women. METHODS: Data recorded in Outcome of Pregnancy Certificates (CIG) from 11 voluntary maternities of the district of Seine-Saint-Denis allowed us to identify those pathologies that were predictive of premature births and prenatal hospitalization of mothers. We built a classification of disease states and of risk level. A logistic regression using disease states as dependent variables and risk levels as independent variables allowed us to compute expected rates with their confidence intervals. RESULTS: Among singletons, malformations, diabetes, toxemia, intra-uterin growth retardation, premature rupture of membranes covered 25% of all pregnancies but explained 64% of maternal hospitalizations; 90% of all mothers hospitalized and with delivery before 37 weeks gestation had at least one of these disease states. But 85% of the women who did not belong to disease classes had a normal pregnancy and delivery. CONCLUSIONS: In a given population, the distribution of risk levels is predictive of the incidence of disease per class. Then, given the length of stay of mothers per class, the rate of transfer of babies and the length of stay in postnatal care, we can simulate bed occupancy and compute bed capacities. The precision of the model is globally good, despite the relatively modest size of our initial data base: it will improve with the use of the model and the expected more widespread availability of data in France.

Cost-effectiveness analysis of the terlipressin-glycerin trinitrate combination in the pre-hospital management of acute gastro-intestinal haemorrhage in cirrhotic patients.

OBJECTIVES: To assess the cost-effectiveness of an early treatment of upper gastro-intestinal haemorrages in cirrhotic patients. DESIGN: Utilization data linked to the results of a double-blind, placebo-controlled trial demonstrating the efficacy of the terlipressin-glycerin trinitrate combination (TER-GTN) in the reduction of mortality at day 42 for haemorragic patients due to rupture of oesophageal varices. SETTING: Hôpital Jean Verdier, Bondy, Assistance Publique-Hôpitaux de Paris, France. SUBJECTS: Eighty-four patients included over 2 years by emergency services and hospitalized in an intensive care unit (ICU) for haemorrage, 41 in the "treated" group and 43 in the "placebo" group. MAIN OUTCOME MEASURES: Mortality at day 42, cost per death avoided. RESULTS: The mortality rate in the placebo group was 46.5% versus 27.5% in the treated group. The mean length of stay was 5 days longer in the treatment group. The excess cost per death avoided was 25,849 FF. Of this extra cost 27% was due to treatment and 24% was due to increased length of stay. The excess cost per case treated was FF 5,097, 10% of the total cost per stay for rupture of oesophageal varices (ROV). CONCLUSIONS: Our results are of the same magnitude as those published by Mac Cormick et al. in the United Kingdom for similar treatment. The extra cost appears to be moderate, and much lower than monoclonal antibody therapy for sepsis. The impact on the study hospital budget did not exceed 1.7 10(-4).

Socio-demographic risk factors for perinatal mortality. A study of perinatal mortality in the French district of Seine-Saint-Denis.

OBJECTIVES: To investigate the impact of a set of socio-demographic risk factors commonly associated with perinatal mortality -- age, parity, marital status, educational attainment, occupation, and ethnic origin in the French district of Seine-Saint-Denis. METHODS: The study has a case-control design with prospective identification of cases. It includes all singleton non-malformed perinatal deaths which occurred between October 1, 1989 and September 30, 1992. Logistic regression is used to estimate odds ratios. Base incidence rates are generated by incorporating sampling information for the controls. RESULTS: All socio-demographic variables are significantly related to the risk of perinatal mortality in univariate analyses. Some of the increased risk due to social factors is explained by differential age and parity distributions. In multivariate models, however, only parity and country of origin are significant. Women born in the French overseas departments and territories and Sub-Saharan Africa have the highest odds ratios. CONCLUSIONS: Women born outside of continental France face an elevated risk of experiencing a perinatal death even after controlling for age, parity and socioeconomic factors. Although, this excess risk may reflect residual variation in socioeconomic status, alternative explanations such as standards of prenatal care, medical problems during pregnancy and delivery, and cultural practices should be explored.

[Morbidity and mortality of premature infants of less than 33 weeks]. / Morbidité et mortalité des prématurés de moins de 33 semaines.

The present study in a case-control study in a population based collection of data of all births from 22 to 32 weeks in all maternities of the Seine-Saint-Denis district for three years, 999 on 67819 total births. The study describes the site of births by level of perinatal care (level 3 maternity associated with a neonatal intensive care unit, level 2 with a neonatal pediatric ward without intensive care, and level 1 without any of these pediatric services. The proportion of births at a level 3 maternity is 6.3% for all births, and 12.9% for live birth of less than 33 weeks. The study describes the transfers of the live babies to a neonatal intensive care by external transfers from level 1 and level 2 units or internal transfers in level 2 and 3 units. All babies are transferred. The study describes the per partum and neonatal deaths up to 28 days by week of gestation duration and site of birth. The study uses the comparison between the deaths during delivery (from 28 to 32 weeks) and in the first 28 days compared to controls, using a regression analysis method. The risk of per partum and neonatal death is: OR = 8.08 [1.03-76.40] when site of birth 2 is compared to 3 and OR = 11.78 [1.33-103.77] when site of birth 1 is compared to 3. The study shows that the french obstetricians and pediatricians have not accepted the international consensus proposing that births of less than 33 weeks should take place in level 3 perinatal units, goal which is reached for 80% of those births, with less neonatal deaths and developmental handicaps.

[Epidemiology of fetal deaths in the Seine-Saint-Denis perinatal survey]. / Epidémiologie des morts foetales avant le travail dans l'enquête pèrinatale de la Seine-Saint-Denis.

OBJECTIVE: To analyse the epidemiological characteristics of antepartum stillbirths. DESIGN: A population based cases-cohort study in a limited geographical area, the department of Seine-Saint-Denis, France. Prospective collection of cases and controls between the 1989-10-01 and 1992-09-30, and retrospective collection of data. SUBJECTS: All antepartum stillbirths of 28 weeks gestation of greater, except lethal malformations and multiple pregnancies. RESULTS: 273 antepartum stillbirths were collected during the 3-year study period (52, 2% of the perinatal deaths). The causes were mainly, abruptio placenta and cordonal causes; however, unexplained antepartum stillbirth was the most important group (38, 8%). Hypotrophy was present for 49.5% of cases versus 10.1% of controls (p < 0.001). It was associated with death whatever cause or gestational age, particularly in unexplained antepartum death (54.7%). In univariate analysis, the usual risk factors including obstetrical history, socio-economic characteristics, obstetric care and country of birth were associated with death. But, in multivariate analysis, only "no pregnancy déclaration", "deficient obstetric care", "history of stillbirth", "born in Black Africa" and "born in DOM-TOM" were significantly associated with death. CONCLUSION: More than one half of perinatal deaths concern antepartum stillbirth; the causes have remained unchanged for twenty years and unexplained antepartum stillbirth remains the most important group. The principal risk factor is fetal hypotrophy. The other significant risk factors after multivariate analysis are deficient obstetric care and birth in Black Africa or in the DOM-TOM. To propose prevention actions, progress is necessary in in utero diagnostic of hypotrophy and in the understanding in the risk associated with country of origin.