[Review of reimbursement for instrumental techniques used for assisted coughing and thoracic expansion. A French National Health Authority assessment (HAS)]. / Avis sur le remboursement de techniques instrumentales d'aide à la toux et à la mobilisation thoracique. Une évaluation de la Haute Autorité de santé (HAS).

INTRODUCTION: In France, children with neuromuscular diseases and patients with traumatic spinal cord injuries receive reimbursement for home use of intermittent positive-pressure breathing and mechanical in-exsufflators devices. The aim of the study was to update the indications for reimbursement for these both devices. METHODS: A literature review was conducted with several bibliographic databases using the main keywords: intermittent positive-pressure breathing, mechanical insufflation, mechanically-assisted cough, airway clearance. Nine health professionals were interviewed during two meetings. One health professional was interviewed via a questionnaire. An estimation of the population treated with in-exsufflators or intermittent positive-pressure breathing was undertaken from consumer data available for all beneficiaries of the health insurance system. STATE OF THE ART: The review identified 111 references which included 14 clinical practice guidelines, two systematic reviews and one randomized controlled trial. Some clinical data were available. Clinical practice guidelines were in favor of using intermittent positive-pressure breathing and in-exsufflators in patients with neuromuscular disease and spinal cord injuries. The healthcare professionals emphasized the need to reimburse the patient for home use of intermittent positive-pressure breathing and in-exsufflators. The patient population treated in the identified clinical situations was estimated at 3100 per year. CONCLUSIONS: Despite the low level of evidence and after interviewing healthcare professionals, the Haute Autorité de santé (HAS) recommended reimbursement of the costs of in-exsufflators (assisted coughing) and intermittent positive-pressure breathing (thoracic expansion) devices in adults and children with neurological and neuromuscular disease, including spinal cord injury.

Surgical hemostatic agents: assessment of drugs and medical devices.

Surgical hemostatic agents are indicated to improve hemostasis when conventional techniques (compression, sutures or electrocoagulation) are inadequate. The National French Authority for Health (Haute Autorité de santé [HAS]) set out to assess these products (medical devices and agents) to determine their optimal utility. This evaluation included one class of products containing some form of human fibrinogen and thrombin and eight classes of medical devices and automated devices to prepare autologous fibrin. The assessment was based on a systematic review of the literature and expert opinion of health care professionals. The main measures of effectiveness of hemostatic agents were the success rate as expressed in terms of the time necessary to obtain adequate hemostasis, the volume of intra and/or postoperative blood loss, the need for blood transfusions, complication rate, duration of operations and hospital stay. A meta-analysis and 52 controlled randomized studies were selected involving cardiac or vascular surgery (19), ENT surgery (11), gastrointestinal surgery (5), urology (4), orthopedic surgery (4). Approximately half of the studies retained in this analysis evaluated blood derived agents (fibrin sealants) while the other half evaluated medical devices. The working group considered that there is not any evidence that these surgical hemostatic agents decrease the rates of transfusion, complications, reoperation, mortality, duration of operation and/or hospital stay. The working group considered that the use of surgical hemostatic agents to improve the safety of hemostasis in the absence of identified bleeding as an alternative to adequate conventional hemostasis was not justified. Surgical hemostatic agents can be used in ad hoc settings, as a complement to conventional methods to control persistent bleeding after conventional hemostatic techniques, or when abundant bleeding has led to biologic hemostatic disorders. The working group also distinguished several particular settings (mouth and dental care in patients under antiagregant or anticoagulation therapy, central nervous system surgery or acute aortic dissection). Comparative data are insufficient to determine if one product is superior to another for a specific use. To evaluate the clinical value of these products, methodologically sound clinical studies are necessary.

[Reference and selective list in hospital hygiene. Impact on practical improvement]. / Référentiel et liste positive en hygiène hospitalière. Impact sur l'amélioration des pratiques.

In hospitals, the infection control programs requires a basic policy on selection and use of appropriate antibiotics, as well as antiseptics and disinfectants. The selective list concept, born in Germany, spread in France during the nineties, essentially based on national microbiological standards. With the European free circulation of products, more antiseptics and disinfectants with heterogeneous status are available to customers, who must settle on the essential data, with the help of scientific societies: among these data, efficacy against multiresistant strains, adaptation to specific hospital patients, ergonomic handling and tolerance today precede economical criteria and supplement the European micro-biological standards for antiseptics and disinfectants.