[Self-employed and small business owners diagnosed with cancer: effect on entrepreneurial survival]. / Travailleurs indépendants et dirigeants de très petites entreprises atteints d'un cancer: effet sur la survie entrepreneuriale.

AIM: When self-employed andsmall business owners are diagnosed with cancer what is the effect on their small-firm survival duration? METHODS: Data Sources: secondary data for 3,587 subjects, 18-65 years, working when diagnosed with cancer in 1995-2009 and a comparison group of 27,688 subjects matched for gender, age and occupation. Study design: a comprehensive population-based longitudinal study. A Cox model described time to failures of small businesses and terminations ofself-employment. Data Collection Methods: extraction from the statutory mandatory self-employed social security scheme database. RESULTS: Findings were that age, cancer prognosis and very intense physical workload occupation were independent predictors of enterprise failure for cancer-exposed subjects. Compared with unexposed subjects, their global hazard ratio was 1.59 (95% CI = 1.50 - 1.70). However, the difference atfiveyears after cancer diagnosis became non-significant: hazard ratio 1.11 (95% CI = 0.95 - 1.30). CONCLUSION: These findings demonstrate that beyond 5 years of maintenance of activity, the economic cost of cancer supported by very small businesses and self-employed is not important. However, support is required to pass through these first 5 years. The authors describe the various possible aids that could be implemented.

[What strategy can be developed by a regional health agency to reduce social inequalities in health?]. / Quelle stratégie peut développer une Agence régionale de santé pour réduire les inégalités sociales de santé??

Reducing social inequalities in health (SIH) is a key priority for the Provence Alpes Côte d'Azur Regional Health Agency (Paca ARS). The actions and objectives defined in the regional health project were divided into a two-way table (determinants/policies by target population) to verify the consistency and extent of such measures. Sustaining actions of the ARS, alone or in partnership on the determinants of SIH and their effects, target three distinct levels of intervention: in the scope of its own jurisdiction, as a resource for other actors, including support of action research and finally in the context of partnership approaches. It has developed fine measurement and monitoring tools and has supported the development of a continuing education e-learning programme developed with partners in Paca and Quebec. However, further efforts are needed to develop actions on fundamental determinants, including environmental determinants and more effective implementation of this policy. The objectives of certain territorial health programmes designed to make local primary care structures responsible for the population concerned are very promising.

Health care services and disease modifying therapies use in community-based multiple sclerosis patients: Evolution from 2013 to 2015 and demographic characteristics.

INTEREST OF THE WORK: Multiple sclerosis (MS) disease modifying therapies (DMT) utilization increased during the last decade with the approval of new drugs. Symptomatic treatments also play an important role. Describing time trends and demographic characteristics for DMT and symptomatic treatments utilization in population-based MS patients will lead to a better knowledge of the resources distribution. METHODS: Repeated cross-sectional analysis on each calendar year were implemented retrospectively on the health insurance claims database in France from 2013 until 2015 regarding DMT, fampridine, fluoxetine, psychiatrist office visits, and Physical therapy sessions to calculate an utilization rate defined as the number of MS patients (whenever the date of diagnosis) who filled at least 1 prescription or service within the studied calendar year per cent MS patients covered the same calendar year (number of users per cent MS population per annum). Beneficiaries with MS were identified by their exemption of co-payment for long-term disease (ALD). RESULTS: DMT utilization rate increased from 34.22% in 2013 to 38.73% in 2015. The increase was due to recently developed DMT as first-generation DMT utilization rate decreased from 30.20% to 20.06%. Rates were not different between genders but significantly decreased with age. The average age of users was significantly lower for DMT than for symptomatic treatments (recently developed DMT: 43.63, first-generation DMT: 45.84, psychiatrist office visits: 49.08, Fampyra®: 55.41, Physical therapy sessions: 55.88, fluoxetine: 58.26). Regional DMT utilization rates ranged from 31.68% in Auvergne-Rhône-Alpes to 42.58% in Normandie. They were not correlated to regional rates of MS prevalence (R-Square=0.0558; P=0.2556) nor to the presence of a MS reference centre in the region (Chi-Square=0.0190; P=0.8905). In 2015 the six DMTs with the highest rates were by decreasing orders: Tecfidera®, Avonex®, Gilenya®, Aubagio®, Copaxone®, and Rebif®. Half of them were recently developed orally-administered drugs. PERSPECTIVES: Complex factors may explain the interprovincial variability. Low DMT utilization rates in the most aged patients who also have the highest recourse rate to symptomatic treatments reflect the fact that the indication of disease modifying therapies do not address older patient's needs. New DMTs with medical indications for the late degenerative phase are needed.

[Analgesic and anti-inflammatory drug prescriptions and number of radiograms predict antidepressant treatment: study of reimbursement data from the Provence health insurance fund]. / Les prescriptions d'antalgiques, d'anti-inflammatoires ou le nombre d'actes radiologiques sont des facteurs prédictifs d'un traitement par antidépresseur: une étude des données de remboursements de la Caisse médicale régionale de Provence.

OBJECTIVES: Physicians frequently fail to detect mental health disorders in patients consulting them. This study tests the hypothesis that patients repeatedly prescribed analgesics or antiinflammatory drugs or X-ray examinations for unexplained somatic symptoms are at higher risk of antidepressant treatment, independent of physical comorbidity. METHODS: This case-control study is based on health reimbursement data for self-employed artisans and shopkeepers. Cases were subjects who first began antidepressant treatment between January and March 2003. Controls, matched for age, sex, and urban or rural residence, had not been reimbursed for any psychotropic drug in the 18 months before and 6 months after this quarter. Reimbursement data for analgesic and antiinflammatory drugs, and X-rays, temporary disability payments and their reasons, chronic diseases, and hospitalizations over the 18-month period before inclusion were compared for cases and controls with simple and multiple logistic regressions. RESULTS: The study included 988 cases (36.5% of whom were reimbursed only once for an antidepressant) and 1976 controls. The multiple logistic regressions adjusted for history of psychiatric morbidity and somatic comorbidity showed significant linear associations between starting antidepressant treatment and reimbursements for analgesic and anti-inflammatory drugs or X-rays. DISCUSSION: Severe somatic diseases can induce psychological distress. At the same time, mental disorders may be manifested as unexplained chronic pain, without the individual recognizing the link between them. CONCLUSION: These results confirm the initial hypothesis and suggest signs that may alert physicians to possible undetected psychological distress or mental disorders.

Geographic variations of multiple sclerosis prevalence in France: The latitude gradient is not uniform depending on the socioeconomic status of the studied population.

BACKGROUND: In France, two studies analysed multiple sclerosis prevalence nationwide: one was carried out in farmers, and the other one in employees. A south-north gradient of prevalence was found solely in farmers. OBJECTIVE: In order to better describe the latitude gradient in France, which is not uniform depending on the studied population, we assessed whether a gradient exists in another population than farmers and employees: independent workers. The same methods of case ascertainment have been used. METHODS: Altogether 4,165,903 persons insured by the French health insurance scheme for independent workers were included. We searched the database for (a) long term disease status 'multiple sclerosis', (b) domicile, (c) gender and (d) age. RESULTS: A total of 4182 cases of multiple sclerosis were registered giving a prevalence of 100.39/100,000. Adjustment by age and sex and spatial smoothing with a Bayesian analysis showed a gradual increase of prevalence from the southwest to the northeast of France. Standardised morbidity ratio was correlated with latitude and longitude (p<0.0001; p = 0.0031; adjusted R2 = 0.3038). CONCLUSION: A discrepancy of geographic distribution between farmers and independent workers on the one hand and employees on the other cannot be attributable to environment. Assuming that socioeconomic status by itself is not associated with multiple sclerosis risk, employees' geographic mobility at adulthood for professional reasons could have interfered with the gradient effect.

Membership in a diabetes-care network and adherence to clinical practice guidelines for treating type 2 diabetes among general practitioners: A four-year follow-up.

OBJECTIVES: To assess whether private general practitioners (GPs) belonging to a diabetes-care network adhered more closely to clinical practice guidelines for diabetes care than GPs not in such a network, for all their patients with type 2 diabetes treated with medication (patients with diabetes), regardless of whether they received care through a network (that is, whether a halo effect occurred). RESEARCH DESIGN AND MEASURES: The study, based on health insurance reimbursement databases in southeastern France, included 468 GPs in two networks and 468 non-network GPs in the same geographical area, matched one-to-one by propensity scores. We followed up their patients with diabetes (n=22,808) from 2008 through 2011, conducting multivariate time-to-event analyses (Cox models) that took the matching design into account to evaluate time from inclusion until performance of the given number of each of six recommended examinations/tests. RESULTS: GPs belonging to a diabetes-care network adhered more closely to clinical practice guidelines but our result were slightly pronounced. Hazard ratios (HR) were significantly higher for patients of network GPs for the implementation of 3 HbA1C assays (HRa=1.13; [95%CI=1.10-1.16]), or 1 microalbuminuria assay (1.4 [1.35-1.45]); they were lower for LDL-cholesterol assays (1.04 [1.01-1.07]) and ophthalmological checkups (1.07 [1.04-1.10]), and not significant for creatinemia or cardiac monitoring. CONCLUSIONS: Network GPs had better diabetes monitoring practices for all their patients with diabetes than the other GPs, especially for the most diabetes-specific tests. Further research is needed in other settings to confirm the existence of this halo effect.

[Transfer to a rehabilitation center after hip replacement surgery, frequency and related factors]. / Hospitalisation en centre de réadaptation après prothèse de hanche, fréquence et facteurs associés.

OBJECTIVE: To assess the need to clarify indications for transfer to a rehabilitation center after hip arthroplasty, we sought to determine the number of hip prostheses placed in the year 2000 in southwestern France (PACA region), the frequency of transfer for inpatient rehabilitation after total hip arthroplasty, and the factors associated with transfer. We also examined the differences between private and public hospitals and between hip replacement due to fracture and those for other reasons. METHODS: We searched the database of the regional medical information systems program (MPSI) to identify short term hospitalizations for orthopedic surgery during the year 2000 in the region's public and private hospitals. RESULTS: In all, 4705 hospitalizations included hip arthroplasty, and 46% of the patients were subsequently transferred to a rehabilitation center. Multivariate analysis showed that the following factors were associated with this transfer: age (older patients), sex (women), hospital status (public hospital) and district of residence (the three Alpine districts). Public hospitals performed arthroplasties were more frequently due to femoral fractures and in patients with psychiatric or mental disorders. CONCLUSION: Hip replacement is a common surgical procedure that frequently leads to discharge to a rehabilitation center. This transfer is not related to the complexity of the surgery or the duration of hospitalization. The differences observed between public and private hospitals and between the districts within the region demonstrate the need for guidelines to harmonize practices.

[The appropriateness of the indications and diagnostic efficiency of colonoscopy. Results of a survey conducted in all the hospital centers of the Provence-Alpes-Côte d'Azur area]. / Pertinence des indications et efficience diagnostique des coloscopies. Résultats d'une enquête réalisée dans la totalité des établissements hospitaliers de la région Provence-Alpes-Côte d'Azur.

OBJECTIVE: To evaluate the appropriateness of indications and the diagnostic efficiency of colonoscopy taking into account available guidelines. METHODS: This was a retrospective study conducted by the Union Régionale des Caisses d'Assurance Maladie de Provence-Alpes-Côte d'Azur (URCAM-Paca) aimed at assessing the appropriateness of the indications and diagnostic efficiency of colonoscopy. Anonymous data concerning near totality of the colonoscopies carried out during one week in all the establishments (public and private) of the area, were collected by consulting the medical records. RESULTS: The indications for colonoscopy were first analyzed with regard to the guidelines for good clinical practices (références médicales opposables and consensus conference) according to two scales of reading (literal interpretation and broad interpretation). We noted that the available guidelines do not cover the totality of the colonoscopies performed, that their formulation does not make them all controllable, and that the colonoscopies, which respect them, range from 27.5% (strict reading) to 74.1% (broad reading). When taking into account not only the quality of the preparation, but also the result of the examination after re-classification into benign, pathological or normal examinations, the differences in efficiency appear only when one retains the broad interpretation of the reference guidelines. The efficiency analysis makes it possible to highlight a defect of predictability of the recommendations with regard to the pathologies considered as serious. It also appears that approximately 10% of the colonoscopies are, at the same time, out of the reference and have a normal result, and thus can be considered as absolutely not justified. CONCLUSION: Better compliance of the practitioners to colonoscopy recommendations would initially be generated by improvement in the predictability and the legibility of the current reference guidelines.

[Psychotropic medication use by French active self-employed workers]. / Consommation de médicaments psychotropes par les travailleurs indépendants français en activité.

UNLABELLED: INTERESTS OF THE STUDY: In the self-employed workers population (shop keepers, craft men, industrialists and liberal professions), psychotropic medications use and discrepancies between occupational situations have never been evaluated before. It is nevertheless a prerequisite in preventive actions against addictions, stress and injuries caused by disorders of attentiveness at work. METHOD: The French Self Employed Workers Health Care Insurance Fund affiliate members data base was analysed for active workers from 18 to 60 years of age living in the Provence Alpes Côte d'Azur Region. From this population the cases were defined as having refunded ambulatory prescription of behind the counter psychotropic treatment during the year 2009 (anxiolytic, antidepressant, hypnotic, neuroleptic, lithium, alcoholic or opioid dependance therapy) and the randomised control sample was constituted by drawing the key of the social security number. A case-control multivariate logistic regression adjusted for gender, age and place of abode was used for searching discrepancy between occupational situations. RESULTS: Anxiolytic, antidepressant or hypnotic consumers are the most numerous (906; 557 and 446 consumers per 10 000 persons-year respectively). Antidepressant, neuroleptic and opioid dependance therapy are the three main posts of expense for the health insurance (584 505; 169 947 and 151 201 € per year respectively). When compared to workers of the construction sector, workers of retail trade of clothes had an Odd Ratio of 2,04 [95%CI 1,46-2,85] for anxiolytics consumption and 2,29 [95%CI 1,67-3,14] for antidepressants consumption, workers in the sector of the hotel and catering had an Odd Ratio of 1,62 [95%CI 1,19-2,22] for alcoholic dependance therapy medicines consumption, workers in the accountant, legal and financial sector had an Odd Ratio of 0,05 [95%CI 0,01-0,32] for opioid dependence therapy medicines consumption. PERSPECTIVES: Occupations associated with increased psychotropic medicines consumption are important to consider when assessing or fighting against psychotropic or addictive substance consumption, psychological stress and vigilance or attention perturbation at work.