[Arguments for centralization of surgical treatment of ovarian cancer in France based on morbidity and mortality data]. / Intérêts de la centralisation de la chirurgie du cancer de l'ovaire en France.

OBJECTIVE: To examine the current state for ovarian cancer surgery in France from 2009 to 2016 and to examine the impact of the volume of activity on morbidity and mortality by institution. MATERIAL AND METHOD: National retrospective study analyzing surgical sessions for ovarian cancer from the program of medicalization of information systems (PMSI), from January 2009 to December 2016. Institutions were divided according to the number of annual curative procedures into 3 groups: A<10; B: 10-19; C≥20. A propensity score (PS) and the Kaplan-Meier method were employed for statistical analyses. RESULTS: In total, 27,105 patients were included. The 1-month mortality rate in group A, B and C was 1.6; 1 and 0.7 %, respectively (P<0.001). Compared to group C, the Relative Risk (RR) of death within the first month was 2.22 for group A and 1.32 for group B (P<0.01). After MS, the 3- and 5-year survival in group A+B and group C were 71.4 and 60.3% (P<0.05) and 56.6, and 60.3% (P<0.05), respectively. The 1-year recurrence rate was significantly lower in group C (P<0.0001). CONCLUSION: An annual volume of activity>20 advanced stage ovarian cancers is associated with a decrease in morbidity, mortality, recurrence rate and improved survival.

Days Spent at Home and Mortality After Critical Illness: A Cluster Analysis Using Nationwide Data.

BACKGROUND: Beyond the question of short-term survival, days spent at home could be considered a patient-centered outcome in critical care trials. RESEARCH QUESTION: What are the days spent at home and health care trajectories during the year after surviving critical illness? STUDY DESIGN AND METHODS: Data were extracted on adult survivors spending at least 2 nights in a French ICU during 2018 who were treated with invasive mechanical ventilation or vasopressors or inotropes. Trauma, burn, organ transplant, stroke, and neurosurgical patients were excluded. Stays at home, death, and hospitalizations were reported before and after ICU stay, using state sequence analysis. An unsupervised clustering method was performed to identify cohorts based on post-ICU trajectories. RESULTS: Of 77,132 ICU survivors, 89% returned home. In the year after discharge, these patients spent a median of 330 (interquartile range [IQR], 283-349) days at home. At 1 year, 77% of patients were still at home and 17% had died. Fifty-one percent had been re-hospitalized, and 10% required a further ICU admission. Forty-eight percent used rehabilitation facilities, and 5.7%, hospital at home. Three clusters of patients with distinct post-ICU trajectories were identified. Patients in cluster 1 (68% of total) survived and spent most of the year at home (338 [323-354] days). Patients in cluster 2 (18%) had more complex trajectories, but most could return home (91%), spending 242 (174-277) days at home. Patients in cluster 3 (14%) died, with only 37% returning home for 45 (15-90) days. INTERPRETATION: Many patients had complex health care trajectories after surviving critical illness. Wide variations in the ability to return home after ICU discharge were observed between clusters, which represents an important patient-centered outcome.

The Economic Burden of Disease in France From the National Health Insurance Perspective: The Healthcare Expenditures and Conditions Mapping Used to Prepare the French Social Security Funding Act and the Public Health Act.

BACKGROUND: Identifying the most frequently treated and the costliest health conditions is essential for prioritizing actions to improve the resilience of health systems. OBJECTIVES: Healthcare Expenditures and Conditions Mapping describes the annual economic burden of 58 health conditions to prepare the French Social Security Funding Act and the Public Health Act. DESIGN: Annual cross-sectional study (2015-2019) based on the French national health database. SUBJECTS: National health insurance beneficiaries (97% of the French residents). MEASURES: All individual health care expenditures reimbursed by the national health insurance were attributed to 58 health conditions (treated diseases, chronic treatments, and episodes of care) identified by using algorithms based on available medical information (diagnosis coded during hospital stays, long-term diseases, and specific drugs). RESULTS: In 2019, €167.0 billion were reimbursed to 66.3 million people (52% women, median age: 42 y). The most prevalent treated diseases were diabetes (6.0%), chronic respiratory diseases (5.5%), and coronary diseases (3.2%). Coronary diseases accounted for 4.6% of expenditures, neurotic and mood disorders 3.7%, psychotic disorders 2.8%, and breast cancer 2.1%. Between 2015 and 2019, the expenditures increased primarily for diabetes (+€906 million) and neurotic and mood disorders (+€861 million) due to the growing number of patients. "Active lung cancer" (+€797 million) represented the highest relative increase (+54%) due to expenditures for the expensive drugs and medical devices delivered at hospital. CONCLUSIONS: These results have provided policy-makers, evaluators, and public health specialists with key insights into identifying health priorities and a better understanding of trends in health care expenditures in France.

Association of Age With Short-term and Long-term Mortality Among Patients Discharged From Intensive Care Units in France.

Importance: An aging population is increasing the need for intensive care unit (ICU) beds. The benefit of ICU admission for elderly patients remains a subject of debate; however, long-term outcomes across all adult age strata are unknown. Objective: To describe short-term and long-term mortality (up to 3 years after discharge) across age strata in adult patients admitted to French ICUs. Design, Setting, and Participants: Using data extracted from the French national health system database, this cohort study determined in-hospital mortality and mortality at 3 months and 3 years after discharge of adult patients (older than 18 years) admitted to French ICUs from January 1 to December 31, 2013, focusing on age strata. The dates of analysis were November 2017 to December 2018. Exposure: Intensive care unit admission. Main Outcomes and Measures: In-hospital mortality and mortality at 3 months and 3 years after hospital discharge. Results: The study included 133 966 patients (median age, 65 years [interquartile range, 53-76 years); 59.9% male). Total in-hospital mortality was 19.0%, and 3-year mortality was 39.7%. For the 108 539 patients discharged alive from the hospital, 6.8% died by 3 months, and 25.8% died by 3 years after hospital discharge. After adjustment for sex, comorbidities, reason for hospitalization, and organ support (invasive ventilation, noninvasive ventilation, vasopressors, inotropes, fluid resuscitation, blood products administration, cardiopulmonary resuscitation, renal replacement therapy, and mechanical circulatory support), risk of mortality increased progressively across all age strata but with a sharp increase in those 80 years and older. In-hospital and 3-year postdischarge mortality rates, respectively, were 30.5% and 44.9% in patients 80 years and older compared with 16.5% and 22.5% in those younger than 80 years. Total 3-year mortality was 61.4% among patients 80 years and older vs 35.1% in those younger than 80. After age and sex standardization, excess mortality was highest among young patients during their first year after hospital discharge and persisted into the second and third years. In contrast, the mortality risk was close to the general population risk among elderly patients (≥80 years). Age and reason for hospitalization were strongly associated with long-term mortality (9-, 13-, and 20-fold increase in the risk of death 3 years after ICU discharge in patients aged 80-84, 85-89, and ≥90 years, respectively, compared with patients aged <35 years), while organ support use during ICU showed a weaker association (all organ support had 1.3-fold or lower increase in the risk of death). Conclusions and Relevance: Results of this study suggest that aging was associated with an increased risk of mortality in the 3 years after hospital discharge that included an ICU admission, with a sharp increase in those 80 years and older. However, compared with the general population matched by age and sex, excess long-term mortality was high in young surviving patients but not in elderly patients.

Cost-effectiveness of primary prophylaxis of AIDS associated cryptococcosis in Cambodia.

BACKGROUND: Cryptococcal infection is a frequent cause of mortality in Cambodian HIV-infected patients with CD4+ count ≤100 cells/µl. This study assessed the cost-effectiveness of three strategies for cryptococcosis prevention in HIV-infected patients. METHODS: A MARKOV DECISION TREE WAS USED TO COMPARE THE FOLLOWING STRATEGIES AT THE TIME OF HIV DIAGNOSIS: no intervention, one time systematic serum cryptococcal antigen (CRAG) screening and treatment of positive patients, and systematic primary prophylaxis with fluconazole. The trajectory of a hypothetical cohort of HIV-infected patients with CD4+ count ≤100 cells/µl initiating care was simulated over a 1-year period (cotrimoxazole initiation at enrollment; antiretroviral therapy within 3 months). Natural history and cost data (US$ 2009) were from Cambodia. Efficacy data were from international literature. RESULTS: In a population in which 81% of patients had a CD4+ count ≤50 cells/ µl and 19% a CD4+ count between 51-100 cells/µl, the proportion alive 1 year after enrollment was 61% (cost $ 472) with no intervention, 70% (cost $ 483) with screening, and 72% (cost $ 492) with prophylaxis. After one year of follow-up, the cost-effectiveness of screening vs. no intervention was US$ 180/life year gained (LYG). The cost-effectiveness of prophylaxis vs. screening was $ 511/LYG. The cost-effectiveness of prophylaxis vs. screening was estimated at $1538/LYG if the proportion of patients with CD4+ count ≤50 cells/µl decreased by 75%. CONCLUSION: In a high endemic area of cryptococcosis and HIV infection, serum CRAG screening and prophylaxis are two cost effective strategies to prevent AIDS associated cryptococcosis in patients with CD4+ count ≤100 cells/µl, at a short-term horizon, screening being more cost-effective but less effective than prophylaxis. Systematic primary prophylaxis may be preferred in patients with CD4+ below 50 cells/µl while systematic serum CRAG screening for early targeted treatment may be preferred in patients with CD4+ between 51-100 cells/µl.