Incorporation of skin preparation guidelines in local surgical facility protocols: what kind of barriers does it face? A multi-centre study in France.

BACKGROUND: Surgical site infection (SSI) is the most frequent and severe adverse event after surgery. Among preventive measures, the preoperative skin preparation (PSP) is known to be heterogeneously implemented in routine practice. A prerequisite would be the actual incorporation of guidelines in French surgical local protocols. AIM: To assess whether PSP recommendations have been incorporated in local protocols and to identify the reasons for the non-incorporation. METHODS: An online survey was proposed to all infection control teams (ICTs) in facilities participating in the French national surveillance and prevention of SSI network Spicmi. The reference recommendations were based on the French Society for Hospital Hygiene guidelines. FINDINGS: In all, 485 healthcare facilities completed the questionnaire. The incorporation of recommendations in the facility protocol varied between 30% and 98% according to the recommendation. The measures most frequently incorporated were antisepsis with an alcoholic product and cessation of systematic hair removal. The least frequently incorporated were the use of plain soap for preoperative shower and the non-compulsory skin cleaning in the operating room. Barriers reported were either specific to PSP (e.g. 'Concern about an increase of SSI', 'Scepticism about recommendations', 'Force of habit') or non-specific (e.g. 'The protocol not yet due to be updated'). CONCLUSION: We suggest that although some major prevention measures have been incorporated in the local protocol of most facilities, local protocols still frequently include some non-evidence based former recommendations. Communication about evolution of SSI rates, diffusion of guidelines by learned societies, and exchange with judiciary experts could make clear the conditions for applying recommendations.

Compliance with good practice guidelines for the prevention of vascular access infections: the multi-centre PHYDEL survey in French haemodialysis units.

BACKGROUND: French guidelines for the prevention of vascular access infections in a haemodialysis setting were released in 2005. Compliance with these guidelines is currently unknown. The aim of this study was to assess compliance with the guidelines for vascular access infection prevention in French haemodialysis units, and to describe the difficulties reported. METHODS: A cross-sectional survey was conducted between March and December 2019 in 200 haemodialysis units in France, selected at random. Data were collected via questionnaire, completed by telephone interview with an infection control practitioner. A practice was deemed compliant when >85% of units declared that they always complied with the guidelines. RESULTS: In total, 103 units (51.5%) agreed to participate. Most practices complied with the guidelines; however, some practices did not reach the 85% compliance threshold for working in pairs when connecting central venous catheter (CVC) lines, performing hand hygiene before disconnecting lines, rinsing antiseptic soap before painting CVC exit site or arteriovenous fistula (AVF) puncture site, allowing antiseptic paint to dry, handling CVC branches with antiseptic impregnated gauze, performing hand hygiene after AVF compression with gloves, wearing protective eyewear when connecting/disconnecting CVC or when puncturing AVF, and wearing a gown when puncturing AVF. The most frequently reported difficulties were understaffing, difficulties with skin preparation because of exit site skin damage, and lack of buttonhole technical expertise. CONCLUSIONS: Despite good overall compliance, this survey highlights some shortcomings in compliance with infection prevention guidelines, which could be associated with either higher risk of vascular access infection or increased blood-borne virus transmission.

[Information for patients about hospital infections in psychiatry: An assessment of healthcare professionals' knowledge, opinion and attitude]. / Connaissances, opinions et pratiques des professionnels concernant l'information des patients sur les infections nosocomiales : évaluation en milieu psychiatrique.

INTRODUCTION: French legislation makes mandatory for healthcare providers the disclosure of hospital infection (HI) risk and actual occurrence to the patient. Given the specific diseases encountered in psychiatry, some difficulties may be expected in practical application of this regulation. OBJECTIVES: The aim of our study was to describe the knowledge, declared practices and opinions of healthcare workers (HCW) in psychiatry concerning information for patients about HI. METHODS: We randomly selected doctors, nurses and head nurses from four hospitals with psychiatric activity in Normandy. The HCW were asked to self-complete an anonymous questionnaire, including data describing the responding HCW and questions aiming at describing his/her knowledge, attitude in routine daily practice and opinion about information to patients about HI. RESULTS: One hundred and forty-one HCW were initially selected, of which 114 (80.9%) eventually agreed to complete the questionnaire. Only eight HCW (7.0%) were considered to have a correct overall knowledge of legal obligations. Main errors concerned the obligation to inform the patient of the HI risk according to the medical procedures that are to be performed (43.9% of correct answers) and the obligation to inform the patient of the HI risk according to his/her medical condition (46.5%). The obligation to inform the patient of the occurrence of a HI was largely known (84.2%). HCW usually giving information about the risk of HI to patients without HI accounted for 5.3%. Main reasons advocated for not informing patients were a low level risk of HI in psychiatry (80.4%) and the lack of patients' demand (59.8%). In the case of HI occurrence, the percentage of HCW routinely informing patients was 13.2%. HCW systematically informing the patient's family about the occurrence of HI accounted for 9.6%. A large proportion of HCW supported delivering information to patients about HI (86.0%). HCW expected from information better approval of prevention programs by the patients (87.7%) but feared an increased anxiety in patients (75.4%) and a higher rate of care refusal (48.2%). CONCLUSION: Whereas a very large proportion of HCW in psychiatry support delivering information to patients about HI, our study shows HCW's lack of awareness of regulations and lack of declared practices. Among factors explaining this contrast, a lower perceived HI risk and severity level are to be mentioned. Training programs focusing on risk and mechanisms of HI could be offered to professionals in psychiatry. The issue of specific communication difficulties with psychiatric patients should be addressed as well. In order to develop information on HI, specific methods suited to those patients should be developed.

Lack of effect of a poster-based intervention to reduce the number of blood culture samples collected.

OBJECTIVE: To reduce the number of blood culture samples collected. PATIENTS AND METHOD: We performed a cluster randomized controlled trial in adult acute care, and subacute care and rehabilitation wards in a university hospital in France. A poster associating an image of eyes looking at the reader with a summary of blood culture sampling guidelines was displayed in hospital wards in the intervention group. The incidence rate of blood cultures per 1000 days during pre- and post-intervention periods was calculated. RESULTS: Thirty-one wards participated in the study. The median difference in blood cultures/1000 days between periods was -1.863 [-11.941; 1.007] in the intervention group and -5.824 [-14.763; -2.217] in the control group (P=0.27). CONCLUSION: The intervention did not show the expected effect, possibly due to the choice of blood cultures as a target of good practice, but also to confounding factors such as the stringent policy of decreasing unnecessary costly testing.

Influence of infection control report cards on patients' choice of hospital: pilot survey.

The impact on patients' attitudes of quality report cards on infection control in hospitals has never previously been studied. In 2006, the French government implemented a mandatory report card on infection control activity (ICALIN) in all hospitals. This approach was aimed at encouraging professionals to change their routine practices in case they should lose patients due to a low ICALIN score. Our objective was to assess what impact ICALIN could have on patients' attitude as regards hospital choice. We performed a survey of patients and visitors in 14 randomly selected hospitals of various ICALIN scores. A convenience sample of 381 patients and visitors completed an anonymous questionnaire on ICALIN, their reasons for choosing a hospital and attitude in the event of a low ICALIN score. Factors associated with interest in ICALIN and impact of ICALIN on hospital choice were assessed by logistic regression. Our results showed that 77% of participants were interested in ICALIN. ICALIN was ranked sixth as a reason for choosing a hospital. In the case of a low ICALIN, 24.1% of participants would refuse admission and 54.9% would seek advice from their general practitioner. Sociodemographic factors had no influence on patients' attitude. In conclusion, our survey suggests that patients take note of poor performance on infection control report cards. As most patients rely on their general practitioner to interpret these report cards, there is a definite need for further communication with general practitioners on this issue.

What factors influence healthcare professionals' opinion and attitude regarding information for patients about hospital infection?

Although informing patients about medical risks is said to decrease the number of malpractice claims, most inpatients receive no information about hospital infection. Using a self-administered questionnaire, we surveyed 1270 healthcare workers randomly selected from 22 French hospitals to assess their opinion on information for patients about hospital infection risks, and their practice of informing patients with, or without, hospital infection. The influence of healthcare worker characteristics on opinion and practice was assessed using logistic regression. Response rate was 87.2%. Although 85.4% supported giving more information, only 17.0% routinely informed non-infected patients and 31.6% informed infected patients about infection. Attitudes were influenced by healthcare worker characteristics and environmental factors. Knowledge of obligations influenced practice when informing non-infected patients, but not those with hospital-acquired infection. Further research is needed to help healthcare professionals improve risk communication and disclosure of hospital infection.

Reassessment of antibiotic therapy in hospitals.

INTRODUCTION: French national guidelines state that antibiotic therapies should be reassessed between 48 and 72hours after treatment initiation and that reassessment of antibiotic therapy (RA) must be recorded in patients' files. OBJECTIVE: To determine whether RA is performed and recorded in patients' files in hospitals in a region of France. METHODS: Setting: hospitals participating in the National nosocomial infection point- prevalence survey (NPS) in Upper-Normandy, France. Patients included those receiving antibiotic therapy (excluding antibiotic prophylaxis) on NPS day, started in the hospital in which the survey was conducted and ongoing for more than 72hours. Data collected included characteristics of participating hospitals and, for each included patient, characteristics of ward, infection and antibiotic therapy, and mention in the patients' files of explicit or implicit RA. The rate of explicit and implicit RA was calculated and factors associated with explicit or implicit RA were evaluated using a univariate analysis. RESULTS: Thirty-three hospitals representing 87% of hospital beds region-wide were included in the study. In addition, 933 prescriptions were assessed for 724 infections in 676 patients. The overall rate of RA was 67.6% (49.3% of explicit RA and 18.3% of implicit RA). The rate of RA differed significantly according to infection and antibiotic class but not according to hospital or ward characteristics. CONCLUSION: Our study provides new and reassuring results regarding reassessment of antibiotic therapy.

Alcohol-based hand rub: influence of healthcare workers' knowledge and perception on declared use.

Handrubbing with alcohol-based hand rub (AHR) is a validated alternative to handwashing. The aims of this study were to compare knowledge and declared use of AHR between different categories of healthcare worker (HCW), and to assess factors associated with the use of AHR. A standardized questionnaire was sent to all HCWs in a tertiary care university hospital. The following data were collected for each HCW: job title (physician, nurse, nursing assistant or other), sources of information about AHR; knowledge and perception of AHR and declared use of AHR in daily practice instead of unmedicated or antiseptic soap. Of 5238 questionnaires, 1811 were returned. Physicians had better knowledge about AHR than other HCWs. HCWs' knowledge of AHR efficacy and skin tolerance were independently associated with the use of AHR instead of unmedicated or antiseptic soap. The declared use of AHR differed according to professional category.

Surgical hand rubbing compared with surgical hand scrubbing: comparison of efficacy and costs.

The aim of this study was to compare the efficacy of surgical hand rubbing (SHR) with the efficacy of surgical hand scrubbing (SHS), and to determine the costs of both techniques for surgical hand disinfection. A review of studies reported in the literature that compared the efficacy of SHS and SHR was performed using MEDLINE. The costs of SHR and SHS were estimated based on standard hospital costs. The literature showed that SHR had immediate efficacy that was similar to that of SHS, but SHR had a more lasting effect. SHR reduced costs by 67%. In conclusion, SHR is a cost-effective alternative to SHS.

Knowledge and opinions of surgical patients regarding nosocomial infections.

UNLABELLED: Sixty-five inpatients in various surgery departments were questioned about their knowledge and opinions regarding nosocomial infection, the information they were given on nosocomial infection, and their supposed attitude should they contract a nosocomial infection. RESULTS: Seventeen (26%, [16-39%]) were able to describe nosocomial infections as infections acquired in hospital. Identification of nosocomial infections as hospital-acquired infections was significantly associated with a high educational level and with having a member of their own family working in a health-related field. Fifty-two patients (80.0%, [68.2-88.9%]) stated that during their hospitalization they had received no information concerning nosocomial infections and 50 patients (76.9% [64.8-86.5]) mentioned that patients would welcome information about nosocomial infections. Thirty-three patients [50.8, 95% CI(38.6-62.9%)] declared that they would seek legal action against the hospital should they contract a nosocomial infection. There was a trend toward a higher probability of legal action in patients who rated their own risk of nosocomial infection as low or absent versus those who rated their own risk of nosocomial infection as medium or high (58.0% vs. 28.6%, p=0.051). The intention of seeking legal action against the hospital in case of nosocomial infection was not significantly influenced by patients' opinion regarding nosocomial infection preventability.

Assessment of prolonged hospital stay attributable to surgical site infections using appropriateness evaluation protocol.

BACKGROUND: The accepted standard in estimating the stay prolongation attributable to surgical site infections is the matched-cohort study method (MCS), which is associated with selection bias. The Appropriateness Evaluation Protocol (AEP) has been used to estimate stay prolongation attributable to nosocomial infections but has not been validated specifically for surgical site infections. AIM OF THE STUDY: To compare estimates of stay prolongation attributable to surgical site infections after digestive surgery, obtained by AEP and by MCS. METHODS: Sixty-five surgical site infections after digestive tract surgery were analyzed by AEP and MCS. AEP stay prolongation was the number of days judged specifically appropriate for the care of surgical site infections. MCS stay prolongation was the difference of stay duration in surgical site infection cases and two controls matched by age, sex, and diagnosis-related groups. Sensitivity and specificity of AEP, and agreement between both methods, were calculated. RESULTS: The mean AEP stay prolongation was 3.5 days vs 7.2 days for MCS. The sensitivity of AEP was 58% and the specificity was 75%. The agreement between the two methods was poor. CONCLUSION: Surgical site infections after digestive tract surgery increased the hospital stay. Accurate estimations of a prolongation of stay will vary according to the method selected.

Mediastinitis after coronary artery bypass graft surgery: influence of the mammary grafting for diabetic patients.

Mediastinitis is a severe complication of coronary artery bypass graft surgery (CABG) particularly when harvesting internal mammary arteries (IMA). CABG in diabetic patients often uses two IMA because the saphenous graft is damaged. To our knowledge this risk of mediastinitis has not previously been reported in diabetic patients. All consecutive diabetic patients undergoing CABG over a three-year period from 1998 to 2000 were included in the study. Data recorded were: age, sex, duration of stay, whether one or two IMA were used, diagnosis of mediastinitis. Calculation of relative risk and analysis of trends by chi2 trend tests was also performed. In total 256 diabetic patients were included in the cohort. The incidence of mediastinitis was 4.3% (11/256). The risk of mediastinitis was higher in patients with two IMA than in patients with one IMA (relative risk 5.97, 95 CI 1.63-21.93, P=0.004). Age and sex were not confounding factors. No patients with mediastinitis died. Bilateral IMA grafting is associated with higher risk of mediastinitis in diabetic patients. The authors suggest that the risk of mediastinitis in diabetic patients should be taken into consideration when cardiac surgeons choose unilateral or bilateral IMA harvesting for surgery.

Case fatality and health care costs in HIV-infected patients: evolution from 1992 to 2000 at Rouen University Hospital, France.

Vital prognosis in HIV-infected patients has been improved by new therapies, leading to an increase in treatment and outpatient costs but lower inpatient care costs. The aim of the study was to compare the health care costs between 1992-1996 (first half) and 1996-2000 (second half) in HIV-infected patients at Rouen University Hospital. Hospitalization costs (including inpatient and outpatient care), infectious complication treatment and antiretroviral therapy costs were evaluated from a National Health Insurance viewpoint. Between 1992 and 2000, 1212 patients were admitted at least once. Total expenditure increased between the two periods from 13,660 Euro to 27,567 Euro, i.e., a two-fold increase. During the same period, 125 deaths were avoided, and 3602 years of life were gained. The cost of one avoided death was 108,320 Euro and the cost per life-year gained was 3776 Euro.

[Efficiency of hepatitis C virus screening before and after blood transfusion]. / Evaluation médicoéconomique du suivi sérologique péritransfusionnel du virus de l'hépatite C.

UNLABELLED: Efficiency of a viral hepatitis C screening strategy before and after blood transfusion has to be evaluated. METHODS: Four screening strategies were virtually applied to the population of transfused patients at Rouen University Hospital during 1996 and then compared : the first without any systematic HCV screening test; the second with systematic testing both before and 3 months after transfusion; the third with systematic testing both before and 6 months after transfusion ; the last defined as systematic testing before transfusion only. The efficacy (i.e. number of positive tests), the efficiency (i.e. average cost per positive test) and the marginal costs of moving from a strategy to another one were assessed using decision analysis. RESULTS: The efficacy of systematic screening test before transfusion only (361 per positive test), systematic testing both before and three months after (523 per positive test) or six months after (488 per positive test) transfusion was similar, but the efficacy of the strategy without any systematic screening test (385 per positive test) was lower. The systematization of screening test both before, and three months, or 6 months after transfusion lead to a marginal cost of 619 , and 559 per positive test respectively. The systematization of testing before transfusion only lead to a marginal cost of 343 per positive test. Adding systematic testing after transfusion lead to a marginal cost of 5824 per positive test. CONCLUSION: Systematic screening tests before transfusion only can be considered as the most efficient strategy.

[Survival after blood transfusion: a study at Rouen university hospital]. / Facteurs de survie à six mois des patients transfusés: étude au CHU de Rouen.

UNLABELLED: The aim of this study was to estimate short term survival rate after blood transfusion according to various criteria. PATIENTS AND METHODS: Patients admitted and transfused from January, 1 until June, 30 1996 at Rouen university hospital were retrospectively included, and their status (alive or dead) was determined. The characteristics of patients admitted and transfused were compared to the overall population of inpatients. Independent factors associated with mortality six months after blood transfusion were evaluated using Cox model. RESULTS: During the study period, 1887 patients were transfused. These patients were older, more often admitted in surgical or in intensive care units, and had a longer duration of stay, than the overall inpatients population. The survival rate at six months in transfused patients was 76.1%. Mortality rate at six months was independently higher in patients aged 75 and older, in men, in patients admitted in intensive care units, or transfused with homologous fresh-frozen plasma or packed platelet blood cells. Mortality rate was lower in patients who underwent a surgical procedure, in children under 16, and in patients whose stay was classified in "Circulatory system disorders", "Musculoskeletal system and connective tissues disorders or trauma", or "Injuries, allergy or poisoning". CONCLUSION: In this study implemented in a teaching hospital inpatients receiving blood transfusion, the survival was mainly associated with the severity and characteristics of the diseases requiring transfusion.

[Upper digestive hemorrhage in patients over 80 years of age: incidence and prognostic factors]. / Hémorragies digestives hautes du sujet âgé de plus de 80 ans: fréquence et facteurs pronostiques.

OBJECTIVES: The aim of this study was to assess the incidence and the prognosis of upper gastrointestinal hemorrhage in patients aged over 80 years. METHODS: Between January and December 1993, among 360 patients admitted for upper gastrointestinal hemorrhage, 63 were older than 80 years (18%). Data were prospectively collected in all patients. RESULTS: Before admission, 8 experienced a lipothymia and 3 a shock. The median initial hematocrit was 29%. Endoscopy was performed in 59 patients and a cause was determined in 49 (83%). The main cause of bleeding was gastric and duodenal ulcer (n = 26, 53%) and ten of them were graded Forrest < or = IIb. Endoscopy did not contribute in 10 patients and was impossible in 4 because of an hemodynamic failure. Gastrotoxic drugs intake was found in 28 patients: non steroidal anti-inflammatory drugs (n = 14) and aspirin (n = 14). Endoscopic injection therapy was performed in the 10 patients with gastric or duodenal ulcer < or = Forrest IIb and permanent hemostasis was achieved in 8 out of 10. No further bleeding was seen in 53 patients (84%), while bleeding persisted in 4 and rebleeding occurred in 6 (9.5%) (3 duodenal ulcers, 2 gastric carcinomas and 1 esophageal varices bleeding). Only one patient required emergency surgery (rebleeding duodenal ulcer). The overall mortality was 12/63 (19%):50% of the deaths were related to hemorrhagic complications and 50% to concomitant disease. Only one patient among those taking gastrotoxic drug died from bleeding. The risk factors of death from bleeding were: initial shock (P = 0.02), lipothymia before admission (P = 0.02), rebleeding (P < 0.01), persistence of bleeding (P < 10(-4)). Gastrotoxic drugs intake was associated with a favorable prognosis (P < 0.05). The prognosis was not significantly affected by an initial hematocrit < 30% or blood units transfused > or = 4. CONCLUSIONS: People older than 80 years account for a large proportion of upper gastrointestinal bleeding (18%). The more common cause is gastric or duodenal ulcer. Mortality in these patients is high (19%). An initial shock or lipothymia, rebleeding or persistence of bleeding worsens prognosis. Gastrotoxic drugs intake is frequent (44%), but is associated with a good prognosis.

[Compared efficiency of three strategies of management of chronic hepatitis C. Effect on the risk of cirrhosis 8 years after diagnosis]. / Efficience comparée de trois stratégies de prise en charge de l'hépatite chronique C. Influence sur le risque de cirrhose à 8 ans.

OBJECTIVES AND METHODS: The goal of treating chronic hepatitis C with alfa interferon is to eradicate HCV infection. The actual influence of this treatment on the development of cirrhosis is unknown. Moreover, the poor results and the high cost of this treatment have caused a public health problem. Three strategies were evaluated by decision analysis: no treatment (S1), treatment of chronic active hepatitis only (S2), treatment of all chronic hepatitis (S3). For each strategy, we estimated the probability of the occurrence of the following events based on data in the literature: presence of chronic active hepatitis, chronic persistent hepatitis or cirrhosis at the time of diagnosis; discontinuation of interferon because of adverse events; biological response to treatment; incidence of cirrhosis 8 years after diagnosis without treatment or in case of response to treatment. RESULTS: The risk of cirrhosis was 28.5% with S1, 25.4% with S2, and 25.2% with S3, 8 years after diagnosis. If HCV infection was detected early before cirrhosis, the number of cases of cirrhosis occurring in an 8 year-followup period would be 45,600 with S1, 40,640 with S2, and 40,320 with S3 and the cost of S2 and S3 would be 1.23 10(9) French Francs (FF), and 2.57 10(9) FF, respectively. The mean cost to prevent one case of cirrhosis would vary from 248,000 FF with S2 to 487,000 FF with S3. CONCLUSION: This decision analysis study suggests that the S3 strategy is not suitable for a population of HCV infected patients, because of its low efficiency and high cost.

[Risk factors of contamination by hepatitis C virus. Case-control study in the general population]. / Facteurs de risque de contamination par le virus de l'hépatite C. Etude cas-témoins en population générale.

UNLABELLED: In 30% of patients with hepatitis C virus, the source of infection is unknown. OBJECTIVE: To identify the risk factors of infection by hepatitis C virus in a case-control study. METHODS: Cases had positive hepatitis C virus serology, and were living in Fecamp (Normandy, France). Controls (2 for each case) were age and sex-matched subjects with negative hepatitis C virus serology, living in Fecamp. Demographic, medical, professional, and environmental data were collected. Statistical analysis included chi 2 or Fisher's exact test and multiple logistic regression. RESULTS: The risk factors of hepatitis C virus by univariate analysis were: history of transfusion, high number of sexual partners, hepatitis C virus infection in a relative, history of digestive or genitourinary surgery, an invasive medical procedure, digestive endoscopy, biopsy, lumbar or pleural puncture, medical care after an accident, injections, multiple deliveries or abortion. Risk factors of hepatitis C virus infection by multivariate analysis: hepatitis C virus infection in a relative (Odds ratio: 4.58), history of transfusion (Odds ratio: 2.32), of a surgical procedure (Odds ratio: 2.50), of medical care after an accident (Odds ratio: 1.51), of injections (Odds ratio: 2.24). CONCLUSION: Our results suggest the possible nosocomial transmission of hepatitis C virus. Intrafamilial transmission is also possible.

[Cost of early management of chronic inflammatory intestinal disease]. / Coût de la première prise en charge des maladies inflammatoires chroniques de l'intestin.

OBJECTIVES: The aim of this study was to assess the cost of the first management of inflammatory bowel disease (IBD) from the onset of first symptoms until 6 weeks after the diagnosis. This cost was calculated in French francs (FF) for all IBD and namely for Crohn's disease (CD), ulcerative colitis (UC), and ulcerative proctitis (UP). MATERIAL AND METHODS: Data concerning 258 patients were collected by the mean of a standardized questionnaire from 3 different sources: the patient, his general practitioner, and his gastroenterologist. RESULTS: Two hundred and fifty eight patients were included: 144 CD (55.8%), 76 UC (29.5%), 30 UP (11.6%), and 8 chronic unclassifiable colitis (CUC) (3.1%). The mean direct costs of the diagnosis (m +/- SD) were 23,116 +/- 40,820 FF for CD, 10,628 +/- 17,316 FF for UC and 3,451 +/- 2,743 FF for UP. Although unplanned hospitalizations occurred in only 38% of the patients (98/258), they represented the 3/4 of the mean costs: 78.2% for CD and 64% for UC. Indirect costs generated by days off work were 4,719 +/- 6,610 FF for CD, 2,996 +/- 6,897 FF for UC and 1,230 +/- 3,622 FF for UP. CONCLUSION: The first management of a patient with CD was twice more expensive than the one with UC and 6.5 times than the one with UP.

[Diagnostic and therapeutic management of patients with chronic inflammatory bowel disease]. / Prise en charge diagnostique et thérapeutique des patients atteints de maladie inflammatoire chronique de l'intestin.

BACKGROUND: The period of time required for the diagnosis of a chronic illness depends on initial clinical symptoms and their perception by the patient and the physicians. The aim of this study was to describe the procedures of diagnosis of incident cases of Inflammatory Bowel Disease (IBD). METHODS: Patients reported by the Registry of inflammatory bowel disease of northern France (EPIMAD) in 1994 were included. Standardized questionnaires describing clinical history, patient behavior, medical consultations and examinations were collected by an interviewer practitioner from three sources: patients, general practitioners (GP) and gastroenterologists (GE). Patients were divided in 2 groups according to the time between symptom onset and diagnosis: more than 9 months or less than 9 months (D > 9 and D < or = 9). RESULTS: 258 patients were included: 144 Crohn's disease (CD) (56%), 106 ulcerative colitis (UC) (41%) and 8 chronic unclassifiable colitis (CUC). Median time between symptom onset and diagnosis was 3 months, 196 (76%) patients belonged to the group D < or = 9 and 62 (24%) to the group D > 9. There was no difference between the 2 groups for initial clinical symptoms. The delay between symptom onset and the consultation to the GP and the GE was longer in the group D > 9: respectively 1 month vs 0 and 7.6 vs 2. Thirty-five percent of patients in the group D > 9 had consulted more than one GP vs 14% (p < 0.05). Diagnosis management by the GE was the same in both groups. Patients of group D < or = 9 had more often perceived their symptoms as serious (p < 0.05). CONCLUSIONS: Delay to diagnosis in a quarter of patients with IBD was more than 9 months. This later diagnosis was not due to patient management by the GE but rather to a longer delay to consulting the GP and between GP and GE referral. Patient interpretation of the symptoms could also explain the variability of this delay.