Population health management in France: specifying population groups through the DRG system.

BACKGROUND: Population health management (PHM) by hospital groups is not yet defined nor implemented in France. However, in 2019, the French Hospitals Federation launched a pilot program to experiment PHM in five territories around five Territorial Hospital Groups (GHT's). In order to implement PHM, it is necessary to firstly define the population which healthcare facilities (hospitals) have responsibility for. In the French healthcare system, mapping of health territories however relies mainly on administrative data criteria which do not fit with the actual implementation of GHT's. Mapping for the creation of territorial hospital groups (GHTs) also did not include medical criteria nor all healthcare offers particularly in private hospitals and primary care services, who are not legally part of GHT's but are major healthcare providers. The objective of this study was to define the French population groups for PHM per hospital group. METHODS: A database study based on DRG (acute care, post-acute and rehabilitation, psychiatry and home care) from the French National Hospitals Database was conducted. Data included all hospital stays from 1 January 2016 to 31 December 2017. The main outcome of this study was to create mutually exclusive territories that would reflect an accurate national healthcare service consumption. A six-step method was implemented using automated analysis reviewed manually by national experts. RESULTS: In total, 2840 healthcare facilities, 5571 geographical zones and 31,441,506 hospital stays were identified and collated from the database. In total, 132 GHTs were included and there were 72 zones (1.3%) allocated to a different GHTs. Furthermore, 200 zones were manually reviewed with 33 zones allocated to another GHT. Only one area did not have a population superior to 50,000 inhabitants. Three were shown to have a population superior to 2 million. CONCLUSIONS: Our study demonstrated a feasible methodology to define the French population under the responsibility of 132 hospital groups validated by a national group of experts.

[Suspected non-accidental trauma in children: pseudofracture of the parietal bone]. / Suspicion de traumatisme non accidentel à enfant: à propos d'une pseudo-fracture pariétale.

We reported the case of a three month old child who was suspected of abuse syndrome because of a possible parietal bone fracture during radiographic investigation. At autopsy, the parietal bone abnormalities were not fractures, but proved to be unossified membranous strips. A review of the literature about normal variants of parietal suture on roentgenograms was made to avoid the diagnosis of non-accidental trauma in children, especially in live children where autopsy cannot be made.

[Patients refusal to be treated, the problem of Jehovah's witnesses]. / Refus de soins du patient, le problème épineux des témoins de Jéhovah.

The principle of respecting the patient's wishes is an international medical principle, found in several texts. In France, it was recalled in the 1994 Civil Code concerning bioethical laws and has recently been included in the Public health Code (law concerning patient's rights dated March 4, 2002). According to these various texts, the patient's wishes must always be respected, even in life threatening cases, so long as the patient has been informed of the risk. The refusal by Jehovah's witnesses to receive blood transfusion is always a problem. When, in full consciousness, a patient refuses a blood transfusion that his life depends on, what should the physician do? In June 1998, the Paris Court of Appeal ruled on this case. The judges found that "the obligation of the physician to always respect the wishes of the patient.is limited by the other obligation of the physician (the basis of a physician's activity) which is to protect the health and life of that same patient". In October 2001, the State Council ruling on this particular case found that, given the critical conditions of this case and the absence of a therapeutic alternative, the physicians had not committed an error. But it was also clearly underlined that a physician must respect the wishes of the patient and that this obligation must not be superseded by the duty of saving a life, thus disputing the judges of the Court of Appeal. Two questions. Two emergency interim rulings confirmed the position of the judges: the non-respect of the patient's wishes is an infringement of individual freedom. It is only in extreme and clearly defined circumstances that the physician will not be punished for this offence. This raises two questions: can a physician treat a patient against his/her wishes? And what risks does the physician take when respecting the patient's wishes when his/her life is at stake?

Patients refusing medical attention: the case of Jehovah's Witnesses in France.

Respect for the wishes of a patient is internationally accepted as standard medical practice. In French law, this principle is enshrined in the Civil Code of 1994 which concerns bioethics. More recently in 2002, we find it included in the Code of Public Health (in the law concerning patient's rights). According to these texts, the patient's wishes must always be respected even when his life is at stake, so long as the patient has been informed of the risk. The refusal by Jehovah's witnesses to receive blood transfusion always poses a problem. When, in full consciousness, a patient refuses a blood transfusion his life depends on, what should the doctor do? In June 1998, the Paris Administrative Court of Appeals ruled on such a case. The judges found that. In October 2001, the State Council decided in this particular case, that given the critical situation and the absence of a therapeutic alternative, the doctor had not committed an error. But it also clearly reiterated that the doctor is required to respect the wishes of the patient and that this obligation does not override the duty of saving a life. Two emergency interim rulings by the Lille Administration Court (25th August, 2002,) and by the State Council (6th August, 2002) confirm the position of the judges. Not respecting the patient's wishes is a great infringement of individual freedom. The doctor will not err only under extreme and precise conditions. Should the doctor go against those wishes? Should the wishes of the patient be respected when their life is at stake? The authors will discuss these two questions.