Peripheral arterial obliterative disease. Cost of illness in France.

The main purpose of this study, carried out in 1995, was to determine, using available sources, the cost of peripheral arterial obliterative disease (PAOD) in France over a 1-year period. This cost-of-illness study was based on a retrospective analysis of the available literature and databases. It involved a description of epidemiological data and a cost estimate of the different medical resources consumed over 1 year. For this latter purpose, a payer perspective was chosen. Data were extracted from national representative surveys and databases with respect to morbidity and mortality [from the National Institute of Health and Medical Research (Institut National de la Santé et de la Recherche Médicale; INSERM) and the National Sickness Insurance Fund for Salaried People (Caisse Nationale d'Assurance Maladie des Travailleurs Salariés; CNAMTS)], consultations, examination tests and drug prescriptions [from the French Medical Audit conducted by Intercontinental Medical Statistics (IMS)], hospitalisations [from the Statistical Unit of the Department of Health-Service des Statistiques, des Etudes et des Systemes d'Information (SESI) and the National Public Research Centre in Health Economics (Centre de Recherche d'Etude et de Documentation en Economie de la Santé; CREDES)] and related health expenditure from CNAMTS. In France, the prevalence of stage II PAOD (Leriche and Fontaine classification) in 1992 was estimated to be 675,000; 53% of these patients had undergone vascular or bypass surgery. The total annual cost of healthcare (including consultations, drugs, laboratory tests, hospitalisation and hydrotherapy) for the management of patients with PAOD ranged from 3.9 billion French francs (F) to F4.6 billion (1995 values), depending on the type of hospital considered. 50% of this cost was related to hospitalisations and 75% was covered by the CNAMTS. Although this study was only a partial evaluation and did not take into account indirect costs or nonmedical direct costs, such as transport and care by healthcare assistants and paramedics, these results may help to establish public health priorities and modify clinical practice to favour an earlier diagnosis of PAOD.

[Can the results of large-scale clinical trials be applied to clinical practice?]. / Les résultats des grands essais médicamenteux sont-ils applicables en pratique?

The management of a patient in cardiac failure should lead the physician to ask if the patient might benefit from treatment with an angiotensin converting inhibitor. Meta-analyses give a positive reply but often lack detail. Analysis of large scale therapeutic trials is the only way to determine whether the results are applicable in an individual case. This analysis starts with validation of the methodology (correct randomisation, respect of double blind protocol, identity of groups) and synthesis of results expressed, if possible, in absolute values. In a second stage, the criteria of inclusion, exclusion, and the comorbidity of enrolled patients, should be compared with those of the patient under consideration. In addition, the amplitude of the therapeutic benefit and the importance of undesired effects must be taken into account in the therapeutic decision. This approach allows a reasoned prescription based on documented facts.

[Toxoplasmic pleuro-pericarditis associated with Hodgkin's disease]. / Pleuro-péricardite toxoplasmique associée à une maladie de Hodgkin.

Pericarditis caused by toxoplasma infection is exceptional: 16 cases only have been published since 1943. The authors report a case of Hodgkin's disease associated with, and revealed by, toxoplasmic pleuro-pericarditis, and they review the literature on this complication of toxoplasmosis. Since the infection can be cured and since pericarditis may become chronic and constrictive if untreated, toxoplasmosis should be envisaged and confirmed or infirmed by serological tests in all patients presenting with pericarditis of uncertain origin. Provided it has not reached the chronic stage, toxoplasmic pericarditis responds well to the conventional treatment with pyrimethamine and sulfonamides.

[Changes in prescription patterns for peripheral and cerebral vasoactive drugs before and after establishing prescription standards in France]. / Evolution de la prescription des vaso-actifs périphériques et cérébraux avant et après les références médicales opposables.

OBJECTIVES: Assess changes in the number of prescriptions for peripheral and cerebral vasoactive drugs for the treatment of lower limb arteritis and cerebrovascular disease since the promulgation in 1995 of prescription standards for the treatment of lower limb arteritis. Assess compliance to prescription standards with a detailed analysis of patient features, prescriptions written for lower limb arteritis, cerebrovascular disease and concomitant diseases and evaluate changes in treatment costs for lower limb arteritis and cerebrovascular disease as well as cost of the full prescription, including treatments for associated diseases. METHODS: This study was based on data recorded during the Permanent Study of Medical Prescriptions conducted from March 1994 to February 1995 and from March 1995 to February 1996 by the IMS. Prescription costs were established from the National Description Files of the IMS. Treatment costs were expressed as public price (FF) tax included. Prescriptions meeting the following criteria were selected for each period: prescriptions written by general practitioners for drugs with peripheral and cerebral vasoactivity (excepting calcium antagonists with a cerebral target) belonging to the Anatomic Therapeutic Classes C4A1 of the European Pharmaceutical Marketing Research Association, Bromly 1996; prescriptions for diagnoses 447.6 (arteritis) and 437.9 (cerebrovascular disease) according to the 9th WHO classification. A random sample of 500 prescriptions was selected to calculate costs. RESULTS: Since the advent of the prescription standards in 1995, prescriptions have dropped off by 6.3% for lower limb arteritis and by 14.8% for cerebrovascular disease. There was a 3.7 point decline in the percentage of multiple prescriptions of vasoactive drugs for lower limb arteritis (21.7% prior to March 1995 versus 18% after promulgation of the prescription standards, p > 0.1) and a 1.8 increase in the percentage of multiple prescriptions for cerebrovascular disease (14% prior to March 1995 and 15.8% after promulgation of the prescription standards, p > 0.1). For the treatment of lower limb arteritis, prescription costs fell by a mean 9% per prescription and for the treatment of cerebrovascular disease they rose by a mean 7% per prescription. The price rise, due to multiple prescriptions of vasoactive drugs was 190 FF per prescription for lower limb arteritis and 104 FF per prescription for cerebrovascular disease. CONCLUSION: Despite the retrospective nature of this study where confounding factors could not be controlled, our findings are in agreement with those reported earlier suggesting that cost containment policy implemented by the prescription standards has had little efficacy. In patients with arterial disease of the lower limbs, the percentage of prescriptions not complying with the recommended standards decreased by one-third to one-half over a 2-year period since the prescription standards were first announced in 1994.

[Epidemiology of tumors of the testis in Indre-et-Loire from 1978 to 1987]. / Epidémiologie des tumeurs du testicule en Indre-et-Loire de 1978 à 1987.

All the testicular tumors found among the inhabitants of the Indre-et-Loire department between 1978 and 1987 were reviewed. There was a total of 122 tumors, i.e. a direct standardised incidence rate of 4.55/100,000. The incidence increased over the years 1978-1982, with an abrupt decrease at 50% in 1983 and the increase since then has been minimal. There was an excessive morbidity rate of 22% for patients living in an urban environment. There was no preferential side for the tumor. The histological types of the tumors permit to distinguish three types of populations: non seminiferous germ cell tumors (51.3%) at the age of 30 years; seminoma (41.3%) at the age of 40 years and lymphoma (7.4%) at the age of 74 years. An indirect standardisation revealed an excessive rate of 22% for the socioprofessional category of employers and a rate of 28% for artisan, business men and company directors. The study confirms the known notions about the age and the histologic distribution of testicular tumors. The highest incidence rate of all the French departments, the drop in the rate of this growth curve in 1983 and the over representation of the employee category appear to be the most specific notions in the Indre-et-Loire department.

[Psychosocial management of retinitis pigmentosa patients from the viewpoint of the physician and the patient]. / Psychosoziale Betreuung des RP-Patienten aus der Sicht des Arztes und des Betroffenen.

For patients with retinitis pigmentosa (RP), the disease means having to adapt and adjust continuously to their visual loss, i.e., repeatedly giving up everyday activities which they are no longer capable of performing. RP patients and those around them (parents, partner, children) face a lifetime of coming to terms with the disease and coping. The ophthalmologist is confronted with a patient to whom he can offer no therapy. Rather, once the diagnosis has been established, the patient must be assisted and advised according to the development of the disease, and given the necessary support. In other words, RP is a challenge not only for the patient, but also for the ophthalmologist.

[Descriptive epidemiology of tumors of the renal parenchyma in adults, in Indre-et Loire from 1980 to 1987]. / Epidémiologie descriptive des tumeurs du parenchyme rénal de l'adulte, en Indre-et-Loire de 1980 à 1987.

296 solid renal tumors were studied retrospectively, i.e. the total number of renal tumours diagnosed in the Indre-et-Loire region between 1980 and 1987 inclusive. The crude incidence rate increased from 5.4 per 100,000 in 1980 to 8 per 100,000 in 1987. The standardised rates were 6.7 per 100,000 for men and 3.2 per 100,000 for women. These figures being quite high for France. The mean age at the time of diagnosis, 67 years for women and 65 years for men, decreased during the study, especially for women. Patients in whom the renal cancer was discovered accidentally, tended to be older than those in whom the tumour was symptomatic. The percentage of tumours discovered at stage I rose from 29 to 49% the percentage of tumours at stage IV fell from 45 to 23.5%. In parallel, the percentage of nephrectomies rose from 40 to 70%. The overall 5 year survival rate was 43.5%, rising to 71% for stage I tumours. It appeared that patients who consulted in the private sector tended to be younger and were therefore at an earlier stage in the natural history of the disease. From an epidemiological viewpoint, the introduction of ultrasonography in the Indre-et-Loire region and its more widespread use did not produce any change in the means of diagnosis of renal cancer.

[Practice patterns of dentists and maxillofacial surgeons in private practice, in 1993, in France]. / Mode d'exercise des médecins stomatologistes et des chirurgiens maxillo-faciaux dans le secteur libéral, en 1993, en France.

Actually, oral medicine and maxillo-facial surgery are really moving. There is no detail's study of the different aspects of our specialty, so we had like to realise a "picture" of our activity in the private sector in 1993. In this evaluation, an answering has been sent to the whole professional. Per 37.2% of answers have been received. The aim of this article is describing you the oral medicine and maxillo-facial surgery population following, in 4 points: old and sex demography; university and post-university formation; surgical or no activity repartition; exercises and installations.