Achieving universal health coverage in France: policy reforms and the challenge of inequalities.

Since 1945, the provision of health care in France has been grounded in a social conception promoting universalism and equality. The French health-care system is based on compulsory social insurance funded by social contributions, co-administered by workers' and employers' organisations under State control and driven by highly redistributive financial transfers. This system is described frequently as the French model. In this paper, the first in The Lancet's Series on France, we challenge conventional wisdom about health care in France. First, we focus on policy and institutional transformations that have affected deeply the governance of health care over past decades. We argue that the health system rests on a diversity of institutions, policy mechanisms, and health actors, while its governance has been marked by the reinforcement of national regulation under the aegis of the State. Second, we suggest the redistributive mechanisms of the health insurance system are impeded by social inequalities in health, which remain major hindrances to achieving objectives of justice and solidarity associated with the conception of health care in France.

[Respiratory cancers attributable to occupational exposures: what is the cost to society in France]. / Cancers des voies respiratoires attribuables aux expositions professionnelles : quels coûts pour la société française ?

OBJECTIVE: To estimate the social cost of respiratory cancers attributable to occupational risk factors in France in 2010. METHODS: We estimated the number of cases of respiratory cancers attributable to each identified occupational risk factor according to the attributable fractions method. We also estimated direct (costs of hospital stays, drugs, outpatient care) and indirect costs (production losses) related to morbidity (absenteeism and presenteeism) and mortality (years of lost production). Production losses for paid work and unpaid domestic activities were taken into account. RESULTS: The social cost of respiratory cancers (lung, larynx, sinonasal, pleural mesothelioma) attributable to exposure to asbestos, chromium, diesel engine exhaust, polycyclic aromatic hydrocarbons, painting occupations (unidentified carcinogen), crystalline silica, wood and leather dust in France in 2010 was estimated to be between €960 and 1,866 million. The cost of lung cancer represents between €804 and 1,617 million. The three risk factors with the greatest impact are asbestos (€530 to 890 million), diesel engine exhaust (€227 to 394 million), and crystalline silica (€116 to 268 million). CONCLUSION: These results provide a conservative estimate of the public health and economic burden of respiratory cancers attributable to occupational risk factors from a societal perspective.

The cost-effectiveness of neonatal versus prenatal screening for congenital toxoplasmosis.

BACKGROUND: Congenital Toxoplasmosis (CT) can have severe consequences. France, Austria, and Slovenia have prenatal screening programs whereas some other countries are considering universal screening to reduce congenital transmission and severity of infection in children. The efficiency of such programs is debated increasingly as seroprevalence among pregnant women and incidence of congenital toxoplasmosis show a steady decrease. In addition, uncertainty remains regarding the effectiveness of pre- and postnatal treatments. METHOD: To identify cost-effective strategies, prenatal and neonatal screenings were compared using a decision-analytic model based on French guidelines and current knowledge of long-term evolution of the disease in treated children. Epidemiological data were extracted from the scientific literature and clinical data from the French Lyon cohort. Strategies were compared at one year of age, when infection can be definitively evaluated, and at 15 years of age, after which validated outcome data become scarce. The analysis was performed from the French Health Insurance System perspective and included direct medical costs for pregnant women and their children. RESULTS: The 1-year Incremental Cost-Effectiveness Ratio showed that prenatal screening would require investing €14,826 to avoid one adverse event (liveborn with CT, fetal loss, neonatal death or pregnancy termination) compared to neonatal screening. Extra investment increased up to €21,472 when considering the 15-year endpoint. CONCLUSIONS: Prenatal screening is cost-effective as compared to neonatal screening in moderate prevalence areas with predominant Type II strains. In addition, prenatal screening, by providing closer follow-up of women at risk increases the number of occasions for education avoiding toxoplasmosis.

Exome sequencing in clinical settings: preferences and experiences of parents of children with rare diseases (SEQUAPRE study).

Exome sequencing (ES) has revolutionized diagnostic procedures in medical genetics, particularly for developmental diseases. The variety and complexity of the information produced has raised issues regarding its use in a clinical setting. Of particular interest are patients' expectations regarding the information disclosed, the accompaniment provided, and the value patients place on these. To explore these issues in parents of children with developmental disorders and no diagnosis with known etiology, a multidisciplinary group of researchers from social and behavioral sciences and patient organizations conducted a mixed-methodology study (quantitative and qualitative) in two centers of expertise for rare diseases in France. The quantitative study aimed to determine the preferences of 513 parents regarding the disclosure of ES results. It showed that parents wished to have exhaustive information, including variants of unknown significance possibly linked to their child's disorder and secondary findings. This desire for information could be a strategy to maximize the chances of obtaining a diagnosis. The qualitative study aimed to understand the expectations and reactions of 57 parents interviewed just after the return of ES results. In-depth analysis showed that parents had ambivalent feelings about the findings whatever the results returned. The contrasting results from these studies raise questions about the value of the information provided and parents' high expectations regarding the results. The nature of parental expectations has emerged as an important topic in efforts to optimize accompaniment and support for families during the informed decision-making process and after disclosure of the results in an overall context of uncertainty.

Preference heterogeneity with respect to whole genome sequencing. A discrete choice experiment among parents of children with rare genetic diseases.

The information to which whole genome sequencing (WGS) provides access raises questions about its disclosure to patients. The literature focused on the nature of findings, shows patients share the same expectations while evoking possible heterogeneity. Our objective is to test this hypothesis of preference heterogeneity with respect to the disclosure of results from WGS by means of a discrete choice experiment (DCE). Our DCE includes six attributes for studying preferences with respect to (1) variants of unknown significance and (2) secondary findings, and more innovatively with respect to (3) repeat analysis of the tests, (4) the decision-making process, (5) patient support and (6) the cost of testing. The survey was conducted at two genetic centres in France from February to December 2015 and included 528 parents of patients with development disorders with no aetiological diagnosis. By using a latent class model, it was possible to identify two preference profiles with parents opting for either a prospective (75% of sample) or a targeted (25%) diagnostic approach. The former valued the exhaustive and diverse genetic information the test can provide, even when the information is uncertain or not directly related to their child's illness; the latter valued only the least uncertain information relating to their child's illness. Understanding patients' preference patterns can help professionals to better accommodate and support patients and enables policy-makers to measure the diversity of expectations in the face of current developments in genomic medicine.

Which patients with colorectal cancer are followed up by general practitioners? A population-based study.

The aim of the study was to assess the contribution of general practitioners in the surveillance of colorectal cancer, and to examine characteristics and survival of patients with routine general practitioner follow-up. This French registry-based study included 389 patients diagnosed with first colorectal cancer in 1998 and free of disease at least 6 months after curative surgery. For each physician involved, medical records were thoroughly reviewed to collect information about the clinical examinations and follow-up tests prescribed within 3 years after surgery or until death or detection of recurrence. Five-year vital status was obtained through registry records. The proportion of routine clinical examinations performed by general practitioners increased from 35% in the first year to 65% in the third year. Patients having undergone regular general practitioner routine examinations (> or =one examination every 6-month period) had significantly less advanced disease (odds ratio: 0.45; 95% confidence interval: 0.21-0.96), preoperative complications (odds ratio: 0.28; 95% confidence interval: 0.08-0.91) and routine examinations by gastroenterologists/oncologists (odds ratio: 0.37; 95% confidence interval: 0.14-0.98) compared with those without general practitioner examinations. Routine general practitioner follow-up had no influence on 3 and 5-year survival. General practitioners detected significantly more recurrences than specialists in patients over 75 and in those presenting symptoms. French general practitioners are widely involved in the surveillance of patients with early-stage colorectal cancer, without any unfavourable impact on the patient's survival. Some suggestions exist that continuing education in oncology may increase the implication of general practitioners in colorectal cancer surveillance.

Variations in activity and practice patterns: a French study for GPs.

OBJECTIVES: To identify the different practice profiles of general practitioners (GPs) in order to test the hypothesis of heterogeneity in physician behaviour. DATA: For the year 2000, 4,660 GPs from two regions in France. VARIABLES: volume and structure of the physicians' medical activity, income level, personal characteristics, socioeconomic and geographical environment, characteristics of their patients. METHODS: A cluster analysis to identify different practice profiles and a regression analysis to display the determinants of the physicians' activity. RESULTS: Four different homogeneous groups can be identified, each one associating a physician's level of activity to his socioeconomic status. The level and the intensity of medical activity depend on individual factors, patients' characteristics as well as the socioeconomic context. CONCLUSIONS: There is no uniformity in the way GPs practice medicine. An immediate consequence is that any cost-containment measure that is applied uniformly to all GPs inevitably results in different outcomes according to the physicians' category type.

Modeling the economic burden of diseases imputable to stress at work.

This study evaluated the costs of work-related stress in France. Three illnesses--cardiovascular diseases, depression, musculoskeletal diseases and back pain--that may result from exposure to stress are identified and the proportions of cases attributable to the risk factor are calculated from epidemiological studies. Two methodological hypotheses allow us to provide complementary evaluations of the social cost of occupational stress and raise the ethical questions inherent in the choice of methodology. For the year 2000 our model shows that of a working population of 23.53 million in France some 310,000-393,400 persons (1.3-1.7%) were affected by illnesses attributable to work-related stress, and that 2,300-3,600 persons died as a result of their illness. Work-related stress costs society between Euro 1,167 million and Euro 1,975 million in France, or 14.4-24.2% of the total spending of social security occupational illnesses and work injuries branch.

Estimating the social cost of respiratory cancer cases attributable to occupational exposures in France.

PURPOSE: The objective of this article was to estimate the social cost of respiratory cancer cases attributable to occupational risk factors in France in 2010. METHODS: According to the attributable fraction method and based on available epidemiological data from the literature, we estimated the number of respiratory cancer cases due to each identified risk factor. We used the cost-of-illness method with a prevalence-based approach. We took into account the direct and indirect costs. We estimated the cost of production losses due to morbidity (absenteeism and presenteeism) and mortality costs (years of production losses) in the market and nonmarket spheres. RESULTS: The social cost of lung, larynx, sinonasal and mesothelioma cancer caused by exposure to asbestos, chromium, diesel engine exhaust, paint, crystalline silica, wood and leather dust in France in 2010 were estimated at between 917 and 2,181 million euros. Between 795 and 2,011 million euros (87-92%) of total costs were due to lung cancer alone. Asbestos was by far the risk factor representing the greatest cost to French society in 2010 at between 531 and 1,538 million euros (58-71%), ahead of diesel engine exhaust, representing an estimated social cost of between 233 and 336 million euros, and crystalline silica (119-229 million euros). Indirect costs represented about 66% of total costs. CONCLUSION: Our assessment shows the magnitude of the economic impact of occupational respiratory cancers. It allows comparisons between countries and provides valuable information for policy-makers responsible for defining public health priorities.

Psychosocial and organizational work environment of nurse managers and self-reported depressive symptoms: cross-sectional analysis from a cohort of nurse managers.

OBJECTIVES: The association between depressive symptoms and psycho-organisational work environment has been established in the literature. Some studies have evaluated depressive symptoms in healthcare workers, but little research has been carried out among nurse managers. The aim of the study is to evaluate the depressive symptoms prevalence among nurse managers' population and work environment factors. MATERIAL AND METHODS: A descriptive correlational research design was used. Data were collected from 296 nurse managers in five hospitals in the eastern area of France between 2007 and 2008. Health outcomes were evaluated by measuring depressive symptoms (CES-D scale), the exposure data by assessing psycho-organisational work environment with effort-reward imbalance-model of Siegrist. Multiple logistic regressions were used to describe the strength of the association between depressive symptoms and effort-reward imbalance adjusted for personal and occupational characteristics of the nurse managers. RESULTS: Among the nurse managers, a third had depressive symptoms, and 18% presented an effort-reward imbalance (ratio: ≥ 1). A significant association was found between depressive symptoms and effort-reward imbalance (OR = 10.81, 95% CI: 5.1-23, p < 10(-3)), and with esteem as a reward (OR = 3.21, 95% CI: 1.6-6.3, p < 10(-2)). CONCLUSION: In view of the hierarchical situation of nurse managers and their primary roles in hospitals, it is necessary to take prevention measures to improve their work environment and health.

Cost-effectiveness analysis of fecal occult blood screening for colorectal cancer.

OBJECTIVES: Clinical trials have demonstrated that fecal occult blood screening for colorectal cancer can significantly reduce mortality. However, to be deemed a priority from a public health policy perspective, any new program must prove itself to be cost-effective. The objective of this study was to assess the cost-effectiveness of screening for colorectal cancer using a fecal occult blood screening test, the Hemoccult-II, in a cohort of 100,000 asymptomatic individuals 50-74 years of age. METHODS: A decision analysis model using a Markov approach simulates the trajectory of the cohort allocated either to screening or no screening over a 20-year period through several health states. Clinical and economic data used in the model came from the Burgundy trial, French population-based studies, and Registry data. RESULTS: Modeling biennial screening versus the absence of screening over a 20-year period resulted in a 17.7 percent mortality reduction and a discounted incremental cost-effectiveness ratio of 3357 Euro per life-year gained among individuals 50-74 years of age. Sensitivity analyses performed on epidemiological and economic data showed the strong impact on the results of colonoscopy cost, of compliance to screening, and of specificity of the screening test. CONCLUSIONS: Cost-effectiveness estimates and sensitivity analyses suggest that biennial screening for colorectal cancer with fecal occult blood test could be recommended from the age of 50 until 74. Our findings support the attempts to introduce large-scale population screening programs.