Long-term work outcomes and the efficacy of multidisciplinary rehabilitation programs on labor force participation in cancer patients - a protocol for a longitudinal prospective cohort study.

Background. Many cancer survivors experience late effects of cancer treatment and therefore struggle to return to work. Norway provides rehabilitation programs to increase labor force participation for cancer survivors after treatment. However, the extent to which such programs affect labor force participation has not been appropriately assessed. This study aims to investigate i) labor force participation, sick leave and disability rates among cancer survivors up to 10 years after being diagnosed with cancer and identify comorbidities contributing to long-term sick leave or disability pensioning; ii) how type of cancer, treatment modalities, employment sectors and financial- and sociodemographic factors may influence labor force participation; iii) how participation in rehabilitation programs among cancer survivor affect the longterm labor force participation, the number of rehospitalizations and incidence of comorbidities. Design and methods. Information from four medical, welfare and occupational registries in Norway will be linked to information from 163,279 cancer cases (15.68 years old) registered in the Norwegian Cancer Registry from 2004 to 2016. The registries provide detailed information on disease characteristics, comorbidities, medical and surgical treatments, occupation, national insurance benefits and demographics over a 10-year period following a diagnosis of cancer. Expected impact of the study for Public Health. The study will provide important information on how treatment, rehabilitation and sociodemographic factors influence labor force participation among cancer survivors. Greater understanding of work-related risk factors and the influence of rehabilitation on work-participation may encourage informed decisions among cancer patients, healthcare and work professionals and service planners.

Healthcare consumption after a change in health insurance coverage: a French quasi-natural experiment.

BACKGROUND: Compared with the number of studies performed in the United States, few studies have been conducted on the link between health insurance and healthcare consumption in Europe, likely because most European countries have compulsory national health insurance (NHI) or a national health service (NHS). Recently, a major French private insurer, offering voluntary complementary coverage in addition to the compulsory NHI, replaced its single standard package with a range of offers from basic coverage (BC) to extended coverage (EC), providing a quasi-natural experiment to test theoretical assumptions about consumption patterns. METHODS: Reimbursement claim data from 85,541 insurees were analysed from 2009 to 2018. Insurees who opted for EC were matched to those still covered by BC with similar characteristics. Difference-in-differences (DiD) models were used to compare both the monetary value and physical quantities of healthcare consumption before and after the change in coverage. RESULTS: As expected, the DiD models revealed a strongly significant, though transitory (mainly during the first year), increase after the change in coverage for EC insurees, particularly for costly care such as dental prostheses and spectacles. Surprisingly, consumption seemed to precede the change in coverage, suggesting that one possible determinant of opting for more coverage may be previous unplanned expenses. CONCLUSION: Both catching-up behaviour and moral hazard are likely to play a role in the observed increase in healthcare consumption.

The positive effect of workplace accommodations on the continued employment of cancer survivors five years after diagnosis.

PURPOSE: To address the gap highlighted in the literature on the effect of professional interventions to facilitate continued employment, this study aims to evaluate the effect of workplace accommodations on the continued employment 5 years after a cancer diagnosis. METHODS: This study is based on VICAN5, a French survey conducted in 2015-2016 to examine the living conditions of cancer survivors 5 years after diagnosis. Two subsamples, one with and one without workplace accommodations, were matched using a propensity score to control for the individual, professional, and medical characteristics potentially associated with receipt of workplace accommodations. RESULTS: The study sample was composed of 1514 cancer survivors aged 18-54 and employed as salaried at diagnosis. Among them, 61.2% received workplace accommodations within 5 years after diagnosis: 35.5% received a modified workstation, 41.5% received a modified schedule, and 49.2% received reduced hours. After matching, receipt of workplace accommodations appeared to improve the continued employment rate 5 years after cancer diagnosis from 77.8% to 95.0%. CONCLUSIONS: Receipt of workplace accommodations strongly increases the continued employment of cancer survivors 5 years after diagnosis. More research is needed to better understand the differences in receipt of workplace accommodations along with the related selection effect.

Work-Related Outcomes in Self-Employed Cancer Survivors: A European Multi-country Study.

Purpose To describe: (i) patterns of self-employment and social welfare provisions for self-employed and salaried workers in several European countries; (ii) work-related outcomes after cancer in self-employed people and to compare these with the work-related outcomes of salaried survivors within each sample; and (iii) work-related outcomes for self-employed cancer survivors across countries. Methods Data from 11 samples from seven European countries were included. All samples had cross-sectional survey data on work outcomes in self-employed and salaried cancer survivors who were working at time of diagnosis (n = 22-261 self-employed/101-1871 salaried). The samples included different cancers and assessed different outcomes at different times post-diagnosis. Results Fewer self-employed cancer survivors took time off work due to cancer compared to salaried survivors. More self-employed than salaried survivors worked post-diagnosis in almost all countries. Among those working at the time of survey, self-employed survivors had made a larger reduction in working hours compared to pre-diagnosis, but they still worked more hours per week post-diagnosis than salaried survivors. The self-employed had received less financial compensation when absent from work post-cancer, and more self-employed, than salaried, survivors reported a negative financial change due to the cancer. There were differences between self-employed and salaried survivors in physical job demands, work ability and quality-of-life but the direction and magnitude of the differences differed across countries. Conclusion Despite sample differences, self-employed survivors more often continued working during treatment and had, in general, worse financial outcomes than salaried cancer survivors. Other work-related outcomes differed in different directions across countries.

Seasonal influenza vaccine uptake among people with disabilities: A nationwide population study of disparities by type of disability and socioeconomic status in France.

People with disabilities use various preventive health services less frequently than others, notably because of a lower socioeconomic status (SES). We examined variations of seasonal influenza vaccine uptake according to type/severity of disability and SES. We analyzed (in 2016) data from the 2008 French national cross-sectional survey on health and disability (n=12,396 adults living in the community and belonging to target groups for seasonal influenza vaccination). We defined seasonal influenza vaccine uptake during the 2007-2008 season by the self-reporting of a flu shot between September 2007 and March 2008. We built scores of mobility, cognitive, and sensory limitations, and an SES score based on education, occupation, and income. We performed bivariate analyses and then multiple log-binomial regressions. The prevalence of vaccine uptake was 23% in the 18-64 group and 63% in the ≥65 group. In bivariate analyses, it was higher among people in both age groups who had mobility and/or cognitive limitations and in the ≥65 group among those with sensory limitations. In the multiple regression analyses, only the presence of major mobility limitations in the18-64 group remained significant. The probability of vaccine uptake was higher in the highest SES category than in the lowest. Among at-risk groups, people with disabilities were more frequently vaccinated than others, mainly because of their higher levels of morbidity and healthcare use. Socioeconomic inequalities in access to vaccination persist in France. Future research is needed to monitor the trend in vaccine uptake in institutions.

Return to work among self-employed cancer survivors.

PURPOSE: The aim of this study is to investigate whether salaried and self-employed workers differ regarding factors relevant for return to work after being diagnosed with cancer. The possible mediators of an effect of self-employment on work ability were also investigated. METHODS: A total of 1115 cancer survivors (1027 salaried and 88 self-employed) of common invasive cancer types who were in work at the time of diagnosis completed a mailed questionnaire 15-39 months after diagnosis. RESULTS: Twenty-four percent of self-employed cancer survivors reported that they had not returned to work at the time of the survey, and 18 % of those who were salaried had not. While 9 % of the self-employed had received disability or early retirement pension, only 5 % had received such a pension among salaried employees. Compared with the salaried workers, the self-employed people reported significantly more often reduced work hours (P < 0.001), negative cancer-related financial (P < 0.001), and occupational changes (P = 0.005) and low overall health (P = 0.02), quality of life (P = 0.04), and total work ability (P = 0.02). The negative effect of self-employment on total work ability seems to be mediated by reduced work hours and a negative cancer-related financial change. CONCLUSIONS: Compared with salaried, self-employed workers in Norway, they seem to struggle with work after cancer. This may be because the two groups have different work tasks and because self-employed people have lower social support at work and less legal support from the Working Environment Act and public health insurance. IMPLICATIONS FOR CANCER SURVIVORS: Self-employed people with cancer should be informed about the work-related challenges they may encounter and be advised to seek practical help from social workers who know about the legal rights of self-employed people.

Transitions in the labor market after cancer: a comparison of self-employed workers and salaried staff.

PURPOSE: The aim of this study was to investigate whether the labor market mobility of a population of cancer survivors 2 years after diagnosis differed compared to the French general population by focusing on the differences between self-employed workers and salaried staff. METHODS: Coarsened exact matching was implemented to reduce the sampling bias introduced by the comparison of individuals from two different surveys. Then, labor market mobility was analyzed by estimating transition probability matrices from 2010 to 2012 under the framework of a continuous-time Markov technique and by estimating a two-step model. RESULTS: Salaried employees and self-employed workers from the general population were more likely to remain employed 2 years after 2010 compared to salaried employees and self-employed workers who survived cancer. There was no major difference between salaried and self-employed workers surviving cancer in terms of job retention. CONCLUSIONS: French workers surviving cancer face the same difficulties that were observed in the National Cancer Survey of 2004: unemployment and inactivity caused by the diagnosis of cancer. Among cancer survivors, self-employed workers do not seem to be particularly more affected by inactivity than salaried staff. However, unemployment insurance is not compulsory for them, contrary to salaried staff. In this regard, self-employed workers might be a more vulnerable group.

Rates of admission for ambulatory care sensitive conditions in France in 2009-2010: trends, geographic variation, costs, and an international comparison.

BACKGROUND: Admissions for ambulatory care sensitive conditions (ACSCs) are considered preventable and indicators of poor access to primary care. We wondered whether per-capita rates of admission for ACSCs in France demonstrated geographic variation, were changing, were related to other independent variables, or were comparable to those in other countries; further, we wanted to quantify the resources such admissions consume. METHODS: We calculated per-capita rates of admission for five categories (chronic, acute, vaccination preventable, alcohol-related, and other) of ACSCs in 94 departments in mainland France in 2009 and 2010, examined measures and causes of geographic variation in those rates, computed the costs of those admissions, and compared rates of admission for ACSCs in France to those in several other countries. RESULTS: The highest ACSC admission rates generally occurred in the young and the old, but rates varied across French regions. Over the 2-year period, rates of most categories of ACSCs increased; higher ACSC admission rates were associated with lower incomes and a higher supply of hospital beds. We found that the local supply of general practitioners was inversely associated with rates of chronic and total ACSC admission rates, but that this relationship disappeared if we accounted for patients' use of general practitioners in neighboring departments. ACSC admissions cost 4.755 billion euros in 2009 and 5.066 billion euros in 2010; they consumed 7.86 and 8.74 million bed days of care, respectively. France had higher rates of ACSC admissions than most other countries examined. CONCLUSIONS: Because admissions for ACSCs are generally considered a failure of outpatient care, cost French taxpayers substantial monetary and hospital resources, and appear to occur more frequently in France than in other countries, policymakers should prioritize targeted efforts to reduce them.

Economics of the Iceberg: Informal Care Provided to French Elderly with Dementia.

OBJECTIVES: Dementia has a substantial effect on patients and their relatives, who have to cope with medical, social, and economic changes. In France, most elderly people with dementia live in the community and receive informal care, which has not been well characterized. METHODS: Using a sample of 4680 people aged 75 years and older collected in 2008 through a national comprehensive survey on health and disability, we compared the economic value of the care received by 513 elderly people with dementia to that received by a propensity score- matched set of older people without dementia. RESULTS: More than 85% of elderly people with dementia receive informal care; the estimation of its economic value ranges from €4.9 billion (proxy good method) to €6.7 billion (opportunity cost method) per year. CONCLUSIONS: The informal care provided to people with dementia has substantial annual costs; further work should be done to examine the social and economic roles foregone as a result of this care.

Characteristics and patterns of elective admissions to for-profit and not-for-profit hospitals in France in 2009 and 2010.

In the mid 2000s, in an effort to increase competition among hospitals in France - and thereby reduce hospital care costs - policymakers implemented a prospective payment system and created incentives to promote use of for-profit hospitals. But such policies might incentivize 'upcoding' to higher-reimbursed procedures or overuse of preference-sensitive elective procedures, either of which would offset anticipated cost savings. To explore either possibility, we examined the relative use and costs of admissions for ten common preference-sensitive elective surgical procedures to French not-for profit and for-profit sector hospitals in 2009 and 2010. For each admission type, we compared sector-specific hospitalization characteristics and mean per-admission reimbursement and sector-specific relative rates of lower- and higher-reimbursed procedures. We found that, despite having substantially fewer beds, for-profit hospitals captured a large portion of market for these procedures; further, for-profit admissions were shorter and less expensive, even after adjustment for patient demographics, hospital characteristics, and patterns of admission to different reimbursement categories. While French for-profit hospitals appear to provide more efficient care, we found coding inconsistencies across for-profit and not-for-profit hospitals that may suggest supplier-induced demand and upcoding in for-profit hospitals. Future work should examine sector-specific changes in relative use and billing practices of for elective surgeries, the degree to which these elective surgeries are justified in either sector, and whether outcomes differ according to sector used.

Geographic variation in rates of common surgical procedures in France in 2008-2010, and comparison to the US and Britain.

Geographic variation in use of elective surgeries has been widely studied in the US, where over-utilization is incentivized. We wanted to explore recent trends in the geographic variation of common surgical procedures in France--where a global budget, centralized planning process, and compulsory insurance scheme are in place--and to compare measures of variation there to those in the US and Britain. For 2008-2010, we calculated French age- and sex-adjusted per capita utilization rates and four measures of geographic variation for hip fracture admission (which is standard treatment and shows minimal geographic variation across countries) and 14 elective surgical procedures. We found substantial geographic variation in age-sex adjusted per capita admission rates for elective procedures: radical prostatectomy, spine surgery, and CABG showed the greatest variation, while hip fracture, colectomy, and cholecystectomy showed the least. Among older patients, most French admission rates were lower than those seen in the US. In general, measures of geographic variation were lower in France than those reported in the US or Britain. French policymakers could use analyses of geographic variation in service utilization to inform policy, to identify areas for intervention, or to measure the effectiveness of efforts designed to reduce variation in care.

Geographic variation in admissions for knee replacement, hip replacement, and hip fracture in France: evidence of supplier-induced demand in for-profit and not-for-profit hospitals.

INTRODUCTION: We sought to determine whether there was evidence of supplier-induced demand in mainland France, where health care is mainly financed by a public and compulsory health insurance and provided by both for-profit and not-for-profit hospitals. METHODS: Using a dataset of all admissions to French hospitals for 2009 and 2010, we calculated department-level age-adjusted and sex-adjusted per capita admission rates for hip replacement, knee replacement, and hip fracture for 2 age groups (45-64 and 65-99 y old), for-profit and not-for-profit hospitals. We used spatial regression analysis to examine the relationship between ecological variables, procedure rates, and supply of surgeons or sector-specific surgical beds. RESULTS: The large majority of hip and knee replacement surgeries were performed in for-profit hospitals, whereas the large majority of hip fracture admissions were in not-for-profit hospitals; nonetheless, we found approximately 2-fold variation in per capita rates of hip and knee replacement surgery in both age groups and settings. Spatial regression results showed that among younger patients, higher incomes were associated with lower admission rates; among older patients, higher levels of reliance on social benefits were associated with lower rates of elective surgery in for-profit hospitals. Although overall surgical bed supply was not associated with admission rates, for-profit-specific and not-for-profit-specific bed supply were associated with higher rates of elective procedures within a respective hospital type. DISCUSSION: We found evidence of supplier-induced demand within the French for-profit and not-for-profit hospital systems; however, these systems appear to complement one another so that there is no overall national supplier-induced effect.

Sex-based differences in income and response to proposed financial incentives among general practitioners in France.

Women represent a growing proportion of the physician workforce, worldwide. Therefore, for the purposes of workforce planning, it is increasingly important to understand differences in how male and female physicians work and might respond to financial incentives. A recent survey allowed us to determine whether sex-based differences in either physician income or responses to a hypothetical increase in reimbursement exist among French General Practitioners (GPs). Our analysis of 828 male and 244 female GPs' responses showed that females earned 35% less per year from medical practice than their male counterparts. After adjusting for the fact that female GPs had practiced medicine fewer years, worked 11% fewer hours per year, and spent more time with each consultation, female GPs earned 11,194€, or 20.6%, less per year (95% CI: 7085€-15,302€ less per year). Male GPs were more likely than female GPs to indicate that they would work fewer hours if consultation fees were to be increased. Our findings suggest that, as the feminization of medicine increases, the need to address gender-based income disparities increases and the tools that French policymakers use to regulate the physician supply might need to change.

General practitioners' choices and their determinants when starting treatment for major depression: a cross sectional, randomized case-vignette survey.

BACKGROUND: In developed countries, primary care physicians manage most patients with depression. Relatively few studies allow a comprehensive assessment of the decisions these doctors make in these cases and the factors associated with these decisions. We studied how general practitioners (GPs) manage the acute phase of a new episode of non-comorbid major depression (MD) and the factors associated with their decisions. METHODOLOGY/PRINCIPAL FINDINGS: In this cross-sectional telephone survey, professional investigators interviewed an existing panel of randomly selected GPs (1249/1431, response rate: 87.3%). We used case-vignettes about new MD episodes in 8 versions differing by patient gender and socioeconomic status (blue/white collar) and disease intensity (mild/severe). GPs were randomized to receive one of these 8 versions. Overall, 82.6% chose pharmacotherapy; among them GPs chose either an antidepressant (79.8%) or an anxiolytic/hypnotic alone (18.5%). They rarely recommended referral for psychotherapy alone, regardless of severity, but 38.2% chose it in combination with pharmacotherapy. Antidepressant prescription was associated with severity of depression (OR = 1.74; 95%CI = 1.33-2.27), patient gender (female, OR = 0.75; 95%CI = 0.58-0.98), GP personal characteristics (e.g. history of antidepressant treatment: OR = 2.31; 95%CI = 1.41-3.81) and GP belief that antidepressants are overprescribed in France (OR = 0.63; 95%CI = 0.48-0.82). The combination of antidepressants and psychotherapy was associated with severity of depression (OR = 1.82; 95%CI = 1.31-2.52), patient's white-collar status (OR = 1.58; 95%CI = 1.14-2.18), and GPs' dissatisfaction with cooperation with mental health specialists (OR = 0.63; 95%CI = 0.45-0.89). These choices were not associated with either GPs' professional characteristics or psychiatrist density in the GP's practice areas. CONCLUSIONS/SIGNIFICANCE: GPs' choices for treating severe MD complied with clinical guidelines better than those for mild MD; GPs rarely recommended psychotherapy alone but rather as a complement to pharmacotherapy. Their decisions were mainly influenced by personal life experience and attitudes regarding treatment more than by professional characteristics. These results call into question the methods and content of continuing medical education in France about MD management.

Perceptions and attitudes of French general practitioners towards rapid antigen diagnostic tests in acute pharyngitis using a randomized case vignette study.

OBJECTIVES: This study had three objectives: (i) to assess the use of rapid antigen diagnostic tests (RADTs) and their impact on the antibiotic prescribing behaviour of general practitioners (GPs) for acute pharyngitis; (ii) to study the barriers to the use of RADTs; and (iii) to identify GPs' characteristics associated with non-compliance with French guidelines. METHODS: We conducted a cross-sectional survey of a representative sample of 369 self-employed GPs in south-eastern France using a randomized case vignette study. RESULTS: The availability of an RADT allowed a 44% relative reduction in the rate of antibiotic prescriptions. Of GPs for whom the test was available, 34% did not use an RADT in our acute pharyngitis vignette and 13% of those who used the test prescribed an antibiotic despite a negative RADT result. Non-compliance with French guidelines (i.e. not using an RADT and/or prescribing an antibiotic despite a negative RADT result) was independently associated with the following factors: less reading of medical journals, less benefits/risks discussion with patients about vaccinations and higher perception that clinical examination was sufficient to prescribe antibiotics. The three main declared barriers to RADT use were: time to perform the test, patient expectations regarding antibiotics and the perception that clinical examination was sufficient to decide to prescribe an antibiotic. CONCLUSIONS: RADTs are a useful but not sufficient tool to reduce antibiotic prescribing in general practice. The results of this study increase understanding of the factors underlying clinical decision making for acute pharyngitis and may contribute to the development of interventions to improve practice.

Formal and informal care for disabled elderly living in the community: an appraisal of French care composition and costs.

OBJECTIVES: Choices between formal and informal care for disabled elderly people living at home are a key component of the long-term care provision issues faced by an ageing population. This paper aims to identify factors associated with the type of care (informal, formal, mixed or no care at all) received by the French disabled elderly and to assess the care's relative costs. METHODS: This paper uses data from a French survey on disability; the 3,500 respondents of interest lived at home, were aged 60 and over, had severe disability and needed help with activities of daily living. We use a multinomial probit model to determine factors associated with type of care. We also assess the cost of care with the help of the proxy good method. RESULTS: One-third of disabled elderly people receive no care. Among those who are helped, 55% receive informal, 25% formal, and 20% mixed care. Low socioeconomic status increases difficulties in accessing formal care. The estimated economic value of informal care is 6.6 billion euro [95% CI = 5.9-7.2] and represents about two-thirds of the total cost of care. CONCLUSION: Public policies should pay more attention to inequalities in access to community care. They also should better support informal care, through respite care or workplace accommodations (working hours rescheduling or reduction for instance) not detrimental for the career of working caregivers.

Density of dental practitioners and access to dental care for the elderly: a multilevel analysis with a view on socio-economic inequality.

OBJECTIVES: To examine the relations between density of dental practitioners (DDP) and socio-economic and demographic factors shown to affect access to dental care for the elderly. METHODS: Data are taken from a cross-sectional survey - 2008 Disability Healthcare - Household section Survey (HSM). HSM is a representative random sample of French people living in their own domiciles. Our study focuses on the 9233 individuals aged 60 years and above. Multilevel models are employed to disentangle the relations between the determinants of dental care utilisation and DDP. Statistical analyses are conducted using SAS 9.2 and HLM 6. RESULTS: Low-income and lack of complementary health insurance are associated with higher odds of not having visited a dentist, revealing a high unequal access to dental care. By using multilevel modelling, DDP appears to be a significant factor to access to dental services. When considering the intricate relations between income gradient and DDP, the latter lessens the income-related inequality to access dental services. CONCLUSION: DDP seems favouring a more equitable access to dental care, mitigating under-caring of the poorest. This point is to be added in the debate about density of healthcare suppliers.

General practitioners and clinical practice guidelines: a reexamination.

General practitioners' (GPs') use of clinical practice guidelines (CPGs) may be influenced by various contextual and attitudinal factors. This study examines general attitudes toward CPGs to establish profiles according to these attitudes and to determine if these profiles are associated with awareness and with use of CPGs in daily practice. The authors conducted a cross-sectional telephone survey of 1,759 French GPs and measured (a) their general attitudes toward CPGs and (b) their awareness and use in daily practice of CPGs for six specific health problems. A bivariate probit model was used with sample selection to analyze the links between GPs' general attitudes and CPG awareness/use. The authors found three GP profiles according to their opinions toward CPGs and a positive association between these profiles and CPG awareness but not use. It is important to build awareness of CPGs before GPs develop negative attitudes toward them.