Cost-effectiveness of a nurse-led internet-based vascular risk factor management programme: economic evaluation alongside a randomised controlled clinical trial.

OBJECTIVE: To assess the cost-effectiveness of an internet-based, nurse-led vascular risk factor management programme in addition to usual care compared with usual care alone in patients with a clinical manifestation of a vascular disease. DESIGN: Cost-effectiveness analysis alongside a randomised controlled trial (the Internet-based vascular Risk factor Intervention and Self-management (IRIS) study). SETTING: Multicentre trial in a secondary and tertiary healthcare setting. PARTICIPANTS: 330 patients with a recent clinical manifestation of atherosclerosis in the coronary, cerebral, or peripheral arteries and with ≥2 treatable vascular risk factors not at goal. INTERVENTION: The intervention consisted of a personalised website with an overview and actual status of patients' vascular risk factors, and mail communication with a nurse practitioner via the website for 12 months. The intervention combined self-management support, monitoring of disease control and pharmacotherapy. MAIN OUTCOME MEASURES: Societal costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness. RESULTS: Patients experienced equal health benefits, that is, 0.86 vs 0.85 QALY (intervention vs usual care) at 1 year. Adjusting for baseline differences, the incremental QALY difference was -0.014 (95% CI -0.034 to 0.007). The intervention was associated with lower total costs (€4859 vs €5078, difference €219, 95% CI -€2301 to €1825). The probability that the intervention is cost-effective at a threshold value of €20,000/QALY, is 65%. At mean annual cost of €220 per patient, the intervention is relatively cheap. CONCLUSIONS: An internet-based, nurse-led intervention in addition to usual care to improve vascular risk factors in patients with a clinical manifestation of a vascular disease does not result in a QALY gain at 1 year, but has a small effect on vascular risk factors and is associated with lower costs. TRIAL REGISTRATION NUMBER: NCT00785031.

Internet based vascular risk factor management for patients with clinically manifest vascular disease: randomised controlled trial.

OBJECTIVE: To investigate whether an internet based, nurse led vascular risk factor management programme promoting self management on top of usual care is more effective than usual care alone in reducing vascular risk factors in patients with clinically manifest vascular disease. DESIGN: Prospective randomised controlled trial. SETTING: Multicentre trial in secondary and tertiary healthcare setting. PARTICIPANTS: 330 patients with a recent clinical manifestation of atherosclerosis in the coronary, cerebral, or peripheral arteries and with at least two treatable risk factors not at goal. INTERVENTION: Personalised website with an overview and actual status of patients' risk factors and mail communication via the website with a nurse practitioner for 12 months; the intervention combined self management support, monitoring of disease control, and drug treatment. MAIN OUTCOME MEASURES: The primary endpoint was the relative change in Framingham heart risk score after 1 year. Secondary endpoints were absolute changes in the levels of risk factors and the differences between groups in the change in proportion of patients reaching treatment goals for each risk factor. RESULTS: Participants' mean age was 59.9 (SD 8.4) years, and most patients (n=246; 75%) were male. After 1 year, the relative change in Framingham heart risk score of the intervention group compared with the usual care group was -14% (95% confidence interval -25% to -2%). At baseline, the Framingham heart risk score was higher in the intervention group than in the usual care group (16.1 (SD 10.6) v 14.0 (10.5)), so the outcome was adjusted for the separate variables of the Framingham heart risk score and for the baseline Framingham heart risk score. This produced a relative change of -12% (-22% to -3%) in Framingham heart risk score for the intervention group compared with the usual care group adjusted for the separate variables of the score and -8% (-18% to 2%) adjusted for the baseline score. Of the individual risk factors, a difference between groups was observed in low density lipoprotein cholesterol (-0.3, -0.5 to -0.1, mmol/L) and smoking (-7.7%, -14.9% to -0.4%). Some other risk factors tended to improve (body mass index, triglycerides, systolic blood pressure, renal function) or tended to worsen (glucose concentration, albuminuria). CONCLUSION: An internet based, nurse led treatment programme on top of usual care for vascular risk factors had a small effect on lowering vascular risk and on lowering of some vascular risk factors in patients with vascular disease. TRIAL REGISTRATION: Clinical trials NCT00785031.

[Socioeconomical status, health behaviors and health status of French adolescents: Health Behavior in School-aged Children (HBSC) survey]. / Statut socio-économique, comportements de santé et santé des adolescents français: l'enquête Health Behaviour in School-aged Children (HBSC).

BACKGROUND: The impact of living conditions on health is not well known, but health inequalities observed in adults seem partly determined by behaviours and health status at an earlier stage, and more particularly during adolescence. So, our aim was to study adolescents' health and their health behaviours function to family socioeconomic status. METHODS: We analysed French data from the international survey "Health Behavior in School-aged Children" carried out in a representative sample of adolescents aged 13 and 15 years in 1998. A self-administered questionnaire was completed by the adolescents who answered questions concerning their health, health behaviours, and their families' socio-economic status. RESULTS: Adolescents from blue-collar families were more numerous to report to be in "fairly good health" or "not very good health" (OR = 1.40, CI 95% = 1.12-1.74) and to be overweight or obese (OR = 1.85, CI 95% = 1.25-2.24) than those from executive families. They were also more numerous to have bad health behaviours than those from executive families. CONCLUSION: This study has established that, in adolescents, differences in health, health behaviours, types of consumption and physical activities depended on the families' socio-economic status.

Sensitivity of fetal anomaly detection as a function of time.

In this paper, we show that the ratio of the number of fetal anomalies detected by ultrasounds (US) to the total number of cases is not a consistent estimator of the US sensitivity. As Eddy pointed out, when the disease evolves over time, the sensitivity of a test also varies over time according to the development of the disease. To assess correctly the detection capability of a test, it is therefore necessary to estimate a time continuous function (sensitivity function) instead of a single parameter. From a methodological point of view, by considering the "detectability" time of a fetal anomaly as a random variable and parametrizing its distribution function, we estimate the probability that an anomaly is detected conditional upon the precise timing of actually performed US during pregnancy. We fit this model with Eurofetus data (about 7,300 abnormal fetuses), and we compare estimations for different kinds of anomalies (classification based on the system involved and/or severity of the handicap). To allow for heterogeneity of anomalies regarding the detectability time, we generally adopt mixture models. For instance, we select a bi-gamma distribution for major malformations and estimate that 63% of such anomalies are detectable quite early in pregnancy (conditional mean: 15.2 weeks of amenorrhea (WA) +/- 4.2 WA), the others becoming detectable later (30.3 WA +/- 6.4 WA). Such results are then integrated in a cost-effectiveness analysis.

Comparison between fluorescent peanut agglutinin lectin and GB24 antibody techniques for the assessment of acrosomal status.

In order to compare fluorescent peanut (Arachis hypogaea) agglutinin lectin and GB24 antibody (specific for the inner acrosomal membrane) techniques for the assessment of acrosome reaction, both methods were applied on semen specimens obtained from patients undergoing in-vitro fertilization (IVF). The acrosome status was evaluated after a 4 h incubation in B2 medium with and without calcium ionophore A23187. Results obtained with both techniques were compared and studied as a function of IVF outcome. The percentage of spontaneous acrosome-reacted spermatozoa was higher when assessed by lectin than by GB24 (19 +/- 2% versus 11 +/- 1%; P < 0.001). The difference between the two methods (lectins minus GB24) was significantly higher in abnormal than in normal spermatozoa (10 +/- 2% versus 4 +/- 2%; P < 0.05), but did not significantly correlate with the percentage of acrosomes with abnormal morphology (r = 0.28; NS). When studied in relation to the IVF results, the response to A23187 was higher in successes than in failures (45 +/- 2% versus 34 +/- 4%; P < 0.05) but there was no significant difference between methods. Thus the assessment of acrosome reaction is strongly influenced by the method used, particularly in abnormal spermatozoa. Since the results obtained with lectins were higher in abnormal spermatozoa, GB24 seems to be more effective for assessment of true acrosome reaction.

Assessment of the predictive value of X-ray pelvimetry and biparietal diameter in cephalopelvic disproportion.

The value of X-ray pelvimetry and ultrasonic measurement of the biparietal diameter for trial of labor prognosis was assessed in 172 healthy primiparas with suspected cephalopelvic disproportion. A decision diagram which is able to correctly predict 50% of the cesarean sections without increasing the number of unnecessary cesarean sections is proposed. In addition, the study confirms the superfluity of X-ray pelvimetry in cases of high station of the fetal head at the end of pregnancy.

[Antenatal assessment of gestational age (author's transl)]. / Détermination anténatale de l'âge gestationnel.

Antenatal assessment of fetal gestational age has been performed by amniotic fluid analyses and ultrasonography. Average estimation of amniotic fluid creatinine and glucose, Clements' test and biparietal diameter measurements produce an accurate assessment of gestational age in 80 % of normal or pathological cases. When amniocentesis is performed to estimate fetal lung maturity, this assessment of gestational age can improve obstetrical care.