[Evaluation of permanent disability levels in occupational pulmonary diseases]. / Comment évaluer en 2019 les taux d'incapacité permanente des pathologies professionnelles pulmonaires ?

Compensation for occupational pulmonary diseases requires the establishment of guidelines based on standardized and objective criteria, in order to provide compensation that is as fair as possible to patients who suffer from them. A review of the elements necessary for the examination of an individual file was carried out by a working group. It is accepted that respiratory functional exploration is the key element in assessing the level of permanent disability in all of these conditions, with the exception of thoracic malignancies. Guiding scales have been developed for the respiratory impairment of three types of conditions: occupational asthma, thoracic malignancy, and other respiratory diseases. Additional criteria for increasing the permanent disability level are also proposed in order to take into account professional prejudice, in particular the possibility or not of continuing the occupational activity, in the same job or after changing to another. For certain respiratory diseases, a periodic reassessment of the initially attributed permanent disability level is recommended as well as the initial one at the time of definitive cessation of occupational activity.

[Economic burden of COPD: the SCOPE study]. / Impact economique de la BPCO en France: etude SCOPE.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a major health problem. Few data about COPD economic burden are available. METHODS: SCOPE was an observational economical retrospective and prospective study conducted in France in 2001, by 114 general practitioners (GPs) and 57 lung specialists. The aim was to describe the burden of COPD patients and to estimate the annual cost according to severity stages. Health resource utilization was collected by questionnaires over a 12-month period for 285 patients. RESULTS: It was a cost-of-illness analysis. COPD patients followed by a lung specialist were more severe than patients followed by a GP and had a higher level of medical resource consumption. The COPD disease and its complications explained 66% of the total cost. The main cost drivers were inpatient care (35%, or 1509,9 euros/year/patient) and prescription medications (31%, or 1340,6 euros/year/patient). The direct total cost varied according to COPD severity on account of inpatient care and respiratory assistance. DISCUSSION: This study confirmed the economic burden of COPD in France. Actions allowed to slow down the disease's evolution and to anticipate the exacerbation could reduce the cost.

[The cost components of the management strategies for lung cancer in France]. / Les composantes du coût des stratégies de prise en charge du cancer du poumon en France.

INTRODUCTION: To evaluate the average cost of therapeutic strategies for the management of lung cancer in relation to histological type and diagnostic staging and of the individual components of the management strategy. METHODS: Samples were taken between 1 September 1998 and 30 June 1999 from centres with sufficient numbers of lung cancer (LC) cases. All events over an 18 Month period were collected from a retrospective analysis of the records. A Markov model was constructed based on decision branches for localised and diffuse small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). Several components of management were identified: first line treatment, second line treatment, observation, terminal care and death. RESULTS: The average cost of LC was 22,006 Euro (10,631-36,296) for one year and 25,643 Euro (10,631-46,191) for two years. For SCLC the average annual costs were 22,420 Euro for diffuse disease and 27,098 for localised disease. For NSCLC the totals ranged from 19,543 Euro for inoperable stage I and II tumours to 39,424 for operable tumours. The cost for stage IV tumours was 24,383 Euro. The cost components over two Years varied according to the tumour type. The cost of diagnosis ranged from 6-14%, the cost of management and of terminal care from 33-45% of the total. Analyses of sensitivity confirmed that whatever the histological type or diagnostic staging the percentage of patients initially treated actively (that is to say not by palliative care) had the greatest effect on the total cost, greater than the costs of terminal care and of two courses of chemotherapy. CONCLUSIONS: This model has allowed for the first time the calculation of the contributions of the different therapeutic components to the total cost of the management of lung cancer in France. In the future it will allow analysis of the economic impact of new methods of treatment.

The SCOPE study: health-care consumption related to patients with chronic obstructive pulmonary disease in France.

OBJECTIVE: The main objective of the SCOPE study was to estimate the total direct medical costs of patients with treated chronic obstructive pulmonary disease (COPD) in France according to severity stages. METHODS: Total medical resources consumption of a sample of COPD patients was collected over a 12-month period through a national physician survey (including both general practitioners and lung specialists). This survey was completed for 255 patients. Data were then extrapolated to all patients with diagnosed and treated COPD in France. Average total medical resources consumption of a COPD patient per year was 4366 euros. Among this cost 41% was directly related to COPD follow-up, 25% to COPD-related complications (mainly exacerbations), and 34% to other diseases. More than one-third of the total direct COPD cost was related to hospitalizations and 31% to drug consumption. COPD-related costs increased markedly with severity based on FEV1 (but data suggested the existence of a threshold effect). SCOPE data did not show any evidence of a significant relationship between direct medical cost and patient age, sex, addiction to tobacco, or duration of COPD. The total medical consumption of COPD patients in France was 3.5 billion euros and accounted for 3.5% of the total medical expenditures (prevalence of COPD was estimated 1.3% in the general population). RESULTS: The SCOPE study revealed the high level of medical resources consumption of patients with COPD. CONCLUSIONS: The burden of COPD itself and its complications appeared to be of considerable magnitude in France especially for severe COPD.

Economics of the clinical management of lung cancer in France: an analysis using a Markov model.

To evaluate, according to the histologic type and initial stage, the mean cost (MC) of managing patients with lung cancer and the costs of the different management phases. A Markov approach was used to model these costs, based on the management of a representative nation-wide sample of 428 patients with newly diagnosed lung cancer. The 18-month MC ranged from US$ 20 691 (95% CI: 5777-50 380 for diffuse non-small-cell lung cancer (NSCLC) to US$ 31 833 (95% CI: 15 866-64 455) for localised small-cell lung cancer (SCLC); first-line treatment costs ranged from 33.8% of MC for medically inoperable localised NSCLC to 74.6% for diffuse SCLC; second- or third-line treatment costs ranged from 7.8% of MC for surgically treated localised NSCLC to 32% for locally advanced NSCLC; and the cost of palliative care ranged from 9.1% of MC for locally advanced NSCLC to 39.9% for medically inoperable localised NSCLC. The cost of first-line chemotherapy and the percentage of actively treated patients impacted more on MC than did the cost of second- or third-line chemotherapy regimens or the cost of palliative care. In conclusion, this model provides a robust economic analysis of the cost of lung cancer management, and will be useful for assessing the economic consequences of future changes in patient management.

[Application of evidence based medicine to the individual patient: the role of decision analysis]. / Application de la médecine factuelle au patient individuel: la place de l'analyse décisionnelle.

INTRODUCTION: The objective of evidence based medicine (EBM) is to contribute to medical decision making by providing the best possible information in terms of validity and relevance. This allows evaluation in a specific manner of the benefits and risks of a decision. METHODS: The limitations and hazards of this approach are discussed in relation to a clinical case where the diagnosis of pulmonary embolism was under consideration. The individual details and the limited availability of some technical procedures illustrate the need to adapt the data of EBM to the circumstances. The choice between two diagnostic tests (d-dimers and ultrasound of the legs) and their optimal timing is analysed with integration of the consequences for the patient of the treatments proposed. This allows discussion of the concept of utility and the use of sensitivity analysis. CONCLUSIONS: If EBM is the cornerstone of rational and explicit practise it should also allow for the constraints of real life. Decision analysis, which depends on the same critical demands as EBM but can also take account of the individual features of each patient and test the robustness of a decision, gives a unique opportunity reconcile rigorous reasoning with individualisation of management.

[Demography of lung specialists in France]. / Démographie des pneumologues en France.

INTRODUCTION: This article analyses the medical demography data in France, particularly the situation concerning lung specialists. METHODS: Study of the published data, particularly institutional reports (Ministry of Health, Sickness Insurance). RESULTS: The demography is characterised by important differences between specialties, regions, and salaried and private practice, as well as the effects of ageing and the increasing numbers of female practitioners. Lung specialists are, on average, younger and more evenly distributed between the different types of practice. Nevertheless they risk experiencing the same difficulties as other specialties in responding to the needs of the French population. The principle proposals of the public authorities concern the restriction of numbers, the regulation of established specialists and new methods of access to the speciality. CONCLUSIONS: Medical demography has a major role in the future of the French health care system.

[Impact of prior biological assessment of coagulation on the hemorrhagic risk of fiberoptic bronchoscopy]. / Bilan de coagulation et risque hémorragique de la fibroscopie bronchique.

INTRODUCTION: The goals of the study were to test the value of coagulation tests to predict bleeding events during fiberoptic bronchoscopy (FOB) and to identify risk factors. METHODS: A monocentric prospective study of 426 procedures performed by one physician was realized. A standardized questionnaire and coagulation tests including prothrombine time, activated cephaline time and platelets counts were performed before the procedure. Bleeding events, defined by a loss of more than 50 ml of blood, were recorded for all patients. RESULTS: 44 patients (10.3%) had bleeding events, modifying the procedure in 19 cases. No death occurred following FOB during the study. Among the 17 patients with abnormalities on coagulation test before FOB, only one had significant bleeding. Two risk factors were found as predictors of bleeding events: nose or gum bleeding (OR=4.99, CI (95%) [2.6-9.5]; p<0.001) and left cardiac failure (OR=4.53, CI (95%) [1.7-12.1]; p<0.01). CONCLUSION: This study shows that abnormalities on coagulation tests are not predictive for bleeding events. Nose or gum bleeding and left cardiac failure may be risk factors for bleeding events during FOB.

[Evaluation of occupational exposures in lung cancer]. / Evaluation des expositions professionnelles et cancer bronchopulmonaire.

Occupational lung cancers are underestimated by the number of cases compensated in the French National Insurance System. Rules of compensation of occupational diseases were recently modified in France. Therefore a study was conducted on incident cases of lung cancer in a general hospital in the Paris area. The aim was to evaluate the exposure to carcinogens using data of a detailed specific occupational questionnaire, and to determine the number of cases who could receive compensation. Two hundred and seven subjects (171 males, 36 females, mean age = 64.5 years) were eligible in 1996, and 122 had an occupational questionnaire. Definite exposure to one or more occupational carcinogens in at least one job was identified in 50 subjects, the most frequent agent was asbestos (42 subjects). Claim for compensation was done in 32 subjects, mainly for asbestos (30 subjects). This study emphasizes the frequency of occupational exposure to carcinogens, and the usefulness of systematic occupational questionnaire in subjects having lung cancer. Social and financial consequences are important for these subjects. Further studies are needed, with recruitement of control subjects to allow calculation of the attributable risk to occupational factors in lung cancer.

[Asbestos-related occupational lung diseases. Role of the pneumology unit in screening and compensation]. / Maladies pulmonaires professionnelles liées à l'amiante. Place du pneumologue dans le dépistage et la réparation.

The application of new decrees concerning the protection of individuals against sanitary risks linked to the various possible expositions to asbestos dusts is leading to a growing involvement of pulmonologists in diagnosis procedures not only for active workers regularly examined via the occupational medicine healthcare system, but also for those who are no longer, the unemployed or retired previously exposed to asbestos fibres. The present chapter presents and comments the revised guidelines about the compensation procedures for occupational diseases, and provides useful recommendations for establishing the records leading to their medical assessment. It emphasises the importance of a close cooperation between pulmonologists and radiologists in order to avoid radiation overdosing, which could increase the risk of lung cancer, as much as possible.

[Asbestos-associated occupational lung diseases. Role of the pneumology unit in screening and compensation]. / Maladies pulmonaires professionnelles liées à l'amiante. Place du pneumologue dans le dépistage et la réparation.

The application of new decrees concerning the protection of individuals against sanitary risks linked to the various possible expositions to asbestos dusts is leading to a growing involvement of pulmonologists in diagnosis procedures not only for active workers regularly examined via the occupational medicine healthcare system, but also for those who are no longer, the unemployed or retired previously exposed to asbestos fibres. The present chapter presents and comments the revised guidelines about the compensation procedures for occupational diseases, and provides useful recommendations for establishing the records leading to their medical assessment. It emphasises the importance of a close cooperation between pulmonologists and radiologists in order to avoid radiation overdosing, which could increase the risk of lung cancer, as much as possible.

CPAP titration by an auto-CPAP device based on snoring detection: a clinical trial and economic considerations.

This study aimed to assess the ability of an auto-nasal continuous positive airway pressure (nCPAP) device (REM + auto; NPBFD, Nancy, France) to predict the optimal constant nCPAP level. The apnoea/hypopnoea detection facility of the auto-nCPAP device was deliberately disabled and nasal mask pressure vibration detection was the only mode of pressure setting. The auto-nCPAP device was tested on 10 previously untreated patients with obstructive sleep apnoea during a single night, with ambulatory polysomnography performed in a conventional hospital room; the efficacy of the fixed pressure determined by the auto-nCPAP device was assessed by an ambulatory full polysomnography 2 weeks after the initiation of treatment at home. The fixed nCPAP pressure was effective (apnoea/hypopnoea and arousal indices <10 events x h(-1)) in all but two of the 10 patients studied. When the fixed nCPAP pressure was increased by 2 cmH2O in these two patients, sleep and respiration were normalized. Since only 12 ambulatory polysomnographic recordings were used to determine the effective nasal continuous positive airway pressure level, and as the device restored normal breathing and sleep in all 10 patients, it was concluded that this method of nasal continuous positive airway pressure titration may improve cost-effectiveness and reduce waiting lists in sleep laboratories.

Routine use of granulocyte colony-stimulating factor is not cost-effective and does not increase patient comfort in the treatment of small-cell lung cancer: an analysis using a Markov model.

PURPOSE: The clinical indications and economic consequences of human granulocyte colony-stimulating factor (G-CSF) prescription during small-cell lung cancer (SCLC) chemotherapy remain controversial. The aim of this study, based on a Markov model, was to assess the impact of routine G-CSF use in the treatment of SCLC on costs and patient comfort. Markov models allow the modeling SCLC chemotherapy, in which the risk of febrile neutropenia (FN) is continuous over time and may occur more than once. PATIENTS AND METHODS: We used a Markov model to compare three strategies: a chemotherapy dose reduction after FN and nonuse of G-CSF ("never" strategy), secondary use of G-CSF ("CSF if FN" strategy) and primary use of G-CSF ("systematic CSF" strategy). Model baseline probabilities were based on a review of medical records for all patients (n = 39) treated for SCLC in our unit during 1993 (when G-CSF was not used) and on published reductions in the incidence of FN obtained by using G-CSF. Two different types of rewards were used: a cost-utility scale that took into account the costs of FN (CFN) episodes and G-CSF (CCSF) courses; and a comfort-utility scale that took into account the discomfort of FN and G-CSF therapy. Costs were analyzed from the health care payer's perspective and utilities were assessed prospectively in standardized interviews with treated SCLC patients. RESULTS: The never strategy was the least costly ($4,875 [United States] versus $5,816 and $7,690 for CSF if FN and systematic CSF) and gave the highest comfort value (378 U v 365 and 327 for CSF if FN and systematic CSF). Sensitivity analyses showed that the never strategy remains the less costly when the probability of a first FN episode was less than 49%, the probability of FN recurrence was less than 60%, or the CFN was less than $6,077, or the CCSF was greater than $863. In terms of patient comfort, the never strategy was the best choice, except for patients who considered that a course of G-CSF caused little or no discomfort, whether or not it prevented FN. CONCLUSION: Routine use of G-CSF during SCLC chemotherapy is not justified by clinical benefits, improved patient comfort, or economic considerations.

[Diagnostic strategies of pulmonary pneumocystis infection in patients with HIV infection. Decision analysis and medico-economic consequences]. / Stratégies diagnostiques de la pneumocystose pulmonaire chez les patients infectés par le VIH. Analyse décisionnelle et conséquences médico-economiques.

P. carinii pneumonia is one of the most frequent opportunistic infections in HIV-infected patients. Clinical and radiological manifestations are non-specific and reference diagnostic procedure remains broncho-alveolar lavage which is costly and invasive. Alternative diagnostic strategies have been proposed. We report here our experience as well as literature date in this field with the purpose to show the usefulness of decision analysis techniques in choosing an optimal cost-effective strategy.

Cost-analysis of four diagnostic strategies for Pneumocystis carinii pneumonia in HIV-infected subjects.

The aim of this study was to analyse the cost-effectiveness ratio of four diagnostic strategies for Pneumocystis carinii pneumonia (PCP) in patients infected with human immunodeficiency virus (HIV). Two hundred and ten HIV-infected patients with suspected PCP underwent induced-sputum (IS) followed, if negative, by bronchoalveolar lavage (BAL); 85 of these patients were able to undergo an exercise test (ET), prior to induced sputum and BAL. The following strategies were analysed: BAL strategy (BAL whenever PCP is suspected); IS strategy (induced sputum followed by BAL if negative); exercise test (ET) strategy, (ET followed by BAL if the results are abnormal); and the ES (exercise sputum) strategy (i.e. BAL only after abnormal ET and negative IS). The cost of each strategy was calculated by taking into account only direct costs; the conditions in which two given strategies would be cost-equivalent were also evaluated. The prevalence of PCP in this population was 31%; IS had 100% specificity and 71% sensitivity, whilst ET had 100% sensitivity and 77% specificity. The costs of BAL, IS, ET and ES strategies were 210,000, 191,940, 140,700 and 112,700 FF, respectively. The ES strategy is, thus, most suitable for our unit. The most economic strategy depends not only on the cost and characteristics of the procedures, but also on the prevalence of PCP in the test population. In conclusion, we developed a model for use by diagnostic centres in choosing the most suitable strategy, on the basis of the local prevalence of PCP.