[Assessment of the budgetary impact of treatment guidelines in type II diabetes mellitus in France]. / Evaluation de l'impact budgétaire de l'application des recommandations de bonne pratique dans le diabète de type II en France.

BACKGROUND: Type II diabetes mellitus is associated with an increasing prevalence and incidence, and with a heavy economic burden in Western countries. As a consequence, health authorities consider that avoidance or delay of occurrence of diabetes-related micro- and macro-angiopathic complications is a public health priority, leading to the definition of treatment guidelines. The aim of the study was to assess the budgetary impact of the application of the French guidelines. METHODS: Etiologic cost ratios. RESULTS: Our results conclude that 10% decrease in body mass index (BMI) among overweight patients, smoking cessation, initiation to undertake a preventive treatment with low-dose aspirin, initiation to undertake or intensify blood pressure control, initiation to undertake or intensify lipidic control, and shift to biguanides among overweight patients are factors associated with significant benefits (avoided costs) which compensate for the increase in treatment costs. The main beneficial strategies are, in decreasing order, initiation to undertake a preventive treatment with low-dose aspirin, smoking cessation, and control of BMI. CONCLUSION: Our results support interest in reinforcing the application of current treatment guidelines for type II diabetes mellitus.

[Elements of economic problems in the field of extra-renal dialysis]. / Eléments de problématique économique dans le domaine de l'épuration extra-rénale.

The aim of this paper is to enlighten, in an economic perspective, the ongoing debate which has emerged surrounding the question of the respective place of peritoneal dialysis and haemodialysis in the treatment of terminal renal failure. In order to accomplish this, the authors used a cost effectiveness approach aiming to create a link between two kinds of data: data on the effectiveness of treatment methods on the one hand, and data on the costs associated with such treatment modalities on the other. The international literature tends to show that the two dialysis techniques are comparable in terms of effectiveness, except in the case of diabetic patients, for a significantly lower treatment cost in the case of peritoneal dialysis as opposed to haemodialysis, regardless of the geographical location and in spite of certain methodological biases existing due to the sample sizes implemented in the cost studies. All things considered, it seems that in comparison to haemodialysis methods, peritoneal dialysis results in lower cost effectiveness ratios (that is to say, lower cost of treatment to attain a certain level of effectiveness). The conclusion of this report therefore emphasizes the need to develop and promote peritoneal dialysis, in situations where this modality is clinically applicable, in countries where it is currently underused, which is the case in France.

[Medico-economical assessment in cancerology]. / Evaluation médico-économique en cancérologie.

In recent studies, the economic criteria has begun to be integrated to the appraisal in cancerology. The question asked by the economist can be framed as follows: what incremental cost should the collectivity or the health insurance system consent, in order to improve the care of cancer patients? This involves first that the cost of the strategies, foreseen or already implemented, can be appraised, then, that indicators can be defined to capture health improvement, and finally, that this health improvement can be quantified. In this article, we present the process of integrated appraisal (cost/result approach). We specifically analyze costs in cancerology, their source and their evolution. We demonstrate the meaning of the integration of economic costs and medical results. We emphasize on the fact that part of the costs, especially those supported by the patient and his close relations, are most of the time excluded from the analysis. Two main points should be carefully analyzed, when proceeding to an appraisal in cancerology: the measurement of the patient's QoL, which represents an expression of the results of the strategy of care; the financing modalities, for the same type of care, if we consider the specificity of the structures involved and the organization of the care. We conclude by mentioning how difficult this task is and under which conditions it should be developed.

[Cost-effective approach to the screening of HIV, HBV, HCV, HTLV in blood donors in France]. / Approche coût-efficacité du dépistage des virus VIH, VHB, VHC, HTLV chez les donneurs de sang en France.

In order to provide greater safety in blood transfusions, public health authorities have imposed the use of screening tests. The purpose of this paper is to estimate the cost-effectiveness ratios of the screening test used in France. Four risks were studied: HIV, HBV, HCV and HTLV. Two efficiency measures were used: cost per positive blood donation detected and cost per case of prevented infection transmission. Moreover, for HTLV alone, the efficiency was estimated by the cost per prevented pathology. Data concerning the costs were provided by the French Blood Agency; those concerning the results of the screening campaigns were provided by the official health authorities, the other data used in the calculations were drawn either from the French Blood Agency data or from a review of international literature. Results gave information about the expenditure devoted to the screening of virologic risks associated with blood transfusion in France (250 million francs per year for the four viruses studied). They stressed the differences in screening efficiency according to the test studied (the cost by prevented seroconversion varied from 31,795 francs for HBV, 72,180 francs for HCV, 676,596 francs for HIV to 6,137,346 francs for HTLV screening test in the base case) and especially the very low efficiency of the systematic screening of the HTLV virus (from 34 to 307 million francs per prevented leukemia).

Attempt to establish a classification of patients suffering from coma and admitted to a hospital structure for short or medium term treatment: medical aspects and costs of hospital care.

We dispose of a database, constituted between 1987 and 1993, containing medical and cost information concerning 515 patients suffering from coma and admitted, after a period of resuscitation, to a French hospital establishment--Etablissement Hélio-Marin of Berck-sur-Mer (EHMB)--for short and medium term treatment, between 1974 and 1986. From this base, which contains demographic and clinical data (age, sex, condition upon admission, duration of consciousness disorders, Glasgow Outcome Scale (GOS) upon discharge) we devised a hierarchical classification analysis following a factorial analysis of multiple correspondences, on 2 sets: a sample of 515 patients (all causes of coma being merged) and a sample of 266 patients suffering from brain injuries. Four groups were determined for each typology. These groups were first described on the basis of the variables used for their construction, and later by considering other available variables: origin of coma, duration of stay at EHMB, future evolution of patients and cost of treatment (cost of specific care, average daily cost, total cost of hospitalization). Thus, typical clinical situations were identified in each classification, depending on age of patient, origin of coma and condition upon admission. These situations led to extremely different treatment costs (ratio from 1 to 5 in the general typology and 1 to 2.85 in the classification of brain injuries.

[Measuring the economic impact of ambulatory dialysis: the case of continuous ambulatory peritoneal dialysis]. / Mesure de l'intérêt économique de la dialyse hors centre: le cas de la dialyse péritonéale continue ambulatoire.

BACKGROUND: As concerns the treatment of terminal renal failure (TRF), France is characterized by a minimal use of peritoneal dialysis, even though this technique is as effective and less expensive than others and that authorities precognize to switch patients to out-of-centre techniques, like peritoneal dialysis. The purpose of the article is to estimate benefits for the Social Security induced by an incitative program leading the current structure of TRF treatment to the existing government standards defined in 1984. METHODS: We computed treatment cost differences, on the basis of an incident case of TRF followed during 7 years, between three different situations: the current French structure of TRF treatment (29.5% of patients treated by out-of-center techniques); two reference situations A and B (respectively 45% and 37% of patients treated by out-of-center techniques). We performed a sensitivity analysis on the rate of use of continuous ambulatory peritoneal dialysis (CAPD). We made assumptions on the cost of techniques, the cost of complications and the rate of CAPD treatment failure. RESULTS: Results stress the existence of benefits induced by increased use of out-of-centre techniques on the basis of a 7-year follow-up of an incident TRF patient: around 65,000 FF in situation A with a 20% rate of use of CAPD; around 5,000 FF in situation B with a 15% rate of use of CAPD. Assumptions concerning CAPD treatment lead to an underestimation of the true benefits. CONCLUSION: The study highlights the therapeutic and economic interest to transfer some patients from hemodialysis to peritoneal dialysis.

Economic aspects of the care of patients in the vegetative state.

The raising of economic issues related to the care of patients in the vegetative state (V.S.) is troublesome to both health-care practitioners and to the public opinion, given the general perception that economics and ethics are incompatible. The main purpose of this article is to show that economic considerations are not merely reconcilable with ethical concerns, they nourish, enrich, and complement them. Three areas of intersection between ethics and economics are described: economic considerations can help bring to the surface the choices involved in decision-making, whether they are explicit or not; these considerations are a natural outgrowth of a well thought-out ethical approach; an economic analysis can accommodate and take into consideration ethical criteria. The second part presents the results of a study conducted in France between 1987 and 1993 which attempted to evaluate the costs of hospital care of comatose patients hospitalized for short and medium term periods. The article concludes with an examination of the economic issues that may be raised in future debates about how much effort should be expended in the care of patients afflicted by V.S.

The introduction of economic criteria into the management of arterial disease: an illustration with regard to the socioeconomic consequences of peripheral occlusive arterial disease of the lower limbs.

A survey of studies was used to investigate the economic repercussions of arterial disease; these repercussions included the cost of the disease and its management, and cost/efficacy, cost/utility, and cost/benefit studies of preventive, diagnostic, and therapeutic strategies. The study presented is an evaluation of the socio-economic consequences of peripheral occlusive arterial disease of the lower limbs (POADLL). The cost of health care was measured by means of a prospective 6-month study of 85 patients recruited in 6 centers. The average cost over the 6-month period was 15,735 FF (1991 francs) ($2,760 U.S.). The 85 patients were classified by age, sex, risk factors, concomitant disease, and how the illness was managed, notably in terms of hospitalization and vascular surgery. The four-group classification was used to calculate an annual management cost for POADLL, which ranged from 9,500 FF ($1,667 U.S.) for a stage II patient (mean age, 66 years) with no major risk factors and not presenting any complication requiring admission to hospital, to 35,000 FF ($6,140 U.S.) for patients (mean age, 62 years) who presented major risk factors and who required vascular surgery during the year.

Cost-effectiveness in patients awaiting transplantation receiving intravenous inotropic support.

Cost-effectiveness, assessed in terms of cost/survivor and cost/additional day of survival, has been evaluated in two groups of patients awaiting cardiac transplantation: in six treated by mechanical support (mechanical bridge) and in 31 treated successfully by the addition of intravenous enoximone to previous existing inotropic support (pharmacological bridge). The mean cost per patient was $45,843, ranging from $38,326 in patients receiving pharmacological support to $84,683 in patients receiving mechanical support. The cost per patient transplanted after pharmacological support was $50,745. The mean cost per survivor at 1 year was $210,000 for all patients, ranging from $192,455 with pharmacological support to $254,000 with mechanical support. At 1 month, the cost per additional day of survival was higher (by 228%) in the mechanical support group than in the pharmacological support group.

[Cost and efficacy of therapeutic strategies in candidates for heart transplantation as salvage therapy]. / Coût, efficacité des stratégies thérapeutiques chez les candidats à la transplantation cardiaque de sauvetage.

A study of the real cost, the cost-effectiveness of treatment was performed in 31 cases of cardiogenic shock referred for cardiac transplantation, treated in a flexible therapeutic protocol associating implantation of an expensive mechanical circulatory support system (mechanical bridge) or treatment by drugs alone (pharmacological bridge) depending on the efficacy of IV enoximone. The average patient cost was 238,386 French Francs, ranging from 440,353 FF in patients receiving the mechanical bridge to 199,296 FF in those receiving the pharmacological bridge. The cost-effectiveness ratio expressed either as cost per patient surviving the different stages of the disease or as cost of obtaining an additional day of survival at the same intervals was twice as favourable in the group receiving the pharmacological treatment. This study suggests that IV enoximone and strict selection procedures for candidates for the more expensive option should help bring together the interest of the individual patient and of society as a whole.

[Determination of cost-effective strategies in colorectal cancer screening]. / Détermination de stratégies coût-efficaces dans le dépistage du cancer colorectal.

The object of the article is to implement particular methodologies in order to determine which strategies are cost-effective in the mass screening of colorectal cancer after a positive Hemoccult test. The first approach to be presented consists in proposing a method which enables all the admissible diagnostic strategies to be determined. The second approach enables a minimal cost function to be estimated using an adaptation of "Data Envelopment Analysis". This method proves to be particularly successful in cost-efficiency analysis, when the performance indicators are numerous and hard to aggregate. The results show that there are two cost-effective strategies after a positive Hemoccult test: coloscopy and sigmoidoscopy; they put into question the relevance of double contrast barium enema in the diagnosis of colo-rectal lesions.

[Artificial hearts. The experience of Henri Mondor University Hospital]. / Les coeurs artificiels. L'expérience du CHU Henri Mondor.

Results obtained with 52 patients referred for urgent heart transplantation or when transplantation was impossible because no graft, mechanical assistance or circulatory support were available, are reported. These suggest that the protocol used to select the indications of assistance and transplantation, based on the response to the introduction of enoximone into the medical treatment, allows reconciling the patients' interest-their survival-with the community's interest-i.e. the control of the costs of implemented treatments.

Cost and cost effectiveness of the mechanical and pharmacologic bridge to transplantation.

A prospective study has been carried out to evaluate the cost and cost effectiveness of the mechanical bridge (MB) or pharmacologic bridge (PB) to transplantation (HTx) in patients referred in cardiogenic shock (CS), who are candidates for Htx unresponsive to sympathomimetics. Selection between MB and PB was based on immediate efficacy of i.v. enoximone (2 mg/kg/BW) therapy. From 1986 to 1989, 37 patients who should have been immediately treated by MB entered the protocol. Six were unresponsive and rapidly received a Jarvik heart or left ventricular bypass (MB). Thirty-one improved (PB), with the need for HTx reconfirmed in 22 and performed in 14. Survival of the entire group was 70% and 51% at 1 and 3 months, respectively. Cost per patient was $45,843 ranging from 38,326 in PB patients to $84,683 in MB patients. Cost per patient transplanted after PB was $50,745. Cost per survivor at 1 year was $210,000 for all, ranging from $254,000 in MB to $192,455 in PB. Cost per added day of survival was higher in MB (+ 228%) at 1 month compared to PB. The difference was reduced at 1 year.

Economic evaluation of cost-benefit ratio of neonatal screening procedure for phenylketonuria and hypothyroidism.

A comparison between the cost of identification and care of patients with phenylketonuria (PKU) and congenital hypothyroidism (CH) and the expenditure for the care of untreated retarded patients has been established on the basis of the activity of the Nord-Pas-de-Calais regional screening centre and of interviews with patients' families. The analysis yields a benefit-cost ratio of 6.6 for PKU and 13.8 for CH prophylaxis. However, cost-benefit varies depending on the economic partner, i.e. the patient's family, Social Security or Administration.

[Cost/benefit study of the neonatal detection of phenylketonuria and hypothyroidism]. / Etude coût/bénéfice du dépistage néonatal de la phénylcétonurie et de l'hypothyroïdie.

The medical importance of an early screening for phenylketonuria (PKU) and congenital hypothyroidism (CH) has been recognized for a long time. However, only rare cost-benefit analysis have been reported. A comparison between the cost of identification and care of PKU and CH patients and the expenditure for the care of untreated retarded patients has been established on the basis of the activity of the Nord-Pas-de-Calais regional screening centre and of patient's families interviews. The present analysis yields a cost-benefit ratio of 6.5 for PKU and 12.2 for CH prophylaxis. However cost-benefit varies depending on the economical partner: patient's family, Social Security or Administration. The present model may also be useful cost-benefit calculation when new tests will be planned to be introduced in the national neonatal screening programme.

To test or not to test--to treat or not to treat: the decision-threshold approach to patient management.

The inability to consider explicitly factors that should enter into clinical judgment compromises physician efforts to make cost-effective decisions regarding diagnostic testing and treatment. The authors describe the decision-threshold approach, a decision-analysis strategy that helps physicians identify an optimal test-treatment decision based upon the prior probability of disease, the characteristics of the test (sensitivity, specificity, risk), and the benefits/costs of treatment. They also present a microcomputer graphics program that makes the decision-threshold approach readily available to physicians.