Are there socio-economic inequities in access to reperfusion therapy: The stroke 69 cohort.

BACKGROUND AND PURPOSE: Low socio-economic status of individuals has been reported to be associated with a higher incidence of stroke and influence the diagnosis after revascularization. However, whether it is associated with poorer acute stroke management is less clear. To determine whether social deprivation was associated with a poorer access to reperfusion therapy, either intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT) in a population-based cohort. METHODS: Over a 14-month period, all consecutive adult patients admitted to any emergency department or a comprehensive or primary stroke center (CSC/PSC) of the Rhône county with a confirmed ischemic stroke were included. The socioeconomic status of each patient was measured using the European Deprivation Index (EDI). The association between EDI and access to reperfusion therapy was assessed in univariate and multivariate logistic regression analyses. RESULTS: Among the 1226 consecutive IS patients, 316 (25%) were admitted directly in a PSC or CSC, 241 (19.7%) received a reperfusion therapy; 155 IVT alone, 20 EVT alone, and 66 both therapies. Median age was 79 years, 1030 patients had an EDI level of 1 to 4, and 196 an EDI of 5 (the most deprived group). The most deprived patients (EDI level 5) did not have a poorer access to reperfusion therapy compared to all other patients in univariate (OR 1.22, 95%CI [0.85; 1.77]) nor in multivariate analyses (adjOR 0.97, 95%CI [0.57; 1.66]). CONCLUSIONS: We did not find any significant association between socioeconomic deprivation and access to reperfusion therapy. This suggests that the implementation of EVT was not associated with increased access inequities.

Patients' productivity losses and informal care costs related to ischemic stroke: a French population-based study.

BACKGROUND AND PURPOSE: Large societal costs of stroke should not be ignored. We aimed to estimate patients' productivity losses and informal care costs during the first year after ischemic stroke. METHODS: A cross-sectional survey was performed within the STROKE69 regional population-based cohort study. At 1 year post-stroke, each patient and the corresponding main informal caregiver received questionnaires followed by a telephone interview if necessary. Time losses were valued using the human capital approach and proxy good method for patients with and without a professional activity, respectively. RESULTS: Among the 222 patients with ischemic stroke (58% men; mean age 68 years; and 86% with a modified Rankin Scale (mRS) score of <3 at 3 months), 54%, 32%, and 25% received informal, formal, and both cares, respectively. Among the 108 main informal caregivers, 63% were women, 74% lived with the patient, and 57% were retired or unemployed. The mean cost of productivity losses was estimated at €7589 ± €12 305 per patient in the first post-stroke year with 5.4%, 71.2%, and 23.4% of these being attributed to presenteeism, absenteeism, and leisure time, respectively. Informal care was given at an average of 25 h/week. The annual mean estimated total cost of informal care was €10 635 per caregiver. CONCLUSIONS: Informal care and productivity losses of patients with ischemic stroke during the first post-stroke year represent a significant economic burden for society comparable to direct costs. These costs should be included in economic evaluations with the adoption of a societal perspective to avoid underestimating the societal stroke economic burden.

Cost-effectiveness of stent-retriever thrombectomy in large vessel occlusion strokes of the anterior circulation: Analysis from the French societal perspective.

OBJECTIVES: To determine the cost-effectiveness of stent retriever thrombectomy (SRT) added to standard of care (SOC) in large vessel occlusion (LVO) strokes, adopting the French societal perspective given the lack of published studies with such perspective. METHODS: We developed an hybrid model (decision tree until one year post-stroke followed by a Markov model from one year onward). The time horizon was 20 years. We calculated transition probabilities across the modified Rankin Scale (mRS) based on a published meta-analysis. The main outcome measure was quality adjusted life-years (QALYs) gained. Resources and input costs were derived from a literature search. We calculated the incremental cost-effectiveness ratio (ICER) expressed as cost/QALY. We used 1-way deterministic and probabilistic sensitivity analysis (PSA) to evaluate the model uncertainty. RESULTS: In the base-case, adding SRT to SOC resulted in increased effectiveness of 0.73 QALY while total costs were reduced by 3,874€ (ICER of -5,400€/QALY). In the scenario analysis adopting the French healthcare system perspective, the ICER was 4,901€/QALY. Parameters the most influential were the relative risks of SRT over SOC for 90-days mortality and for 90-days mRS 0-2, and the time horizon. PSA showed the 95% confidence interval of the ICER was -21,324 to 4,591€/QALY, with SRT having 85.5% chance to be dominant and 100% to be cost-effective at a threshold of 50,000€/QALY. CONCLUSION: SRT was dominant from a French societal perspective, from 9 years post-stroke onwards. Cost-effectiveness of SRT added to SOC becomes undisputable with evidences from payer and societal viewpoints.

Cost-effectiveness analysis of hip fracture prevention with vitamin D supplementation: a Markov micro-simulation model applied to the French population over 65 years old without previous hip fracture.

UNLABELLED: We performed a cost-effectiveness analysis of four vitamin D supplementation strategies for primary prevention of hip fracture among the elderly population and found that the most cost-effective strategy was screening for vitamin D insufficiency followed by adequate treatment to attain a minimum 25(OH) serum level. INTRODUCTION: Vitamin D supplementation has a demonstrated ability to reduce the incidence of hip fractures. The efficiency of lifetime supplementation has not yet been assessed in the population over 65 years without previous hip fracture. The objective was to analyze the efficiency of various vitamin D supplementation strategies for that population. METHODS: A Markov micro-simulation model was built with data extracted from published studies and from the French reimbursement schedule. Four vitamin D supplementation strategies were evaluated on our study population: (1) no treatment, (2) supplementation without any serum level check; (3) supplementation with a serum level check 3 months after initiation and subsequent treatment adaptation; (4) population screening for vitamin D insufficiency followed by treatment based on the vitamin D serum level. RESULTS: "Treat, then check" and "screen and treat" were two cost-effective strategies and dominated "treat without check" with incremental cost-effectiveness ratios of €5,219/quality-adjusted life-years (QALY) and €9,104/QALY, respectively. The acceptability curves showed that over €6,000/QALY, the "screen and treat" strategy had the greatest probability of being cost-effective, and the "no treatment" strategy would never be cost-effective if society were willing to spend over €8,000/QALY. The sensitivity analysis showed that among all parameters varying within realistic ranges, the cost of vitamin D treatment had the greatest effect and yet remained below the WHO cost-effectiveness thresholds. CONCLUSIONS: Population screening for vitamin D insufficiency followed by treatment based on the vitamin D serum level is the most cost-effective strategy for preventing hip fracture occurrence in the population over 65 years old.

Multilevel assessment of atherosclerotic extent using a 40-section multidetector scanner after transient ischemic attack or ischemic stroke.

BACKGROUND AND PURPOSE: The first part of this study assessed the potential of MDCT with a CTA examination of the aorta and the coronary, cervical, and intracranial vessels in the etiologic work-up of TIA or ischemic stroke compared with established imaging methods. The objective of the second part of this study was to assess the atherosclerotic extent by use of MDCT in these patients. MATERIALS AND METHODS: From August 2007 to August 2011, a total of 96 patients with ischemic stroke or TIA without an evident cardioembolic source were enrolled. All patients underwent MDCT. Atherosclerotic extent was classified in 0, 1, 2, 3, and 4 atherosclerotic levels according to the number of arterial territories (aortic arch, coronary, cervical, intracranial) affected by atherosclerosis defined as ≥ 50% cervical, intracranial, or coronary stenosis or ≥ 4-mm aortic arch plaque. RESULTS: There were 91 patients who had an interpretable MDCT. Mean age was 67.4 years (± 11 years), and 75 patients (83.3%) were men. The prevalence of 0, 1, 2, 3, and 4 atherosclerotic levels was 48.3%, 35.2%, 12.1%, 4.4%, and 0%, respectively. Aortic arch atheroma was found in 47.6% of patients with 1 atherosclerotic level. The combination of aortic arch atheroma and cervical stenosis was found in 63.6% of patients with ≥ 2 atherosclerotic levels. Patients with ≥ 2 atherosclerotic levels were older than patients with < 2 atherosclerotic levels (P = .04) in univariate analysis. CONCLUSIONS: MDCT might be useful to assess the extent of atherosclerosis. It could help to screen for high-risk patients who could benefit from a more aggressive preventive strategy.

Quality of fracture risk assessment in post-fracture care in Ontario, Canada.

UNLABELLED: As fracture risk assessment is a basis for treatment decisions, accurate risk assessments on bone mineral density (BMD) reports are important. Over 50 % of sampled BMD reports for Ontarians with fracture histories underestimated fracture risk by a single category. Risk assessments in Ontario may not accurately inform treatment recommendations. INTRODUCTION: The shifting emphasis on fracture risk assessment as a basis for treatment recommendations highlights the importance of ensuring that accurate fracture risk assessments are present on reading specialists' BMD reports. This study seeks to determine the accuracy of fracture risk assessments on a sample of BMD reports from 2008 for individuals with a history of fracture and produced by a broad cross section of Ontario's imaging laboratories. METHODS: Forty-eight BMD reports for individuals with documented history of fragility fracture were collected as part of a cluster randomized trial. To compute fracture risk, risk factors, and BMD T-scores from reports were abstracted using a standardized template and compared to the assessments on the reports. Cohen's kappa was used to score agreement between the research team and the reading specialists. RESULTS: The weighted kappa was 0.21, indicating agreement to be at the margin of "poor to fair." More than 50 % of the time, reported fracture risks did not reflect fracture history and were therefore underestimated by a single category. Over 30 % of the reports containing a "low" fracture risk assessment were assessed as "moderate" fracture risk by the research team, given fracture history. Over 20 % of the reports with a "moderate" fracture risk were assessed as "high" by the research team, given fracture history. CONCLUSIONS: This study highlights the high prevalence of fracture risk assessments that are underestimated. This has implications in terms of fracture risk categorization that can negatively affect subsequent follow-up care and treatment recommendations.

[Critical analysis of French DRG based information system (PMSI) databases for the epidemiology of cancer: a longitudinal approach becomes possible]. / Analyse critique des données du PMSI pour l'épidémiologie des cancers : une approche longitudinale devient possible.

BACKGROUND: Use of French Diagnosis Related Groups (DRGs) program databases, apart from financial purposes, has recently been improved since a unique anonymous patient identification number has been created for each inpatient in administrative case mix database. Based on the work of the group for cancer epidemiological observation in the Rhône-Alpes area, (ONC-EPI group), we review the remaining difficulties in the use of DRG data for epidemiological purposes and we consider a longitudinal approach based on analysis of database over several years. We also discuss limitations of this approach. DIFFICULTIES: The main problems are related to a lack of quality of administrative data, especially coding of diagnoses. These errors come from missing or inappropriate codes, or not being in accordance with prioritization rules (causing an over- or under-reporting or inconsistencies in coding over time). One difficulty, partly due to the hierarchy of coding and the type of cancer, is the choice of an extraction algorithm. In two studies designed to estimate the incidence of cancer cared in hospitals (breast, colon-rectum, kidney, ovaries), a first algorithm, including a code of cancer as principal diagnosis with a selection of surgical procedures less performed than the second one including a code of cancer as principal diagnosis only, for which the number of hospitalizations per patient ratio was stable across time and space. The chaining over several years allows, by tracing the trajectory of the patient, to detect and correct inaccuracies, errors and missing values, and for incidence studies, to correct incident cases by removing prevalent cases. DISCUSSION: However, linkage, complete only since 2007, does not correct data in all cases. Ways of future improvement certainly pass through improved algorithms for case identification and especially by linking DRG data with other databases.

Identifying prevalent cases of breast cancer in the French case-mix databases.

OBJECTIVES: Little is known about cancer prevalence due to a lack of systematic recording of cancer patient follow-up data. To estimate the annual hospital prevalence of breast cancer in the general population of the Isère department (1.1 million inhabitants) in the Rhône-Alpes region, the second largest region in France (6 million inhabitants), we used the inpatient case-mix data, available in most European countries, to develop a method of cancer case identification. METHODS: A selection process was applied to the acute care hospital datasets among women aged 18 years or older, living in the Isère department and treated for breast cancer between 2004 and 2007. The first step in case selection was based on the national anonymous unique patient identifier. The second step consisted of retrieving all hospital stays for each case. The third step was designed to detect inconsistencies in the coding of the primary localization. An algorithm based on ICD-10 code for the hospital admission diagnosis was used to rule out hospitalizations unrelated to breast cancer. Five possible models for estimating prevalence were created combining selection steps with the admission diagnosis algorithm. RESULTS: Hospital prevalence over the four-year period varied from 6073 breast cancer cases for the simplest model (first selection step without the admission diagnosis algorithm) to 4951 when the first selection step was associated with the breast cancer code as admission diagnosis. The model combining the third selection step with a breast cancer-specific admission reason provided 5275 prevalent cases. CONCLUSION: The last model seems more appropriate for case-mix-data coding. Selecting admission diagnosis improved specificity. Combining all hospital stays for each patient has improved diagnostic sensitivity.

Has reimbursement of bone mineral density testing and anti-osteoporotic treatments improved management of osteoporosis in France?

BACKGROUND: Since July 1, 2006 bone mineral density (BMD) testing has been reimbursed for osteoporosis screening under specific clinical conditions in France. Concurrently, drug coverage has been extended to all anti-osteoporotic treatments in women with low BMD. It was thus expected that the utilisation of BMD testing and subsequent treatment would increase significantly. OBJECTIVE: To examine the pattern of use of BMD testing following reimbursement by the French National Health Insurance and subsequent prescriptions reimbursed for anti-osteoporotic treatment in the general population of the Rhone-Alpes area, France. METHODS: Time trends, age and sex distribution of the population, and specialty of the physicians who performed the test were examined from all physicians' claims for BMD testing between 2006 and 2009 in Rhone-Alpes. A prospective inception cohort of all women aged 50 years and older, without prior reimbursement for anti-osteoporotic treatment and who had a BMD test between January 1, 2007 and March 31, 2007, was then created. Women were followed for 1 year for their reimbursements of estrogen or other anti-osteoporotic treatment (bisphosphonates, raloxifene, teriparatide and strontium ranelate) after their initial BMD test. RESULTS: Between July 2006 and August 2009, 140,038 BMD tests were reimbursed in Rhone-Alpes, France, among which 94.8% were performed in women aged 50 years and older. In women, the number of BMD tests tended to significantly decrease during the study period (p for trend=0.047). The inception cohort was composed of 9635 women without prior anti-osteoporotic treatment. Among women without prior estrogen treatment, 27.3% (n=2339) initiated an anti-osteoporotic treatment within 4 months after a BMD test, mostly with bisphosphonates (16.8% n=1441), followed by strontium ranelate (5.8% n=498) and raloxifene (3.4% n=290). At 1 year 1702 women (71.7%) were still on treatment. CONCLUSION: Following the decision by the French National Health Insurance of repayment of BMD measurement, the proportion of women who had BMD testing tended to decrease instead of increase over the time period. Although BMD screening is focused in France on high risk women, only 25% of those who had an initial BMD test were subsequently treated with an anti-osteoporotic medication.

Burden of hip fracture on inpatient care: a before and after population-based study.

SUMMARY: We estimated the excess hospital expenditure attributable to osteoporotic hip fracture (HF) within a population of 6,019 patients. Post-fracture excess of hospital days was 23.1, including 22.7 days in rehabilitation care. HF might result from a patient's pre-fracture poor health status rather than predispose to a worsening of such pre-existing conditions. INTRODUCTION: Hip fracture represents a large burden on hospital services. It is unclear whether the post-fracture expenditure is linked to a worsening of pre-fracture comorbid conditions. We estimated the excess hospital expenditure attributable to osteoporotic HF following the initial hospitalization for acute care (index stay). METHODS: We identified 6,019 patients (> or = 50 years) who experienced HF in 2005 and compared their hospitalizations 1 year before and 1 year after the index stay. Excess expenditure was estimated by subtracting the utilization of hospital days or costs (Euros 2005) before the index stay from those after the index stay. Factors associated with hospitalization during the pre-fracture and post-fracture years were identified using multivariate logistic regressions. RESULTS: Beside the index stay, post-fracture excess of hospital days was 23.1 (95% Confidence Interval (CI) [21.8-24.3]), including 22.7 days (95% CI [21.7-23.7]) in rehabilitation care and 0.3 days (95% CI [0-0.9]) in acute care. Estimated excess cost per patient was 5,986 (95% CI [5,638-6,335]) after the index stay, including 5,673 (95% CI [5,419-5,928]) in rehabilitation care. Male and elderly patients were at higher risk to be hospitalized in acute care during the year preceding and succeeding HF. CONCLUSIONS: Osteoporotic HF represents a pronounced excess expenditure in hospital, which is mostly linked to rehabilitation care. Considering that utilization of inpatient acute care was quite similar before and after the index stay, HF might result from a patient's pre-fracture poor health status, rather than predispose to a worsening of such pre-existing conditions.

Is there an association between serum 25-hydroxyvitamin D concentration and muscle strength among older women? Results from baseline assessment of the EPIDOS study.

OBJECTIVE: To examine whether low serum 25-hydroxyvitamin D (25OHD) concentration were associated with low muscle strength while taking into account the effects of potential confounders among a cohort of community-dwelling women aged 75 years and older. DESIGN: Cross-sectional study corresponding to the baseline assessment of the EPIDOS study. SETTING: Five French cities including Amiens, Lyon, Montpellier, Paris and Toulouse. PARTICIPANTS: Randomized sample of 440 women included in the EPIDOS study. MEASUREMENT: Maximal isometric voluntary contraction strength of the lower limb and hand with computerized dynamometers, serum 25OHD and parathyroid hormone concentration. Age at baseline evaluation, number of chronic diseases, body mass index (BMI), use of calcium drug, practice of a regular physical activity, serum calcium concentration and clearance of creatinine were used as covariables. Subjects were separated into 3 groups based on serum 25 OHD levels with the following cut-off values: < 15 ng/ml, 15-30 ng/ml and > 30 ng/ml. RESULTS: More than 90% of women had a serum 25OHD insufficiency (i.e. < 30 ng/ml) and 40.2% had a related secondary hyperparathyroidism. The mean value of muscle strength was not different among the 3 groups of women (174.9 +/- 53.2 for serum 25OHD < 15 ng/ml versus 175.9 +/- 52.6 for serum 25OHD 15-30 ng/ml versus 173.4 +/- 53.1 for serum 25OHD > 30 ng/ml with P=0.946 for quadriceps, and 56.1 +/- 13.2 for serum 25OHD < 15 ng/ml versus 57.1 +/- 13.5 for serum 25OHD 15-30 ng/ml versus 61.1 +/- 12.7 for serum 25OHD > 30 ng/ml with P= 0.064 for handgrip). There was no significant association between serum 25OHD concentration and quadriceps strength (crude beta = 0.03 with P = 0.891 and adjusted beta = -0.04 with P = 0.837). Univariate linear regression showed a significant association between serum 25OHD concentration and handgrip strength (crude beta = 0.16 with P = 0.049) but not while using an adjusted model (adjusted beta = 0.13 with P = 0.106). CONCLUSIONS: The findings of this study do not support the hypothesis of a relationship between low serum 25OHD concentration and low muscle strength. Further research is needed to corroborate and explain this finding.

[Quality and usefulness of an anonymous unique personal identifier to link hospital stays recorded in French claims databases]. / Qualité et utilité d'un identifiant patient anonyme et unique pour le chaînage des séjours hospitaliers dans les bases de données médicoéconomiques françaises.

BACKGROUND: Since 2001, the French national case mix program is allowed by law to use an enciphering algorithm named "FOIN" to produce a unique anonymous identifier in order to crosslink, within and across hospitals, discharge abstracts from a given patient. This algorithm "thrashes" the person's health insurance number, date of birth and gender. Before using information produced by the case mix program, either for case mix payment or for epidemiology research or for assessing care approaches, the quality of linkage must be evaluated. METHODS: Foin error flags were first assessed in the 2002 Rhône-Alpes regional case mix database. Second, for the two university hospitals of Lyon and Saint-Etienne, double identifiers (two or more Foin identifiers for the same patient) and collisions (a single Foin identifier for at least two patients) were compared with others identifiers: administrative identifier and an anonymous identifier produced by Anonymat software from name, forename and date of birth. Third, Foin error flags are crossed with Foin double identifier or collision mistakes. RESULTS: First, among 1,668,971 hospital discharge abstracts from the regional case mix database, 206,710 (12.4%) had at least one Foin error flag. The most frequent error flag (93026 [5.5%] stays) was due to the lack of the three identifying variables. The greatest number for error flags concerned the stays of newborns (38.5%) and those of public hospitals (17.3%). Second, Foin created a few double identifiers: 1.2% among 137,236 patients from university hospital of Lyon and 0.3% among 39512 patients from university hospital of Saint-Etienne. The collisions concerned 7776 (5.7%) patients from Lyon and 460 (1.2%) from Saint-Etienne. The identifier produced by Anonymat performed better than the one produced by Foin: 99.6% from the two university hospitals. Third, less than 3% of stays without Foin error flag nevertheless had mistakes on Foin when compared with others identifiers. CONCLUSION: The overall assessment is not in favour of a quality threshold using the Foin identifier on a routine basis except in some areas and if certain activities like neonatology are excluded. There are several ways to improve the linkage of health data.

Which screening strategy using BMD measurements would be most cost effective for hip fracture prevention in elderly women? A decision analysis based on a Markov model.

INTRODUCTION: Hip fractures are responsible for excessive mortality, decreasing the 5-year survival rate by about 20%. From an economic perspective, they represent a major source of expense, with direct costs in hospitalization, rehabilitation, and institutionalization. The incidence rate sharply increases after the age of 70, but it can be reduced in women aged 70-80 years by therapeutic interventions. Recent analyses suggest that the most efficient strategy is to implement such interventions in women at the age of 70 years. As several guidelines recommend bone mineral density (BMD) screening of postmenopausal women with clinical risk factors, our objective was to assess the cost-effectiveness of two screening strategies applied to elderly women aged 70 years and older. METHODS: A cost-effectiveness analysis was performed using decision-tree analysis and a Markov model. Two alternative strategies, one measuring BMD of all women, and one measuring BMD only of those having at least one risk factor, were compared with the reference strategy "no screening". Cost-effectiveness ratios were measured as cost per year gained without hip fracture. Most probabilities were based on data observed in EPIDOS, SEMOF and OFELY cohorts. RESULTS: In this model, which is mostly based on observed data, the strategy "screen all" was more cost effective than "screen women at risk." For one woman screened at the age of 70 and followed for 10 years, the incremental (additional) cost-effectiveness ratio of these two strategies compared with the reference was 4,235 euros and 8,290 euros, respectively. CONCLUSION: The results of this model, under the assumptions described in the paper, suggest that in women aged 70-80 years, screening all women with dual-energy X-ray absorptiometry (DXA) would be more effective than no screening or screening only women with at least one risk factor. Cost-effectiveness studies based on decision-analysis trees maybe useful tools for helping decision makers, and further models based on different assumptions should be performed to improve the level of evidence on cost-effectiveness ratios of the usual screening strategies for osteoporosis.

[Role of hospital claims databases from care units for estimating thyroid cancer incidence in the Rhône-Alpes region of France]. / Place du Programme de médicalisation des systèmes d'information (PMSI) dans l'estimation de l'incidence du cancer de la thyroïde dans la région Rhône-Alpes.

BACKGROUND: Incidence measures are essentially based on the data collected by cancer registries. Hospital claims databases from care units (PMSI) can be used as a source of information for registries because they contain standard records of most cancer patients. Regarding thyroid cancer, we have evaluated the PMSI as a source of information for the Rhône-Alpes thyroid cancer registry and usefulness of PMSI as a tool for surveillance of thyroid cancer incidence. METHODS: Patients with incident thyroid cancer in 2002 were identified in the claims data of the Rhône-Alpes region using an algorithm based on DRG codes of thyroidectomy and on diagnosis codes of thyroid cancer in a principal or secondary position. The patients identified were compared to those in thyroid cancer registry of the Rhône-Alpes region regarding sex, age, ZIP code of residence, month of discharge and length of stay versus the diagnosis date. When the percentage of cases of claims data identified in the cancer registry and the percentage of cases of the cancer registry identified in claims data were obtained, the capture-recapture method was applied to estimate the number of missing cases and the total number of incident thyroid cancers in the region. RESULTS: 667 patients were identified in claims data while the cancer registry included 677 patients. 95.2% of patients identified in claims data were in the cancer registry and 82.3% of patients in the cancer registry were identified in claims data. Cases lacking in claims data mostly corresponded to micro-cancers which represented 41% of cases in the cancer registry. Regarding cancer above 1 cm, 92% of the cancer registry cases were identified in claims data. Sensitivity of combining information from cancer registry and claims data was 99.2%. Cases lacking in cancer registry, present in claims data base and considered as true cases after obtaining pathological confirmation represented 2% of the whole thyroid cancer population. CONCLUSION: Claims data obtained from anonymous regional or national bases can be helpful for checking the completeness of thyroid cancer registries and to provide a small amount of unknown cases. They can be considered an acceptable tool for surveillance of thyroid cancer incidence. The significance of the variations in incidence that could be observed from claims data remains to be evaluated in comparison with comparable data obtained from registries.

Estimates of the number of cancer patients hospitalized in a geographic area using claims data without a unique personal identifier.

OBJECTIVE: In French national claims databases, claims are currently anonymous i.e. not linked to individual patients. In order to improve our estimate of the medical activity related to cancer in one French region, a statistical method was developed to use claims data to assess the number of cancer patients hospitalized in acute care. METHODS: This method used the medical and administrative information available in the claims (i.e. age, primary site, length of stay) to predict an average number of stays per patient, followed by a number of patients. It was based on a two-phase study design using an internal dataset which contained personal identifiers to estimate the model parameters. RESULTS: The predicted number of acute care patients hospitalized in one or several health care centers in one French region was 38,109 with a 95% predictive interval (37,990; 38,228) for the first six months of 2002. A prediction error of 24 per thousand was found. CONCLUSION: We provide a good estimate of the morbidity in acute care hospitals using claims data that is not linked to individual patients. This estimate reflects the medical activity and can be used to anticipate acute care needs.

[Evaluation of clinical practices: methods of data collection and information sources?]. / L'évaluation des pratiques cliniques: quels modes de recueil des données et à partir de quelles sources d'information?

OBJECTIVE: The aim of our study is to present the methods used to observe clinical practices, to evaluate their advantages and limits, and to specify the context in which they are preformed. METHODS: We conducted a bibliographical search on MEDLINE using key words, completed by an offline search. We selected articles published in French or English between 1985 and 2003. RESULTS: Thirty articles, of which 3 were reviews, as well as an additional 5 reports and 9 books, were selected. We distinguished direct or objective approaches to clinical practices as well as indirect or declarative approaches. We also noted whether the approach was individual with data collected from individual practitioners, or collective, with data coming from databases. Most methods of collecting data used medical records, often in the context of internal or external clinical audits or peer reviews. The other sources of data were self-administered questionnaires, written case simulations and simulated patients. Data was also extracted from previously existing databases: claims databases, registries and ad hoc databases. CONCLUSION: An objective individual approach insures the highest quality of information, but possible high costs can limit the use of this approach. It is necessary to continue researching the best means of collecting data on clinical practices, because of the obligation of each practitioner to evaluate individual clinical practices.

Should age influence the choice of quantitative bone assessment technique in elderly women? The EPIDOS study.

In a prospective cohort of 7,598 women aged 75 and over, we analyzed the effect of age on the ability of femoral neck bone mineral density (BMD) and of ultrasound (BUA and SOS) of the calcaneus to predict hip fracture. Unadjusted regression analysis showed that the risk of hip fracture was increased 1.7 times for one standard deviation increase in age (3.7 years). Overall, for a decrease of one standard deviation in quantitative bone measures, the risk was significantly increased by 2.2 times for BMD (1.9-2.5), 1.8 for BUA (1.6-2.1), and 1.9 for SOS (1.6-2.2). However the average relative risk associated with a decrease in BMD tends to diminish with advancing age, meaning that a smaller part of the risk is explained by BMD in the very elderly. This is confirmed by the areas under the ROC curves (AUC) of BMD that are significantly better before 80 years (0.75 [0.73-0.76]) than after (0.65 [0.63-0.67] in group 80-84 years and 0.65 [0.61-0.68] in group >/=85). On the other hand, as the absolute risk increases exponentially with age, the number of hip fractures attributable to a low BMD is still important in the very elderly, the risk difference between the lowest and the highest quartile of BMD is 25 hip fractures / 1,000 woman-years in the group >/=85 compared with 16 in the two other groups. Thus, after 80, quantitative assessment of bone may still be of interest for clinical decisions. Compared with quantitative ultrasound parameters, the ability of BMD to predict hip fracture was significantly superior to that of BUA and SOS only before the age of 80 (AUC of BMD 0.75 [0.73-0.76], BUA 0.67 [0.66-0.69], SOS 0.67 [0.65-0.69]). For patients older than 80, we did not observe significant differences in AUC between DXA and QUS to predict hip fracture.

Method of correction to assess the number of hospitalized incident breast cancer cases based on claims databases.

Estimations of the number of hospitalized incident cancer cases show biases when claims databases are used. This is due to false reports of incident cancer because of a lack of specificity, and because of unrecorded cancers resulting from a lack of sensitivity. We present a statistical method to provide corrected estimations. This method is based on a two-phase study design using an external data set for sensitivity and specificity estimates. Inaccuracy of the corrected number of hospitalized incident cancer cases was assessed by a credibility interval determined by a Bayesian approach using a Monte Carlo method. Based on the population hospitalized in a large group of French University hospitals, 334 women were identified in the French claims database as having potential incident cases of breast cancer in 1997. According to our method, the corrected number was 565 (550-580). In absence of hospital-based cancer registries, our approach provides estimates and credibility intervals, and has many potential applications in defining hospital policies with its applicability to other diseases.

Ultrasonic assessment of bone: a review.

In the last 25 years several non-invasive techniques based on the attenuation of ionizing radiation have been developed to quantify bone mineral density in the axial and peripheral skeleton. The use of ultrasounds is another technique which has recently been developed to provide information on the architecture and elasticity of bone. The basic principle of ultrasound measurements is that the speed (SOS = speed of sound) at which ultrasounds propagate in the bone, or the extent of their attenuation (BUA = broad-band ultrasound attenuation) through the bone is determined by bone density and by certain physical properties which are intimately correlated with bone strength. Theoretically, ultrasound bone measurements should provide more information about bone fragility and structure than densitometric techniques. As a result of preliminary studies, several ultrasound devices have been developed by manufacturers. Most of them measure the os calcis which consists almost exclusively of trabecular bone. Measurement precision varies with the instrument used and the site of measurement. The in vitro and in vivo precision for SOS and for BUA are reported in this review. The correlations between ultrasound and bone mineral density measurement suggest that these techniques measure different entities. A significant difference is constantly found between normal and osteoporotic women. Transversal studies have shown a negative correlation between ultrasound measurements and age. Age-related variations are much more significant with BUA than with SOS. Several studies suggest the potential of ultrasound measurements to assess the risk for individuals to develop osteoporosis and its usefulness in treatment follow-up. Further prospective studies are needed to better understand the effectiveness of ultrasounds.(ABSTRACT TRUNCATED AT 250 WORDS)