Out-of-pocket expenditures in France to manage psoriasis in adult patients: results from an observational, cross-sectional, non-comparative, multicentre study.

BACKGROUND: In 2018 in France, overall mean health-related out-of-pocket (OOP) expenditures were 214.00€/year/patient. AIM: To evaluate OOP expenditures for psoriasis patients in France. METHODOLOGY: Observational, cross-sectional, non-comparative, multicentre study in 3000 patients with clinically confirmed psoriasis who responded to a specific digital questionnaire collecting demographic and socio-economic characteristics, assessing the 3 domains (severity, psychosocial impact and past history and interventions) of the patient's Simplified Psoriasis Index (sa-SPI) and expenditures to manage psoriasis, including OOP. Multivariate linear regression was conducted to search for factors associated with higher OOP. RESULTS: In total, 2681 patients completed the questionnaire and, of those, 2562 provided clinically validated data. Overall, 60% were women; the mean age was 49.4 ± 14.8 years. 30% of the patients declared that they suffered from psoriatic arthritis. The final mean sa-SPI core was 10.86 ± 9.70. Of these 2562 patients, 243 (9.5%) had severe, 442 (17.3%) moderate and 1877 (73.3%) mild psoriasis. In addition, 932 (36.4%) patients reported facial involvement, 724 (28.25%) genital impairment and 1124 (43.8%) lesions on the limbs. Mean OOP expenditures to manage psoriasis per patient were 531.00€, 439.74€ ± 939.85€ for patients with mild, 791.06€ ± 1367.67€ with moderate and 1077.64€ ± 1680.14€ for patients with severe psoriasis. For patients with psoriasis in the genital area, the median amount of expenditures (251.17€; CI95% [138.35;363.99]) was significantly higher than that for the face (183.85€; CI95% [78.76;288.94]) or limbs (199.96€; CI95% [93.77;306.15); (P < 0.001). More than 90% of the patients had OOP expenditures for over-the-counter products (97.5%) and alternative care (92.0%), especially for emollients and/or hydrating products. CONCLUSION: In France, in 2019, OOP expenditures to manage psoriasis were on average more than twice as high as the overall mean health-related OOP expenditures estimated by the French Health Agency in 2018. These results should lead health authorities to review certain standards of healthcare reimbursement.

Costs of perennial allergic rhinitis and allergic asthma increase with severity and poor disease control.

BACKGROUND: Perennial allergic rhinitis (PAR) represents a global and public health problem, due to its prevalence, morbidity, and impact on the quality of life. PAR is frequently associated with allergic asthma (AA). Costs of PAR with or without AA are poorly documented. OBJECTIVE: Our study aimed to detail medical resource utilization (MRU) and related direct cost for PAR, with or without concomitant AA, in France. METHODS: Using Electronic Health Records (EHRs), we identified in 2010 two cohorts of PAR patients, based on General Practitioners' diagnoses and prescribing data, with and without concomitant AA. For each patient, the EHRs were linked to corresponding claims data with MRU and costs during years 2011 to 2013. Predefined subgroup analyses were performed according to severity of PAR and level of AA control. RESULTS: The median annual cost reimbursed by social security system for a patient with PAR, and no AA was 159€ in 2013. This varied from 111€ to 188€ depending on PAR severity. For patients with PAR and concomitant AA, the median annual cost varied between 266€ and 375€, and drug treatment accounted for 42-55% of the costs, depending on asthma control. CONCLUSION: This study linking diagnoses from EHRs to claims data collected valid information on PAR management, with or without concomitant AA, and on related costs. There was a clear increase in costs with severity of PAR and control of AA.

CAPECO: Cost evaluation of community acquired pneumonia managed in primary care.

BACKGROUND: Estimating the economic burden of community acquired pneumonia (CAP) managed in ambulatory setting is needed in France since no data are available. METHOD: A retrospective study (CAPECO) was conducted based on a prospective French study describing patients with suspected CAP managed in primary care (CAPA). The aim of the CAPECO study was to estimate and explain medical costs of a disease episode in CAP patients only followed in ambulatory care and in hospitalised patients. Primary endpoints were the direct medical costs, impact on productivity and costs of incident CAP over one year. Secondary endpoint was to describe predictive factors of costs, hospital admission and stay length. RESULTS: In this cohort of 886 patients, resulting in an incidence of CAP of 400 per 100,000 inhabitants per year, the mean direct medical cost of a disease episode of CAP was € 118.8 for strictly ambulatory patients with an equal weight for medical time, drugs, diagnostic procedures and tests. This direct cost was € 102.1 before admission for patients who were finally hospitalised. The mean cost of hospital admissions was € 3522.9. Main predictive factors of hospital admission and stay length were respectively a history of chronic respiratory disease and older age. Factors of direct medical cost were prescribing X-ray examination and having a positive X-ray. The impact of a disease episode on productivity was € 1980 (sd 1400) per ambulatory episode and € 5425 (sd 4760) per episode leading to hospital admission. CONCLUSION: Costs per ambulatory episode were modest but increased substantially in hospitalised patients, who were more numerous when chronic respiratory disorders were present and in the elderly. Indirect costs were significant. Deciders should thus consider both direct and indirect costs when assessing preventive interventions in the context of this disease.

Two-year vascular hospitalisation rates and associated costs in patients at risk of atherothrombosis in France and Germany: highest burden for peripheral arterial disease.

OBJECTIVES: To obtain Western European perspectives on the economic burden of atherothrombosis in patients with multiple risk factors only (MRF), cerebrovascular disease (CVD), coronary artery disease (CAD), and in the under-evaluated group of patients with peripheral arterial disease (PAD), we examined vascular-related hospitalisation rates and associated costs in France and Germany. DESIGN: The prospective REACH Registry enrolled 4693 patients in France, and 5594 patients in Germany (from December 2003 until June 2004). METHODS: For each country, 2-year rates and costs associated with cardiovascular events and vascular-related hospitalisations were examined for patients with MRF, CVD, CAD, and PAD. RESULTS: Two-year hospitalisation costs were highest for patients with PAD (3182.1€ for France; 2724.4€ for Germany) and lowest for the MRF group (749.1€ for France; 503.3€ for Germany). Peripheral revascularizations and amputations were the greatest contributors to costs for all risk groups. Across all PAD subgroups, peripheral procedures constituted approximately half of the 2-year costs. CONCLUSION: Hospitalisation rates and costs associated with atherothrombotic disease in France and Germany are high, especially so for patients with PAD.

Length and cost of hospital stay of radioiodine ablation in thyroid cancer patients: comparison between preparation with thyroid hormone withdrawal and thyrogen.

PURPOSE: Treatment of thyroid cancer consists of thyroidectomy and radioiodine ablation following thyroid-stimulating hormone (TSH) stimulation. Similar ablation rates were obtained with either thyroid hormone withdrawal (THW) or rhTSH. But with rhTSH, the elimination of radioiodine is more rapid, thus reducing its whole-body retention and potentially resulting in a shorter hospital stay. The aim of this study was to assess the financial impact of a reduced length of hospital stay with the use of rhTSH. METHODS: This was a case-control study of thyroid cancer patients treated postoperatively with 3,700 MBq (100 mCi) radioiodine; 35 patients who received rhTSH were matched with 64 patients submitted to THW according to covariates influencing radioiodine retention. The length of hospitalization (LOH) was estimated for each method according to the threshold of radioiodine retention below which the patient can be discharged from the hospital. The economic analysis was conducted from a hospital perspective. Simulations were performed. RESULTS: For a threshold of 400 MBq, the LOH was 2.4 days and 3.5 days with rhTSH and THW, respectively, and the cost for an ablation stay was, respectively, 2,146 and 1,807 . In the French context, 57% of the acquisition cost of rhTSH was compensated by the reduction of the length of hospitalization. CONCLUSION: By increasing the iodine excretion, rhTSH allows a shorter hospitalization length, which partially compensates its acquisition cost.

Sick leave for follow-up control in thyroid cancer patients: comparison between stimulation with Thyrogen and thyroid hormone withdrawal.

INTRODUCTION: The clinical benefits of recombinant human thyroid-stimulating hormone (rhTSH; Thyrogen) are well established as an alternative stimulation procedure to thyroid hormone withdrawal in the diagnostic follow-up of thyroid cancer patients. By avoiding periods of hypothyroidism, patients do not suffer from a decreased quality of life and keep their ability to work. This study compared the frequency, the duration and the cost of sick leave for follow-up control between rhTSH and withdrawal. METHODS: The study population consisted of patients with thyroid carcinoma first treated by thyroidectomy and radioiodine ablation. Patients were recruited at their control visit between October 2004 and May 2006 in three hospitals, both prospectively and retrospectively. Collection data consisted of patient information, job characteristics and duration of sick leave during the month before and the month after control. The valuation of sick leave used the friction cost method. RESULTS: Among the 306 patients included, 292 (95%) completed the entire questionnaire. The mean age was 46.7 years. Among the 194 active patients, patients treated with rhTSH, when compared with patients treated by withdrawal, were less likely to require sick leave (11 vs 33%; P=0.001). The mean duration of sick leave was shorter (3.1 vs 11.2 days; P=0.002) and indirect costs due to absenteeism accounted for 454 Euro +/- 1673 vs 1537 Euro +/- 2899 for withdrawal stimulation. CONCLUSION: For active patients, rhTSH treatment reduced the length and the cost of sick leave by 8.1 days and 1083 Euro per control respectively, when compared with withdrawal treatment.

[Impact of the choice of an antiplatelet therapy for peripheral arterial disease: cost-effectiveness ratio and health economics assessment]. / Impact du choix d'un antiagrégant plaquettaire dans l'artériopathie oblitérante des membres inférieurs sur les pertes de chances et sur les coûts médicaux.

OBJECTIVES: To evaluate in peripheral arterial disease two strategies of antiplatelet therapy (clopidogrel and aspirin) in terms of number of ischemic stroke and hemorrhagic events, to estimate the losses of chances after no-choice of the most favorable strategy and the impact of these losses of chances in terms of days of hospitalizations, to estimate the cost-effectiveness ratio of the most effective and best tolerated strategy. METHOD: The number of patients to be treated to avoid one critical event (ischemic and hemorrhagic events) was calculated from the results of the annual rates established by the CAPRIE trial conducted in a population of French patients with peripheral arterial disease. This number of patients to treat was then extrapolated to the entire French population of peripheral arterial disease patients. The absolute numbers of critical events avoided with clopidogrel in France defined the losses of chances in the case of no-choice of this drug. Estimates in terms of days of hospitalization and cost-effectiveness ratio (in euro per life year gained) were based on data from the French Medical Information System. RESULTS: The number of patients to treat to avoid one ischemic event was 87 and the number of patients to treat to avoid one major hemorrhagic event was 149. In the peripheral arterial disease population, the numbers of ischemic and hemorrhagic events generated by non-treatment with clopidogrel was estimated at 3761 and 2191, respectively i.e. a total of 5952 events per year. These events included: 2025 myocardial infarctions, 1157 ischemic strokes, 579 deaths of vascular origin and 2191 digestive hemorrhages, requiring 60,394 hospitalization days. The cost-effectiveness ratio of clopidogrel was 10,393 euro per life year gained, and was much lower than commonly accepted cost-effective thresholds in Europe, which are around 30,000 euro per life year gained. CONCLUSION: The choice of clopidogrel in patients with peripheral arterial disease improves the prevention of subsequent events (ischemic and hemorrhagic events) with a cost-effectiveness ratio 2 to 3 times lower than the European thresholds accepted by the World Health Organization and avoids 1 day of hospitalization for 5.4 treated patients.

[Cost of an intraperitoneal chemohyperthermia (IPCH) related to cytoreductive surgery]. / Coûts et financement de la chimiohyperthermie intrapéritonéale (CHIP) associée à une chirurgie d'exérèse.

BACKGROUND: A complete cytoreductive surgery followed with an intraperitoneal chemohyperthermia (IPCH) is a new treatment allowing curing some patients with a peritoneal carcinomatosis. The cost of this treatment, evaluated in different countries, is high. In France, we do not have any cost evaluation of this therapy, and this state slows its diffusion in our country. The aim of this study is to evaluate the real cost of maximal cytoreductive surgery with IPCH, and to compare it with the financial support given by the Ministery of Health. MATERIALS AND METHODS: The real cost of this therapy was established on the standard analytic accountancy of our Institute. The analysis of the financial support received was done after the classification of the patients in the current official diagnosis-related groups, and according to the current rates of reimbursing of these acts. RESULTS: Seventy-three patients were treated with IPCH in our Institute during 2002 and 2003. The real mean cost for our hospital was 39,358 euros per patient, with a mean hospital staying of 27.7 days. In counterpart, our hospital received a mean financial support of 20,485 euros, resulting in a deficit of 18,873 euros per patient (and close to 1.4 million of euros for the two years). CONCLUSION: Our current classification of diagnosis-related groups does not allow to describe the real importance of this therapy which combines a maximal cytoreductive surgery with IPCH. In our system of reimbursing, the hospital which offers this type of new therapy to its patients receives only half of the real rate. Two correctives measures are suitable: to describe this combining treatment in the official list of medical acts, and to determine its specific cost for reimbursing.

Choosing where to deliver: decision criteria among women with low-risk pregnancies in France.

As in the rest of Europe, the supply of maternity hospitals has progressively decreased over the past few decades in France. An understanding of user choice criteria is important to help health planners reorganize obstetrical services and to predict changes in utilization patterns in response to supply changes. The objectives were to understand the criteria that women use to select their maternity hospital in France and to analyse the relation to individual and community characteristics. A survey of 536 recently delivered women with low-risk pregnancies explored the factors motivating user choice in three territories with distinct geographical and health service supply characteristics: four districts in Burgundy, two districts in Pays de la Loire, and the district of Seine-Saint-Denis in Ile-de-France. Women were asked to select a principal choice criterion. Their responses were grouped into categories: Accessibility/proximity, reputation of the establishment among users, advice of treating physician, technical quality and cost. Accessibility and proximity were the most selected criteria (33%), followed by the reputation of the maternity (29%), technical quality (15%) and advice of treating physician (13%). Age, parity and education influenced choice criteria. After controlling for individual determinants, region of residence was highly related to choice criteria; women living in Burgundy were more likely to select an establishment based on proximity, in Seine-Saint-Denis women were more likely to follow the advice of their physician, and in Pays de la Loire, more likely to base their decisions on the reputation of the establishment. The association between choice criteria and community characteristics could explain the failure of previous models to predict behaviour in different contexts. It is important to carry out local surveys of user perceptions before restructuring in order to take into consideration women's opinions on their future places of delivery and to refine geographic models.

Cost of a recurrent vs. cost of first-ever stroke over an 18-month period.

When assessing the cost-effectiveness of the secondary prevention of stroke, it is not well known whether the cost of a recurrent brain infarction (BI) is different from a first-ever BI. In a cohort of 435 consecutive prevalent cases of BI (including both recurrent and first-ever BI) we collected medical and socio-economic variables. Handicap was measured with the Rankin scale. Only the direct medical costs were considered over an 18-month period from a societal perspective. We compared first-ever to recurrent BI. Of the 435 patients 20.5% had a recurrent BI. The length of the initial hospitalization and the distribution of the patients into the three classes of handicap (Rankin 0-2, 3, and 4-5) were similar in the first-ever and recurrent BI groups. The average total cost of a first-ever BI was euro 19 725 (95% CI, 17 950-21 501) and euro 18 560 (95% CI, 15 798-21 322) for a recurrent BI (P = 0.48). There were no differences between the two groups when the costs were compared by handicap levels (P = 0.17) or when the costs were compared for each type of expenditure (initial hospitalization, rehabilitation, ambulatory services) except for long-term care, because of the small number of cases. This study suggests that the costs of recurrent BI are roughly similar to the costs of first-ever BI, which may be helpful when studying the cost-effectiveness of secondary stroke prevention trials.

The cost-effectiveness of fondaparinux compared with enoxaparin as prophylaxis against thromboembolism following major orthopedic surgery.

BACKGROUND: The selective antithrombotic fondaparinux is more effective than the low-molecular-weight heparin enoxaparin for prevention of venous thromboembolism (deep-vein thrombosis [DVT] or pulmonary embolism) in patients undergoing major orthopedic surgery, but its cost-effectiveness is undetermined. OBJECTIVES: To evaluate the cost-effectiveness of fondaparinux relative to enoxaparin as prophylaxis against venous thromboembolism (VTE) for patients undergoing total hip replacement, total knee replacement or hip fracture surgery in the UK. PATIENTS/METHODS: A decision analysis model was created simulating the impact of fondaparinux and enoxaparin on patient outcomes and costs over various time points up to 5 years following surgery. The main outcome measures were treatment costs per patient and the incidence of clinical VTE and VTE-related deaths. A weighted (combined) cohort reflects the proportion of patients undergoing these procedures in 2000/2001. RESULTS: In the combined cohort, compared with enoxaparin, fondaparinux is expected to produce 20 fewer clinical VTE events and 3.2 fewer VTE-related deaths per 1000 procedures at 5 years. Cost savings at 5 years are pound 27 per patient with fondaparinux (discounted at 6% per year). In each of the three surgical groups, fondaparinux leads to lower expected costs per patient and to a smaller number of VTE events and VTE-related deaths. RESULTS are sensitive to the price difference between fondaparinux and enoxaparin and variation in the rate of late DVT. The analysis is robust to variations in all other key parameters. CONCLUSIONS: Compared with enoxaparin, fondaparinux is more effective and reduces costs to the healthcare system. At current prices, fondaparinux is the recommended strategy in the UK for prophylaxis following major orthopedic surgery.

[Paroxysmal atrial fibrillation in community medicine: management intentions and cost estimates]. / La fibrillation auriculaire paroxystique en médecine de ville: intentions de prise en charge et estimation du coût.

This study was undertaken to describe the declared management of atrial fibrillation in community medicine in France for patients between 50 and 80 years of age, and to estimate the total cost of treatment for Society in the year 2000. A questionnaire was sent to a sample of 306 private sector cardiologists, representative for their geographic location: 100 replies were received. Only 10% of cardiologists prescribed a treatment in patients without cardiovascular precedents who had a single regressive episode of atrial fibrillation and three quarters of them advised follow-up. This management cost an average between 228 and 296 Euros/year. When the episode of fibrillation was persistent at the time of consultation, 82% of practitioners prescribed antiarrhythmic reduction (amiodarone) after antithrombotic treatment (oral anticoagulants) followed by an antiarrhythmic therapy (class lc mainly) with an average cost of 659 to 783 Euros/year. In patients with previous cardiovascular disease, when a first episode of atrial fibrillation was present at the time of consultation, 92% of cardiologists prescribed pharmacological reduction with amiodarone, followed by long-term therapy when successful for an average cost of 755 to 1,092 Euros/year. All cardiologists requested systematic blood tests to search for thyroid complications of amiodarone with an average cost of 59 Euros/year. The costs were high, especially in chronic and recurrent pathology: the cost of treatment of the first two episodes of atrial fibrillation in the over 65 age group was 305 million Euros/year.

[Cost of managing cataracts. Evaluation of traditional hospitalization and ambulatory surgery]. / Coût de la prise en charge de la cataracte. Evaluation en hospitalisation traditionnelle et en chirurgie de jour.

OBJECTIVE: Demonstrate eventual differences and evaluate the medical costs of treatment of a cataract in traditional hospitalisation and out-patient surgical conditions. METHODS: We conducted a study of minimisation costs in 3 ophthalmologic hospital departments. This retrospective study randomly selected the medical files of 250 patients (100 operated in the out-patient surgical department and 150 operated in traditional surgical conditions). Costs were evaluated on direct hospital costs, according to the standard costs method and the method of true costs. RESULTS: The mean total cost of a cataract is of 10,984 F in traditional hospital conditions and of 7,683 F in out-patient surgical conditions. DISCUSSION: In terms of direct hospital costs, treatment of cataracts in out-patient surgery appears more economic compared with traditional surgery. The difference in cost concerned the fixed hospital charges (structures and staff). CONCLUSION: Out-patient surgery will progress in France in the next few years, but traditional hospitalisation will still be required in ophthalmologic practice.

Cost-effectiveness analysis of the terlipressin-glycerin trinitrate combination in the pre-hospital management of acute gastro-intestinal haemorrhage in cirrhotic patients.

OBJECTIVES: To assess the cost-effectiveness of an early treatment of upper gastro-intestinal haemorrages in cirrhotic patients. DESIGN: Utilization data linked to the results of a double-blind, placebo-controlled trial demonstrating the efficacy of the terlipressin-glycerin trinitrate combination (TER-GTN) in the reduction of mortality at day 42 for haemorragic patients due to rupture of oesophageal varices. SETTING: Hôpital Jean Verdier, Bondy, Assistance Publique-Hôpitaux de Paris, France. SUBJECTS: Eighty-four patients included over 2 years by emergency services and hospitalized in an intensive care unit (ICU) for haemorrage, 41 in the "treated" group and 43 in the "placebo" group. MAIN OUTCOME MEASURES: Mortality at day 42, cost per death avoided. RESULTS: The mortality rate in the placebo group was 46.5% versus 27.5% in the treated group. The mean length of stay was 5 days longer in the treatment group. The excess cost per death avoided was 25,849 FF. Of this extra cost 27% was due to treatment and 24% was due to increased length of stay. The excess cost per case treated was FF 5,097, 10% of the total cost per stay for rupture of oesophageal varices (ROV). CONCLUSIONS: Our results are of the same magnitude as those published by Mac Cormick et al. in the United Kingdom for similar treatment. The extra cost appears to be moderate, and much lower than monoclonal antibody therapy for sepsis. The impact on the study hospital budget did not exceed 1.7 10(-4).

Evaluation of benefits related to reduced length of stays in postanesthesia care units.

The study's purpose was to estimate the potential economic benefit of the optimization of postanesthesia care units (PACUs). A simulation model was designed and used to test the economic impact of a reduction of length of stay. For the studied PACU, a reduction of 25% of length of stay is required to yield significant economic results.

Quality of care initiatives in the French context.

The emergence of the issue of quality of health care systems of developed countries can be interpreted as the result of a growing pressure from payors and regulators on providers for increased accountability. As such, the form that this emergence takes is specific to each country's cultural, economic, and institutional context. A brief description of the French health care system and its political and functional dynamics is provided to set the stage and to explain how providers of care have responded to this pressure. The main emphasis has been put in a first period on the rationalization of medical practices using persuasive and coercive regulations to diffuse practice guidelines. As a consequence, medical data systems are developing in both the hospital and ambulatory care sectors. Quality assurance programmes are in their early years, and total quality management is still to come.

Another look at emergency room overcrowding: accessibility of the health services and quality of care.

PURPOSE: To describe both the social characteristics and the health needs of the medical users of a pediatric hospital Emergency Room with special emphasis on frequent use. STUDY SELECTION: Observational study on health services utilization and health care needs of young children consulting at a teaching hospital's Emergency Room. DATA SOURCES: Mother interview and medical record review. RESULTS OF DATA SYNTHESIS: Children from underprivileged strata are more often high Emergency Room users. Their preventive needs are satisfied but adequate follow-up of their medical problems is more often lacking. CONCLUSION: To understand why some achievable benefits are not achieved it is necessary to evaluate the varying performance of health services according to the social origin of the users.

A prospective comparison of costs and morbidity of laparoscopic versus open cholecystectomy.

BACKGROUND/AIMS: The aims of this study were to compare pain and discomfort after laparoscopic cholecystectomy (LC) and open cholecystectomy (OC), and to quantify the costs of both procedures. MATERIAL AND METHODS: Seventy-six patients undergoing a LC were prospectively compared with 24 patients who had an OC. Pain was assessed with a visual analog scale, and two rating indexes, one day, three months, and six months postoperatively. Hospital costs per patients covered direct expenditures, hospital overhead and depreciation of equipment, and salaries allocated on a per-diem basis. RESULTS: Pain and discomfort were significantly lower in the LC group than in the OC group. Cost for the operation was higher after LC, and lower for post operative care (p < 0.001). Total costs of hospitalization were similar. The mean number of days out of work was less in the LC group (14.7 days) than in the OC group (35.5 days) and the difference of cost due to loss of productivity was significant (p < 0.0001). CONCLUSIONS: The advantages of LC must be counter-balanced with a higher rate of postoperative complications than after OC, mainly common bile duct injuries.