Diffusion de la réhabilitation améliorée après chirurgie en France. Étude nationale à grande échelle, à partir des données du PMSI.

INTRODUCTION: The aim of this study was to analyze the rate of enhanced recovery programs (ERP) implementation in a range of surgical specialties in both the public and private sectors. METHODS: This was a retrospective longitudinal study based on hospital stays between March to December 2019. We studied thirteen of the activity segments most frequently included in ERP protocol. The procedures selected included digestive, gynecological, orthopedic, thoracic, and urological procedures. The assessment criteria was the rate of ERP. The results were analyzed first overall and then matching ERP stays to non-ERP stays according to type of institution, patient age and sex, month of discharge, and Charlson comorbidity score. RESULTS: We took 420,031 stays into account, of which 78,119 were coded as ERP. There were 62,403 non-ERP stays. Depending on the type of surgery, the implementation rate ranged from 5 percent to 30 percent. The overall rate of ERP implementation was higher in the private sector (21.2 percent) than in the public sector (14.4 percent). The results are reversed for some surgeries, notably for some cancers. Patients had a higher Charlson score in the public sector. CONCLUSIONS: This large-scale national study provides a picture of the degree of diffusion of ERPs in France. Although there are differences between sectors, this diffusion is still insufficient overall. Given the demonstrated benefits of ERPs, more educational efforts are needed to improve their implementation in France.

Medico-economic impact of enhanced rehabilitation after surgery: an exhaustive, nation-wide claims study.

BACKGROUND: Study of the medico economic impact of enhanced rehabilitation after surgery (ERAS), by comparing the cost of patient care with or without ERAS, both from the point of view of the hospitals and the Social Security Health Insurance Program. METHODS: Retrospective longitudinal study on matched data from March 1, 2019 to December 31, 2019. The data are extracted from the French prospective payment system. We studied 12 of the most commonly performed in ERAS business segments. The primary outcome was the reduction of the average length of hospital stay and its implications on production costs and excess capacity. We also studied the impact on hospital incomes and Social Security Insurance Program expenses. The potential gain in hospital days was computed by comparing the length of stay of ERAS and non-ERAS cases. The cost reduction was estimated using the mean number of avoidable days of hospitalization, and the mean cost of the stays obtained from the national cost study. Finally, we studied an approximation of the additional expense for the Social Security Health Insurance Program on costs standardized by applying public sector rates. RESULTS: The average length of stay reduction attributed to ERAS is 1.45 (CI 95% 1.42 to 1.48) day per stay, translating to a cost reduction for the hospitals of € 1060 (CI 95% 995 to 1125) per patient and a total of €65 million (CI 95% 61 to 69). At the same time, the additional expenses for the Social Security Insurance Program can conservatively be approximated to € 1.6 million, breaking into a € 2.2 million increase partially compensated by cost savings of € 0.6 million over subsequent stays for complications. Overall, for each percent of additional ERAS activity over the scope of the study, the marginal cost reduction for the hospitals can be estimated to € 1.8 million (CI 95% 1.7 million to 2.0 million). CONCLUSIONS: Associated with previously known clinical benefits for the patients, these convincing results in terms of economic gain strongly support expanding the adoption of ERAS.

Consequences for overcrowding in the emergency room of a change in bed management policy on available in-hospital beds.

Objective Emergency rooms play an important role by providing continuous access to healthcare 24 h a day, 7 days a week, but the lack of available hospital beds has become a major difficulty. Changing bed management policy could improve patient flow. The aim of the present study was to evaluate the consequences of a change in patient prioritisation on available beds. Methods The study consisted of a computerised bed management simulation based on day-by-day data collected from 1 to 31 January 2013 in a teaching hospital. Real hospital data were used to power the computer simulation. The scenarios tested were: (1) priority for emergency and surgery; (2) priority for emergency and medicine; (3) priority for planned admissions and surgery; and (4) priority for planned admissions and medicine. The results of these scenarios were compared with each other and to actual data. Results This study included 2347 patients. The scenario that proved to be the least efficient was the one that gave priority to emergency patients presenting with a medical condition. The scenario that exhibited the best efficiency was the one that gave priority to planned admissions and surgery. Conclusions Changing policies for hospital bed management is worth exploring to improve hospital patient flow and length of stay. What is known about the topic? The lack of available hospital beds is a major difficulty in managing patient flow in emergency rooms (ERs). The ER patient flow competes against a flow of planned hospital admissions for the same beds and the lack of a clearly defined policy on either prioritising ER patient flow over planned admissions or vice versa contributes to a disordered system. What does this paper add? We compared several simulated scenarios corresponding to different bed management policies. The scenario that gave priority to planned admissions and surgery gave the most suitable results. What are the implications for practitioners? Postponing scheduled surgical patients was not an efficient procedure to solve hospital overcrowding.

Prolapse and continence surgery in countries of the Organization for Economic Cooperation and Development in 2012.

OBJECTIVE: The purpose of this study was to report the rates and types of pelvic organ prolapse (POP) and female continence surgery performed in member countries of the Organization for Economic Co-operation and Development (OECD) in 2012. STUDY DESIGN: The published health outcome data sources of the 34 OECD countries were contacted for data on POP and female continence interventions from 2010-2012. In nonresponding countries, data were sought from national or insurer databases. Extracted data were entered into an age-specific International Classification of Disease, edition 10 (ICD-10)-compliant Excel spreadsheet by 2 authors independently in English-speaking countries and a single author in non-English-speaking countries. Data were collated centrally and discrepancies were resolved by mutual agreement. RESULTS: We report on 684,250 POP and 410,352 continence procedures that were performed in 15 OECD countries in 2012. POP procedures (median rate, 1.38/1000 women; range, 0.51-2.55 prolapse procedures/1000 women) were performed 1.8 times more frequently than continence procedures (median rate, 0.75/1000 women; range, 0.46-1.65 continence procedures/1000 women). Repairs of the anterior vaginal compartment represented 54% of POP procedures; posterior repairs represented 43% of the procedures, and apical compartment repairs represented 20% of POP procedures. Median rate of graft usage was 15.7% of anterior vaginal repairs (range, 3.3-25.6%) and 8.5% (range, 3.2-17%) of posterior vaginal repairs. Apical compartment repairs were repaired vaginally at a median rate of 70% (range, 35-95%). Sacral colpopexy represented a median rate of 17% (range, 5-65%) of apical repairs; 61% of sacral colpopexies were performed minimally invasively. Between 2010 and 2012, there was a 3.7% median reduction in transvaginal grafts, a 4.0% reduction in midurethral slings, and a 25% increase in sacral colpopexies that were performed per 1000 women. Midurethral slings represented 82% of female continence surgeries. CONCLUSION: The 5-fold variation in the rate of prolapse interventions within OECD countries needs further evaluation. The significant heterogeneity (>10 times) in the rates at which individual POP procedures are performed indicates a lack of uniformity in the delivery of care to women with POP and demands the development of uniform guidelines for the surgical management of prolapse. In contrast, the midurethral slings were the standard female continence surgery performed throughout OECD countries in 2012.

Outcomes After Hip Fracture Surgery Compared With Elective Total Hip Replacement.

IMPORTANCE: Patients undergoing surgery for a hip fracture have a higher risk of mortality and major complications compared with patients undergoing an elective total hip replacement (THR) operation. The effect of older age and comorbidities associated with hip fracture on this increased perioperative risk is unknown. OBJECTIVE: To determine if there was a difference in hospital mortality among patients who underwent hip fracture surgery relative to an elective THR, after adjustment for age, sex, and preoperative comorbidities. DESIGN, SETTING, AND PARTICIPANTS: Using the French National Hospital Discharge Database from January 2010 to December 2013, patients older than 45 years undergoing hip surgery at French hospitals were included. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), codes were used to determine patients' comorbidities and complications after surgery. A population matched for age, sex, and preoperative comorbidities of patients who underwent elective THR or hip fracture surgery was created using a multivariable logistic model and a greedy matching algorithm with a 1:1 ratio. EXPOSURE: Hip fracture. MAIN OUTCOMES AND MEASURES: Postoperative in-hospital mortality. RESULTS: A total of 690,995 eligible patients were included from 864 centers in France. Patients undergoing elective THR surgery (n = 371,191) were younger, more commonly men, and had less comorbidity compared with patients undergoing hip fracture surgery. Following hip fracture surgery (n = 319,804), 10,931 patients (3.42%) died before hospital discharge and 669 patients (0.18%) died after elective THR. Multivariable analysis of the matched populations (n = 234,314) demonstrated a higher risk of mortality (1.82% for hip fracture surgery vs 0.31% for elective THR; absolute risk increase, 1.51% [95% CI, 1.46%-1.55%]; relative risk [RR], 5.88 [95% CI, 5.26-6.58]; P < .001) and of major postoperative complications (5.88% for hip fracture surgery vs 2.34% for elective THR; absolute risk increase, 3.54% [95% CI, 3.50%-3.59%]; RR, 2.50 [95% CI, 2.40-2.62]; P < .001) among patients undergoing hip fracture surgery. CONCLUSIONS AND RELEVANCE: In a large cohort of French patients, hip fracture surgery compared with elective THR was associated with a higher risk of in-hospital mortality after adjustment for age, sex, and measured comorbidities. Further studies are needed to define the causes for these differences.

Epidemiologic features and outcomes associated with caustic ingestion among adults admitted in intensive care unit from 2013 to 2019: a French national observational study.

PURPOSE: Caustic ingestion is a potential life-threatening condition associated with high morbidity and mortality. Data on patients admitted to Intensive Care Unit (ICU) for severe caustic ingestion are lacking. We aimed to describing epidemiological features and outcomes of patients admitted to ICU for caustic ingestion in France. METHODS: In a retrospective, observational, and multicenter study, data from the national French Programme de Médicalisation des Systèmes d'Informations (PMSI) database were analysed from 2013 to 2019. In-hospital mortality rate (primary outcome) and in-ICU complications (secondary outcomes) were reported and analysed. RESULTS: 569 patients (289 males (50.8%), with median age of 49 years [interquartile (26-62)] were admitted in 65 French ICU for severe caustic ingestion. Five hundred and thirteen patients (90%) were admitted for intentional caustic ingestion. The median length of stay in ICU was 14.0 [4.0-31.0] days. In-hospital mortality occurred in 56 patients (9.8%). In multivariate analysis, age and simplified acute physiology score II were associated with in-hospital mortality age of 40-59 years [OR = 15.3 (2.0-115.3)], age of 60-79 years [OR = 23.6 (3.1-182.5)], and age > 80 years [OR = 37.0 (4.2-328.6)] and SAPS 2 score [OR = 1.0018 (1.003-1.033), p < 0.001]. During ICU stay, 423 complications (74%) were reported in 505 patients (89%). Infectious (244 (42.9%)), respiratory (207 (36.4%)), surgical 62 (10.9%), haemorrhagic (64 (11.2%)) and thrombo-embolic and (35 (6.2%)) complications were the most frequently reported during ICU stay. CONCLUSION: ICU admission for severe caustic ingestion is associated with 9.8% mortality and 74% complications. Age > 40 years and SAPS 2 score were independently associated with mortality.

Intensive Care Unit activity in France from the national database between 2013 and 2019: More critically ill patients, shorter stay and lower mortality rate.

BACKGROUND: Knowledge of the occurrence and outcome of admissions to Intensive Care Units (ICU) over time is important to inform healthcare services planning. This observational study aims at describing the activity of French ICUs between 2013 and 2019. METHODS: Patient admission characteristics, organ dysfunction scores, therapies, ICU and hospital lengths of stay and case fatality were collected from the French National Hospital Database (population-based cohort). Logistic regression models were developed to investigate the association between age, sex, SAPS II, organ failure, and year of care on in-ICU case fatality. FINDINGS: Among 1,594,801 ICU admissions, the yearly ICU admission increased from 3.3 to 3.5 per year per 1000 inhabitants (bed occupancy rate between 83.4 and 84.3%). The mean admission SAPS II was 42 ± 22, with a gradual annual increase. The median lengths of stay in ICU and in hospital were 3 (interquartile range (IQR) = [1-7]) and 11 days (IQR = [6-21]), respectively, with a progressive decrease over time. The in-ICU and hospital mortality case fatalities decreased from 18.0% to 17.1% and from 21.1% to 19.9% between 2013 and 2019, respectively. Male sex, age, SAPS II score, and the occurrence of any organ failure were associated with a higher case fatality rate. After adjustment on age, sex, SAPS II and organ failure, in-ICU case fatality decreased in 2019 as compared to 2013 (adjusted Odds Ratio = 0.87 [95% confidence interval, 0.85-0.89]). INTERPRETATION: During the study, an increasing incidence of ICU admission was associated with higher severity of illness but lower in-ICU case fatality.

Favorable effect of enhanced recovery programs on post-discharge mortality: a French nationwide study.

BACKGROUND: Enhanced recovery programs (ERPs) imply early discharge but few papers have assessed the effect of ERPs on post-discharge mortality (PDM). METHODS: A multicenter nationwide case control study based on administrative data was carried out between March and December 2019. Coding for every episode of care whether in the setting of ERP or not is mandatory for hospital funding (public or private). Twelve surgical specialties or procedures were included. The episodes of care coded with ERP were matched with those without ERP code for several factors such as the type of hospital (public or private), age, gender, month of discharge, and updated Charlson score. Ninety-day PDM was the main outcome. RESULTS: Of 420,031 patients in the database, 78,119 had an ERP code. Finally, 132,600 patients with 66,300 matched pairs were considered for the study. Overall, PDM was significantly reduced after ERPs: 0.075% vs 0.138% (p = 0.00042). Significant one-half and two-thirds reduction in PDM was observed respectively after hip arthroplasty (odds ratio 0.48 [95% CI 0.21-0.99]) and colectomy (odds ratio 0.36 [95% CI 0.16-0.74]). CONCLUSION: The findings, based on a large database and a rigorous matching, strongly suggest that ERPs reduce PDM particularly after colectomy and hip arthroplasty. This is likely due to better post-operative care in ERPs.

Direct blood fluorescence signal intensity of neutrophils (NEU-SFL): A predictive marker of death in hospitalized COVID-19 patients?

Introduction: Coronavirus disease 2019 (COVID-19) is a respiratory disease triggered by immunopathological mechanisms that cause excessive inflammation and leukocyte dysfunction. Neutrophils play a critical role in the innate immunity and are able to produce neutrophil extracellular traps (NETs: NETosis process) to combat infections. Some NETs markers are increased in patients who died from COVID-19. Recently, the neutrophil fluorescence variable (NEU-SFL), available on certain automated complete blood count (CBC) analyzers, has been correlated with NET formation and may reflect NETosis in patients. Here we evaluate whether NEU-SFL measured after admission of COVID-19 patients is associated with in-hospital survival or death. Patients and methods: 1,852 patients admitted for severe COVID-19 at Nîmes University Hospital in 2021 were retrospectively included in the study: 1,564 who survived the hospital stay and 288 who did not. The NEU-SFL was obtained on the Sysmex™ XN-10® analyzer and values for survivors and non-survivors were compared. The intra-patient NEU-SFL variations between the hospital entry and the last day of hospitalization were also analyzed (IRB 22.06.01, NCT05413824). Results: Non-survivors presented higher NEU-SFL values. NEU-SFL values above the 4th quartile were independently associated with a 2.88-fold risk of death. Furthermore, the difference of NEU-SFL values between the first and the last available data during hospitalization revealed that a decrease in NEU-SFL was associated to survivors and vice versa. Conclusion: Our study reinforces the role of neutrophils and NETosis in the pathophysiology and prognosis of COVID-19. Further studies combining NEU-SFL with other NETosis markers could improve the management of COVID-19 patients.

How traditional and digital analytics interventions can enhance lung-protective ventilation strategies during general anaesthesia: A two-year quality improvement project analysis.

PURPOSE: This quality improvement project evaluated interventions implemented to enhance individual adherence to a lung-protective ventilation strategy and its triad: low tidal volume, PEEP ≥ 5, recruitment manoeuvres. METHODS: For two years, nine anaesthesia workstations were connected to an automated cloud-based analytics software tool, which automatically recorded ventilation parameters as soon as a new patient case was opened. Four quality improvement periods were determined over the first year: baseline, intervention, no intervention, intervention + digital. In the second year, the digital strategy was continued for nine months, followed by a final "overtime" period. Baseline and no intervention periods included no training. The intervention period included both conventional and educational programs. The digital period included pop-up messages, which automatically appeared on the screen of the anaesthesia data management system when patients were intubated. The primary endpoint was provider adherence to the recommended triad. RESULTS: From October 2018 to December 2020, 12,883 procedures were performed. Data were available for 8968 procedures: baseline (n = 2361), intervention (n = 2423), no intervention (n = 1064), intervention + digital (n = 1862), overtime (n = 1258). Age, Predicted Body Weight, ASA score, type of surgery and airway management were similar between periods. At baseline, 75.2% of procedures reported low tidal volume but only 6.9% involved the complete triad. At over time, Triad was 22% (p < 0.001). Over study period, each parameter of the Triad (RM, Vt and Peep) increased (p < 0.001 vs. baseline), driving pressure decreased although EtCO2 and plateau pressure had not changed. CONCLUSION: Training with the help of digital apps improved LPV adherence over time.

Assessment of All-Cause Cancer Incidence Among Individuals With Preeclampsia or Eclampsia During First Pregnancy.

Importance: Preeclampsia or eclampsia (preeclampsia/eclampsia) during pregnancy induces major physiological changes and may be associated with specific cancer occurrences in later life. The current data regarding the association between preeclampsia/eclampsia and cancer are heterogeneous, and cancer risk after preeclampsia/eclampsia could be different depending on the organ. These uncertainties warrant reexamination of the association between preeclampsia/eclampsia and the risk of cancer overall and by specific cancer type. Objective: To evaluate the risk of cancer, overall and by type, after preeclampsia/eclampsia during a first pregnancy. Design, Setting, and Participants: This retrospective cohort study used data from the French hospital discharge database to identify all female individuals who had a pregnancy-associated hospitalization between January 1, 2010, and December 31, 2019. To allow a minimum of 2 years for the detection of medical history, individuals with a first detected pregnancy before January 1, 2012, were excluded, as were those with a cancer-associated hospitalization before or during their first detected pregnancy. Exposures, comorbidities, and occurrences of cancer were evaluated using data from the medico-administrative registers of hospitalizations in private and public French hospitals. Cox proportional hazards models were used to analyze cancer risk according to the occurrence of preeclampsia/eclampsia during first pregnancy. Exposures: Preeclampsia/eclampsia-associated hospitalization during the first detected pregnancy. Main Outcomes and Measures: The primary outcome was the incidence of cancer, including myelodysplastic or myeloproliferative diseases, after a first pregnancy with and without preeclampsia/eclampsia. Results: After exclusions, a total of 4 322 970 female individuals (mean [SD] age at first detected pregnancy, 29.6 [6.2] years) with and without preeclampsia/eclampsia during their first pregnancy were included. Of those, 45 523 individuals (1.1%) were diagnosed with preeclampsia/eclampsia during their first detected pregnancy. The maximum follow-up was 8 years, during which 29 173 individuals (0.7%) were diagnosed with cancer. No significant difference in overall cancer incidence was found between those with and without preeclampsia/eclampsia during their first pregnancy (adjusted hazard ratio [AHR], 0.94; 95% CI, 0.84-1.05). Preeclampsia/eclampsia was associated with an increase in the risk of myelodysplastic syndromes or myeloproliferative diseases (AHR, 2.43; 95% CI, 1.46-4.06) and kidney cancer (AHR, 2.19; 95% CI, 1.09-4.42) and a decrease in the risk of breast cancer (AHR, 0.79; 95% CI, 0.62-0.99) and cervical cancer (AHR, 0.75; 95% CI, 0.58-0.96). Conclusions and Relevance: In this study, a history of preeclampsia/eclampsia during first pregnancy was associated with an increase in the incidence of myelodysplastic or myeloproliferative diseases and kidney cancer and a decrease in the incidence of cervical and breast cancers. These associations might reflect an underlying common factor among preeclampsia/eclampsia and these pathologies and/or an association between preeclampsia/eclampsia and the development of these cancers.

Semantic Querying of Hospital Data Using an Ontology-Based Model of Discharge Summaries and ICD 10.

This paper focusses on the question of knowledge-based modeling of discharge summaries for semantic requesting in the context of hospital reporting process. An ontology was designed and implemented to capture patient data and required expert knowledge. The modeling process was carried out manually using Protégé after an initial reverse engineering of the official format of discharge summaries. An OWL 2 model was built integrating discharge summaries ontology and ICD 10 hierarchy. The framework is operationalized using the OpenLink Virtuoso database system (RDF store), enabling SPARQL queries and basic reasoning features. The evaluation was performed by implementing a use case based on patient comorbidities.

Identifying Life-Threatening Admissions for Drug Dependence or Abuse (ILIADDA): Derivation and Validation of a Model.

Given that drug abuse and dependence are common reasons for hospitalization, we aimed to derive and validate a model allowing early identification of life-threatening hospital admissions for drug dependence or abuse. Using the French National Hospital Discharge Data Base, we extracted 66,101 acute inpatient stays for substance abuse, dependence, mental disorders or poisoning associated with medicines or illicit drugs intake, recorded between January 1st, 2009 and December 31st, 2014. We split our study cohort at the center level to create a derivation cohort and a validation cohort. We developed a multivariate logistic model including patient's age, sex, entrance mode and diagnosis as predictors of a composite primary outcome of in-hospital death or ICU admission. A total of 2,747 (4.2%) patients died or were admitted to ICU. The risk of death or ICU admission was mainly associated with the consumption of opioids, followed by cocaine and other narcotics. Particularly, methadone poisoning was associated with a substantial risk (OR: 35.70, 95% CI [26.94-47.32], P < 0.001). In the validation cohort, our model achieved good predictive properties in terms of calibration and discrimination (c-statistic: 0.847). This allows an accurate identification of life-threatening admissions in drug users to support an early and appropriate management.