What is the care pathway of patients who undergo thyroid surgery in France and its potential pitfalls? A national cohort.

CONTEXT: The rate of thyroid cancer is increasing in France, as well as concerns about overdiagnosis and treatment. OBJECTIVES: To examine the care pathway of patients who undergo thyroid surgery in France and detect potential pitfalls. DESIGN: A large observational study based on medical reimbursements, 2009-2011. SETTING: Data from the Sniiram (National Health Insurance Information System). PATIENTS: Patients with thyroid surgery in 2010, classified into 4 groups: thyroid cancer, benign nodule, goitre or multiple nodules, other (hyperthyroidism, head-neck cancer). MAIN OUTCOME MEASURES: Medical investigations during, prior and after thyroidectomy. RESULTS: A total of 35 367 patients underwent surgery (mean age 51 years, 80% women): 17% had a reported diagnosis of thyroid cancer, 20% benign nodule, 38% goitre or multiple nodules and 25% another diagnosis. The ratio of thyroidectomies with cancer over thyroidectomies with benign nodule was 0.8 and varied across regions. In the year preceding surgery, 82% of patients had an investigation by thyroid ultrasonography, 21% thyroid scintigraphy, 34% fine-needle aspiration cytology, 40% serum calcitonin assay and 54% serum calcium assay. In the following year, all patients with total thyroidectomy and 44% of patients with partial thyroidectomy and a diagnosis of benign nodule were taking thyroid hormone therapy. 100 patients had been reoperated for a compressive haematoma and 63 died during the first month, half of whom had been operated for cancer. Mean rates of recurrent laryngeal nerve injury and hypocalcaemia (requiring blood tests plus treatments within 4-12 months) were estimated at 1.5% and 3.4%, respectively, and were higher in the cancer group (2.3% and 5.7%). CONCLUSIONS: This almost nationwide study demonstrates the suboptimal management of patients prior to thyroidectomy in France. It suggests overdiagnosis and potential harms to patients, and calls for a review of the relevance of thyroidectomy, particularly with regard to microcancers.

Improving stroke care: a French health-care organiser's perspective.

The French national action plan: 'Stroke 2010-2014' results from years of increasing concern related to stroke, initially carried by stoke physicians and progressively shared by all other health professionals and more recently by administration and politicians. Its aim is the development not only of stroke care networks, but also of prevention and health education. Its success will mainly depend on the reactivity of the regional health agencies; therefore it is important to maintain political momentum and pressure.

Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding?

BACKGROUND AND AIMS: The position of capsule endoscopy (CE) relative to push enteroscopy (PE) in the diagnostic algorithm of obscure gastrointestinal bleeding is unclear, as previous studies involved the use of both techniques in all patients. We therefore conducted a trial in which patients were randomized to undergo one or other exploration. METHODS: All consecutive patients referred for obscure gastrointestinal bleeding were randomized between CE and PE as the first-line exploration. The alternative method was only used if the first-line method revealed no definite bleeding source, or if required for clinical reasons during follow-up. RESULTS: CE and PE, used as the first-line exploration, identified a bleeding source in 20 of 40 patients and 9 of 38 patients, respectively (50% vs 24%; P = .02). CE missed lesions in 8% of patients, and all these lesions were located in sites accessible to standard endoscopy. PE missed lesions in 26% of patients. At the end of the 12-month follow-up period, the strategy based on CE as first-line exploration followed by PE if necessary only was similar to PE followed by CE in terms of diagnostic yield, clinical outcome, and therapeutic impact, but reduced the percentage of patients needing the alternative exploration (25% vs 79%; P < .001). CONCLUSIONS: CE has a higher diagnostic yield than PE in obscure gastrointestinal bleeding, and a strategy based on CE as first-line exploration avoids unnecessary explorations.

[The TELIF network of Paris-area public hospitals (AP-HP)]. / Le réseau TELIF à l'Assistance Publique--Hôpitaux de Paris.

After a feasibility study, the TELIF network (neurosurgical emergencies in the Paris region) was created in November 1994. The goal was to reduce the number of patient transfers among the different hospitals, by teletransmission of computed tomography images between computers located in the emergency departments of general hospitals and the neurosurgery department. The initial goal has been reached, with a 70 % reduction in the number of patient transfers. The network is also being used with success for teleinterpretation of standard radiographs in gerontology. Today the network's technology is obsolete, and it will now be integrated into the new medical record system, using web-based technology for secure and confidential teletransmission.

Impact of CEDIT recommendations: An example of health technology assessment in a hospital network.

OBJECTIVES: The objective of this study is to assess the impact of CEDIT (French Committee for the Assessment and Dissemination of Technological Innovations) recommendations on the introduction of technological innovations within the AP-HP (Assistance Publique-Hôpitaux de Paris), the French hospital network to which this body is attached. METHODS: In 2002, a study based on semidirective interviews of fourteen people affected by these recommendations and a case study relating to thirteen recommendations issued between 1995 and 1998 were conducted. RESULTS: The CEDIT is very scientifically reputable among interviewees. There is generally widespread interest for the recommendations. They are used as decision-making tools by administrative staff and as negotiating instruments by doctors in their dealings with management. Based on the case study, ten of thirteen recommendations had an impact on the introduction of the technology in health establishments. One recommendation appears not to have had an impact. Furthermore, the impact of two technologies was impossible to assess. CONCLUSIONS: This study highlights the significant impact of recommendations arising from a structure that is attached to a hospital network and the good match between CEDIT's objectives and its assignments.