Days Spent at Home and Mortality After Critical Illness: A Cluster Analysis Using Nationwide Data.

BACKGROUND: Beyond the question of short-term survival, days spent at home could be considered a patient-centered outcome in critical care trials. RESEARCH QUESTION: What are the days spent at home and health care trajectories during the year after surviving critical illness? STUDY DESIGN AND METHODS: Data were extracted on adult survivors spending at least 2 nights in a French ICU during 2018 who were treated with invasive mechanical ventilation or vasopressors or inotropes. Trauma, burn, organ transplant, stroke, and neurosurgical patients were excluded. Stays at home, death, and hospitalizations were reported before and after ICU stay, using state sequence analysis. An unsupervised clustering method was performed to identify cohorts based on post-ICU trajectories. RESULTS: Of 77,132 ICU survivors, 89% returned home. In the year after discharge, these patients spent a median of 330 (interquartile range [IQR], 283-349) days at home. At 1 year, 77% of patients were still at home and 17% had died. Fifty-one percent had been re-hospitalized, and 10% required a further ICU admission. Forty-eight percent used rehabilitation facilities, and 5.7%, hospital at home. Three clusters of patients with distinct post-ICU trajectories were identified. Patients in cluster 1 (68% of total) survived and spent most of the year at home (338 [323-354] days). Patients in cluster 2 (18%) had more complex trajectories, but most could return home (91%), spending 242 (174-277) days at home. Patients in cluster 3 (14%) died, with only 37% returning home for 45 (15-90) days. INTERPRETATION: Many patients had complex health care trajectories after surviving critical illness. Wide variations in the ability to return home after ICU discharge were observed between clusters, which represents an important patient-centered outcome.

Underuse of primary healthcare in France during the COVID-19 epidemic in 2020 according to individual characteristics: a national observational study.

BACKGROUND: The organization of healthcare systems changed significantly during the COVID-19 pandemic. The impact on the use of primary care during various key periods in 2020 has been little studied. METHODS: Using individual data from the national health database, we compared the numbers of people with at least one consultation, deaths, the total number of consultations for the population of mainland France (64.3 million) and the mean number of consultations per person (differentiating between teleconsultations and consultations in person) between 2019 and 2020. We performed analyses by week, by lockdown period (March 17 to May 10, and October 30 to December 14 [less strict]), and for the entire year. Analyses were stratified for age, sex, deprivation index, epidemic level, and disease. RESULTS: During the first lockdown, 26% of the population consulted a general practitioner (GP) at least once (-34% relative to 2019), 7.4% consulted a nurse (-28%), 1.6% a physiotherapist (-80%), and 5% a dentist (-95%). For specialists, consultations were down 82% for ophthalmologists and 37% for psychiatrists. The deficit was smaller for specialties making significant use of teleconsultations. During the second lockdown, the number of consultations was close to that in 2019, except for GPs (-7%), pediatricians (-8%), and nurses (+ 39%). Nurses had already seen a smaller increase in weekly consultations during the summer, following their authorization to perform COVID-19 screening tests. The decrease in the annual number of consultations was largest for dentists (-17%), physiotherapists (-14%), and many specialists (approximately 10%). The mean number of consultations per person was slightly lower for the various specialties, particularly for nurses (15.1 vs. 18.6). The decrease in the number of consultations was largest for children and adolescents (GPs: -10%, dentists: -13%). A smaller decrease was observed for patients with chronic diseases and with increasing age. There were 9% excess deaths, mostly in individuals over 60 years of age. CONCLUSIONS: There was a marked decrease in primary care consultations in France, especially during the first lockdown, despite strong teleconsultation activity, with differences according to age and healthcare profession. The impact of this decrease in care on morbidity and mortality merits further investigation.

Association of Age With Short-term and Long-term Mortality Among Patients Discharged From Intensive Care Units in France.

Importance: An aging population is increasing the need for intensive care unit (ICU) beds. The benefit of ICU admission for elderly patients remains a subject of debate; however, long-term outcomes across all adult age strata are unknown. Objective: To describe short-term and long-term mortality (up to 3 years after discharge) across age strata in adult patients admitted to French ICUs. Design, Setting, and Participants: Using data extracted from the French national health system database, this cohort study determined in-hospital mortality and mortality at 3 months and 3 years after discharge of adult patients (older than 18 years) admitted to French ICUs from January 1 to December 31, 2013, focusing on age strata. The dates of analysis were November 2017 to December 2018. Exposure: Intensive care unit admission. Main Outcomes and Measures: In-hospital mortality and mortality at 3 months and 3 years after hospital discharge. Results: The study included 133 966 patients (median age, 65 years [interquartile range, 53-76 years); 59.9% male). Total in-hospital mortality was 19.0%, and 3-year mortality was 39.7%. For the 108 539 patients discharged alive from the hospital, 6.8% died by 3 months, and 25.8% died by 3 years after hospital discharge. After adjustment for sex, comorbidities, reason for hospitalization, and organ support (invasive ventilation, noninvasive ventilation, vasopressors, inotropes, fluid resuscitation, blood products administration, cardiopulmonary resuscitation, renal replacement therapy, and mechanical circulatory support), risk of mortality increased progressively across all age strata but with a sharp increase in those 80 years and older. In-hospital and 3-year postdischarge mortality rates, respectively, were 30.5% and 44.9% in patients 80 years and older compared with 16.5% and 22.5% in those younger than 80 years. Total 3-year mortality was 61.4% among patients 80 years and older vs 35.1% in those younger than 80. After age and sex standardization, excess mortality was highest among young patients during their first year after hospital discharge and persisted into the second and third years. In contrast, the mortality risk was close to the general population risk among elderly patients (≥80 years). Age and reason for hospitalization were strongly associated with long-term mortality (9-, 13-, and 20-fold increase in the risk of death 3 years after ICU discharge in patients aged 80-84, 85-89, and ≥90 years, respectively, compared with patients aged <35 years), while organ support use during ICU showed a weaker association (all organ support had 1.3-fold or lower increase in the risk of death). Conclusions and Relevance: Results of this study suggest that aging was associated with an increased risk of mortality in the 3 years after hospital discharge that included an ICU admission, with a sharp increase in those 80 years and older. However, compared with the general population matched by age and sex, excess long-term mortality was high in young surviving patients but not in elderly patients.

Health status and drug use 1 year before and 1 year after skilled nursing home admission during the first quarter of 2013 in France: a study based on the French National Health Insurance Information System.

PURPOSE: Changes in prescribing practices following skilled nursing home (SNH) admission have not been clearly described in France. The study aimed to evaluate health status and drug use 1 year before and 1 year after admission to SNH. METHOD: People ≥ 65 years old admitted to SNH in the first quarter of 2013, covered by the national health insurance general scheme (69% of the population of this age) and still alive 1 year after admission were identified in a specific database (Resid-ehpad). Linking with the National Health Insurance Information System (SNIIRAM) allowed analysis of their health status, identified by algorithms, and changes in their use of reimbursed drugs. RESULTS: In a population of 11,687 residents (mean age: 86 years, women: 76%), the most prevalent diseases were cardiovascular/neurovascular diseases (45%) and dementias (35%). The use of certain chronic treatments (≥ 3 reimbursements/year) increased significantly (p < 0.001) after nursing home admission: antidepressants: 34 to 46%, anxiolytics: 32 to 42%, hypnotics/sedatives: 18 to 24%, antipsychotics: 10 to 21% (14 to 30% in patients with dementia). The use of lipid-modifying agents and agents acting on the renin-angiotensin system decreased significantly (33 to 24% and 44 to 37%, respectively, p < 0.001). The use of antibacterials (≥ 1 reimbursement/year) increased also significantly (p < 0.001): 45 to 61%, including quinolones (13 to 20%) and third-generation cephalosporins (10 to 18%). CONCLUSION: These results reveal increased prescribing of psychotropic drugs and antibacterials in SNH, requiring the development or sustainability of actions designed to improve prescribing practices in older people targeted by these treatments.

Professional Cleaning Activities and Lung Cancer Risk Among Women: Results From the ICARE Study.

OBJECTIVES: Lung cancer risk associated with occupational cleaning activities has been investigated in the population-based case-control study ICARE. METHODS: Occupational history was collected by standardized interviews. Jobs were first defined according to the International Standard Classification of Occupations (ISCO) codes and then categorized according to activity sectors. Adjusted odds ratios (ORs) were estimated by unconditional logistic regression, separately for women (619 cases and 760 controls) and men (2265 and 2780). RESULTS: Thirty percent of women and 2.3% of men controls ever held a cleaner or care job. Women who worked as housemaids longer than 7 years showed an OR of 1.76 [95% confidence interval (95% CI) 1.09 to 2.87] with respect to controls. Women employed in domestic service sector for a long time had an OR of 2.06 (95% CI 1.15 to 3.66). CONCLUSION: We confirmed and redefined the association of lung cancer with occupational cleaning, which concerns a considerable proportion of women workers.