Impact of Public Policy and COVID-19 Pandemic on Hepatitis C Testing and Treatment in France, 2014-2021.

Given the World Health Organization's target to eliminate the hepatitis C virus (HCV) by 2030, we assessed the impact of French public policies and the COVID-19 pandemic on HCV testing and initiation of direct-antiviral agents (DAAs). Using the French National Health Data System, we identified individuals living in metropolitan France with at least one reimbursement for an anti-HCV test and those with a first delivery of DAAs between 1 January 2014 and 31 December 2021. During this period, the annual number of people tested increased each year between 3.3 (in 2015) and 9.3% (in 2021), except in 2020, with a drop of 8.3%, particularly marked in April (-55.0% compared to February 2020). A return to pre-pandemic testing levels was observed in 2021. The quarterly number of patients initiating DAAs presented an upward trend from Q1-2014 until mid-2017, with greater increases in Q1-2015, and Q1- and Q2-2017, concomitant with DAA access policies and availability of new therapies. Then, quarterly numbers decreased. A 65.5% drop occurred in April compared to February 2020. The declining DAA initiations since mid-2017, despite new measures improving access and screening efforts, could be due to the shrinking pool of patients requiring treatment and a need to increase awareness among undiagnosed infected people. Further action is needed to eliminate HCV in France.

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.

Varying gestational age patterns in cesarean delivery: an international comparison.

BACKGROUND: While international variations in overall cesarean delivery rates are well documented, less information is available for clinical sub-groups. Cesarean data presented by subgroups can be used to evaluate uptake of cesarean reduction policies or to monitor delivery practices for high and low risk pregnancies based on new scientific evidence. We studied differences and patterns in cesarean delivery rates by multiplicity and gestational age in Europe and the United States. METHODS: This study used routine aggregate data from 17 European countries and the United States on the number of singleton and multiple live births with cesarean versus vaginal delivery by week of gestation in 2008. Overall and gestation-specific cesarean delivery rates were analyzed. We computed rate differences to compare mode of delivery (cesarean vs vaginal birth) between selected gestational age groups and studied associations between rates in these subgroups namely: very preterm (26-31 weeks GA), moderate preterm (32-36 weeks GA), near term (37-38 weeks GA), term (39-41 weeks GA) and post-term (42+ weeks GA) births, using Spearman's rank tests. RESULTS: High variations in cesarean rates for singletons and multiples were observed everywhere. Rates for singletons varied from 15% in The Netherlands and Slovenia, to over 30% in the US and Germany. In singletons, rates were highest for very preterm births and declined to a nadir at 40 weeks of gestation, ranging from 8.0% in Sweden and Norway, to 22.5% in the US. These patterns differed across countries; the average rate difference between very preterm and term births was 43 percentage points, but ranged from 14% to 61%. High variations in rate differences were also observed for near term versus term births. For multiples, rates declined by gestational age in some countries, whereas in others rates were similar across all weeks of gestation. Countries' overall cesarean rates were highly correlated with gestation-specific subgroup rates, except for very preterm births. CONCLUSIONS: Gestational age patterns in cesarean delivery were heterogeneous across countries; these differences highlight areas where consensus on best practices is lacking and could be used in developing strategies to reduce cesareans.

Where does distance matter? Distance to the closest maternity unit and risk of foetal and neonatal mortality in France.

BACKGROUND: The number of maternity units has declined in France, raising concerns about the possible impact of increasing travel distances on perinatal health outcomes. We investigated impact of distance to closest maternity unit on perinatal mortality. METHODS: Data from the French National Vital Statistics Registry were used to construct foetal and neonatal mortality rates over 2001-08 by distance from mother's municipality of residence and the closest municipality with a maternity unit. Data from French neonatal mortality certificates were used to compute neonatal death rates after out-of-hospital birth. Relative risks by distance were estimated, adjusting for individual and municipal-level characteristics. RESULTS: Seven percent of births occurred to women residing at ≥30 km from a maternity unit and 1% at ≥45 km. Foetal and neonatal mortality rates were highest for women living at <5 km from a maternity unit. For foetal mortality, rates increased at ≥45 km compared with 5-45 km. In adjusted models, long distance to a maternity unit had no impact on overall mortality but women living closer to a maternity unit had a higher risk of neonatal mortality. Neonatal deaths associated with out-of-hospital birth were rare but more frequent at longer distances. At the municipal-level, higher percentages of unemployment and foreign-born residents were associated with increased mortality. CONCLUSION: Overall mortality was not associated with living far from a maternity unit. Mortality was elevated in municipalities with social risk factors and located closest to a maternity unit, reflecting the location of maternity units in deprived areas with risk factors for poor outcome.

Choice in maternity care: associations with unit supply, geographic accessibility and user characteristics.

BACKGROUND: Despite national policies to promote user choice for health services in many European countries, current trends in maternity unit closures create a context in which user choice may be reduced, not expanded. Little attention has been paid to the potential impact of closures on pregnant women's choice of maternity unit. We study here how pregnant women's choices interact with the distance they must travel to give birth, individual socioeconomic characteristics and the supply of maternity units in France in 2003. RESULTS: Overall, about one-third of women chose their maternity units based on proximity. This proportion increased steeply as supply was constrained. Greater distances between the first and second closest maternity unit were strongly associated with increasing preferences for proximity; when these distances were ≥ 30 km, over 85% of women selected the closest unit (revealed preference) and over 70% reported that proximity was the reason for their choice (expressed preference). Women living at a short distance to the closest maternity unit appeared to be more sensitive to increases in distance between their first and second closest available maternity units. The preference for proximity, expressed and revealed, was related to demographic and social characteristics: women from households in the manual worker class chose a maternity unit based on its proximity more often and also went to the nearest unit when compared with women from professional and managerial households. These sociodemographic associations held true after adjusting for supply factors, maternal age and socioeconomic status. CONCLUSIONS: Choice seems to be arbitrated in both absolute and relative terms. Taking changes in supply into consideration and how these affect choice is an important element for assessing the real impact of maternity unit closures on pregnant women's experiences. An indicator measuring the proportion of women for whom the distance between the first and second maternity unit is greater than 30 km can provide a simple measure of choice to complement indicators of geographic accessibility in evaluations of the impact of maternity unit closures.

Failure of the vaccination campaign against A(H1N1) influenza in pregnant women in France: results from a national survey.

BACKGROUND AND OBJECTIVE: Pregnant women were a priority group for vaccination during the 2009 A(H1N1) influenza pandemic. In France, vaccination was organized in ad hoc centers. Women received vouchers by mail and were given a non-adjuvanted vaccine. Our objective was to assess the national vaccination rate among pregnant women and to determine the association of vaccination with maternal characteristics, prenatal care, and pregnancy-related health behaviors. METHOD: Data came from a national representative sample of women who gave birth in March 2010 (N=13 453) and were interviewed in the hospital before discharge; they were in the second trimester of pregnancy during the vaccination campaign. Associations between vaccination and socio-demographic and medical characteristics, region of residence, care providers, and preventive behaviors were assessed with bivariable analyses and logistic regression models. RESULTS: Vaccine coverage was 29.3% (95% CI: 28.6-30.1). The main reason for not being vaccinated was that women did not want this immunization (91%). In adjusted analyses, vaccination was more frequent in women who were older, employed, born in France, with a parity of 1 or 2 and specific favourable health behaviors. The adjusted odds ratio for women with a postgraduate educational level was 4.1 (95% CI: 3.5-4.8) compared to those who did not complete high school. Women with additional risk factors for complications from A(H1N1) infection had a vaccination rate similar to that of other women. CONCLUSION: The vaccination campaign resulted in poor vaccination coverage, strong social inequalities, and no special protection for pregnant women at the highest risk of complications. These findings provide essential information for the organization of future vaccination campaigns.

Obstetric interventions for low-risk pregnant women in France: do maternity unit characteristics make a difference?

BACKGROUND: In many countries the closure of small maternity units has raised concerns about how the concentration of low-risk pregnancies in large specialized units might affect the management of childbirth. We aimed to assess the role of maternity unit characteristics on obstetric intervention rates among low-risk women in France. METHODS: Data on low-risk deliveries came from the 2010 French National Perinatal Survey of a representative sample of births (n = 9,530). The maternity unit characteristics studied were size, level of care, and private or public status; the interventions included induction of labor; cesarean section; operative vaginal delivery (forceps, spatulas or vacuum); and episiotomy. Multilevel logistic regression analyses were adjusted for maternal confounding factors, gestational age, and infant birthweight. RESULTS: The rates of induction, cesarean section, operative delivery, and episiotomy in this low-risk population were 23.9 percent, 10.1 percent, 15.2 percent, and 19.6 percent, respectively, and 52.0 percent of deliveries included at least one of them. Unit size was unrelated to any intervention except operative delivery (adjusted odds ratio [aOR] = 1.47 (95% CI, 1.10-1.96) for units with >3,000 deliveries per year vs units with <1,000). The rate of every intervention was higher in private units, and the aOR for any intervention was 1.82 (95% CI, 1.59-2.08). After adjustment for maternal characteristics and facility size and status, significant variations in the use of interventions remained between units, especially for episiotomies. Results for level of care were similar to those for unit size. CONCLUSIONS: The concentration of births in large maternity units in France is not associated with higher rates of interventions for low-risk births. The situation in private units could be explained by differences in the organization of care. Additional research should explore the differences in practices between maternity units with similar characteristics.

Out-of-hospital births and the supply of maternity units in France.

Maternity unit closures in France have increased distances that women travel to deliver in hospital. We studied how the supply of maternity units influences the rate of out-of-hospital births using birth certificate data. In 2005-6, 4.3 per 1000 births were out-of-hospital. Rates were more than double for women living 30km or more from their nearest unit and were even higher for women of high parity. These associations persisted in multilevel analyses adjusting for other maternal characteristics. Long distances to maternity units should be a concern to health planners because of the maternal and infant health risks.

Fracture risk prediction using BMD and clinical risk factors in early postmenopausal women: sensitivity of the WHO FRAX tool.

The aim of this prospective study was (1) to identify significant and independent clinical risk factors (CRFs) for major osteoporotic (OP) fracture among peri- and early postmenopausal women, (2) to assess, in this population, the discriminatory capacity of FRAX and bone mineral density (BMD) for the identification of women at high risk of fracture, and (3) to assess whether adding risk factors to either FRAX or BMD would improve discriminatory capacity. The study population included 2651 peri- and early postmenopausal women [mean age (+/- SD): 54 +/- 4 years] with a mean follow-up period of 13.4 years (+/-1.4 years). At baseline, a large set of CRFs was recorded, and vertebral BMD was measured (Lunar, DPX) in all women. Femoral neck BMD also was measured in 1399 women in addition to spine BMD. Women with current or past OP treatment for more than 3 months at baseline (n = 454) were excluded from the analyses. Over the follow-up period, 415 women sustained a first low-energy fracture, including 145 major OP fractures (108 wrist, 44 spine, 20 proximal humerus, and 13 hip). In Cox multivariate regression models, only 3 CRFs were significant predictors of a major OP fracture independent of BMD and age: a personal history of fracture, three or more pregnancies, and current postmenopausal hormone therapy. In the subsample of women who had a hip BMD measurement and who were not receiving OP therapy (including hormone-replacement therapy) at baseline, mean FRAX value was 3.8% (+/-2.4%). The overall discriminative value for fracture, as measured by the area under the Receiver Operating Characteristic (ROC) curve (AUC), was equal to 0.63 [95% confidence interval (CI) 0.56-0.69] and 0.66 (95% CI 0.60-0.73), respectively, for FRAX and hip BMD. Sensitivity of both tools was low (ie, around 50% for 30% of the women classified as the highest risk). Adding parity to the predictive model including FRAX or using a simple risk score based on the best predictive model in our population did not significantly improve the discriminatory capacity over BMD alone. Only a limited number of clinical risk factors were found associated with the risk of major OP fracture in peri- and early postmenopausal women. In this population, the FRAX tool, like other risk scores combining CRFs to either BMD or FRAX, had a poor sensitivity for fracture prediction and did not significantly improve the discriminatory value of hip BMD alone.