The effect of direct admission to acute geriatric units compared to admission after an emergency department visit on length of stay, postacute care transfers and ED return visits.

BACKGROUND: Compared with conventional hospitalization, admission to an acute geriatric care unit (AGU) is associated with better outcomes in elderly patients. In 2012, 50% of the hospitalizations of elderly patients were preceded by an emergency department (ED) visit. Hospital occupancy, access blocks and overcrowding experienced by patients during ED visits are associated with increased morbidity. OBJECTIVE: Our aim was to evaluate the effect of direct admission (DA) to an AGU on both the hospital length of stay and morbidity of elderly patients. DESIGN: This study was a retrospective cohort study conducted using electronic medical records and administrative claims data from the Greater Paris University Hospitals (APHP) health data warehouse involving 19 different AGUs. PARTICIPANTS: We included all patients ≥ 75 years old who were admitted to an AGU for more than 24 h between January 1, 2013, and December 31, 2018. INTERVENTION: Direct admission to the AGU compared to admission after an ED visit. MAIN MEASURES: The main outcome was hospital length of stay. Two outcomes were used to analyse morbidity: postacute care and rehabilitation ward transfer at the end of the index hospitalization and ED return visit within 30 days after the index hospitalization (for those who survived to hospitalization). We used an inverse probability of treatment weighting (IPTW) approach to balance the differences in patient baseline variables between the two groups. Univariate linear and logistic regression models were built to estimate the effect of DA on hospital length of stay and the likelihood of postacute care transfer and ED return visit. KEY RESULTS: Among the 6583 patients included in the study, DA was associated with a lower hospital length of stay (estimate = -1.28; 95% CI = -1.76-0.80), and a lower likelihood of postacute care transfer (OR = 0.87; 95% CI = 0.77-0.97). It was not significantly associated with a lower risk of ED return visits (OR = 0.81; 95% CI = 0.60-1.08) in the following month. CONCLUSION: DA should be prioritized, and reorganization of the geriatric pathway around DA should be encouraged due to the frailty of elderly individuals.

The economic burden of infertility treatment and distribution of expenditures overtime in France: a self-controlled pre-post study.

BACKGROUND: Recent cost studies related to infertility treatment have focused on assisted reproductive technologies. None has examined lower-intensity infertility treatments or analyzed the distribution of infertility treatment expenditures over time. The Purpose of the study was to analyse the size and distribution of infertility treatment expenditures over time, and estimate the economic burden of infertility treatment per 10,000 women aged 18 - 50 in France from a societal perspective. METHODS: We used French National individual medico-administrative database to conduct a self-controlled before-after analytic cohort analysis with 556 incidental women treated for infertility in 2014 matched with 9,903 controls using the exact matching method. Infertility-associated expenditures per woman and per 10,000 women over the 3.5-year follow-up period derived as a difference-in-differences. RESULTS: The average infertility related expenditure per woman is estimated at 6,996 (95% CI: 5,755-8,237) euros, the economic burden for 10,000 women at 70.0 million (IC95%: 57.6-82.4) euros. The infertility related expenditures increased from 235 (IC95%: 98-373) euros in semester 0, i.e. before treatment, to 1,509 (IC95%: 1,277-1,741) euros in semester 1, mainly due to ovulation stimulation treatment (47% of expenditure), to reach a plateau in semesters 2 (1,416 (IC95%: 1,161-1,670)) and 3 (1,319 (IC95%: 943-1,694)), where the share of expenses is mainly related to hospitalizations for assisted reproductive technologies (44% of expenditure), and then decrease until semester 6 (577 (IC95%: 316-839) euros). CONCLUSION: This study informs public policy about the economic burden of infertility estimated at 70.0 million (IC95%: 57.6-82.4) euros for 10,000 women aged between 18 and 50. It also highlights the importance of the share of drugs in infertility treatment expenditures. If nothing is done, the increasing use of infertility treatment will lead to increased expenditure. Prevention campaigns against the preventable causes of infertility should be promoted to limit the use of infertility treatments and related costs.

Cost-effectiveness analysis of medical management versus conservative surgery for early tubal pregnancy.

STUDY QUESTION: Is conservative surgery (laparoscopic salpingotomy) cost-effective, using fertility as the endpoint compared with medical management (Methotrexate) in women with an early tubal pregnancy? SUMMARY ANSWER: Conservative surgery appeared slightly, but not statistically significantly, more effective than medical management but also more costly. WHAT IS KNOWN ALREADY: Women with an early tubal pregnancy treated with medical therapy (Methotrexate) or conservative surgery (laparoscopic salpingotomy) have comparable future intrauterine pregnancy rates by natural conception. Also, cost-minimisation studies have shown that medical therapy was less expensive than conservative surgery, but there is no cost-effectiveness study comparing these two treatments with fertility as the endpoint. STUDY DESIGN, SIZE, DURATION: A multicentre randomised controlled trial-based (DEMETER study) cost-effectiveness analysis of conservative surgery compared with medical therapy in women with an early tubal pregnancy was performed. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Included women had an ultrasound that confirmed an early tubal pregnancy. They were randomly allocated to conservative surgery or to medical therapy. The study clinical outcome was the intrauterine pregnancy rate. The payer's perspective was considered. Costs of conservative surgery and medical therapy were compared. The analysis was performed according to the intention-to-treat principle. Missing variables were imputed using the fully conditional method. To characterise uncertainty and to provide a summary of it, a non-parametric bootstrap resampling was executed and cost-effectiveness accessibility curves were constructed. MAIN RESULTS AND THE ROLE OF CHANCE: At baseline, costs per woman in the conservative surgery group and in the medical therapy group were 2627€ and 2463€, respectively, with a statistically significant difference of +164€. Conservative surgery resulted in a marginally, but non-significant (P = 0.46), higher future intrauterine pregnancy rate compared to medical therapy (0.700 vs. 0.649); leading, after bootstrap, to an incremental cost-effectiveness ratio of 1299€ (95% CI = -29 252; +29 919). Acceptability curves showed that conservative surgery could be considered a cost-effective treatment at a threshold of 3201€ for one additional future intrauterine pregnancy. LIMITATIONS, REASONS FOR CAUTION: A limitation was that monetary valuation was carried out using 2016 euros while the DEMETER study took place from 2005 to 2009. Anyway, the results would not have been very different given the marginal changes in the health insurance reimbursement tariffs during this period. WIDER IMPLICATIONS OF THE FINDINGS: Conservative surgery can be considered a cost-effective treatment, if the additional cost of 3201€ per additional future intrauterine pregnancy is an acceptable financial effort for the payer. STUDY FUNDING/COMPETING INTEREST(S): None. TRIAL REGISTRATION NUMBER: NCT 00137982.

Primary care physicians' knowledge, attitudes, beliefs and practices regarding childhood obesity: a systematic review.

Obesity is an important public health issue with an epidemic spread in adolescents and children, which needs to be tackled. This systematic review of primary care physicians' knowledge, attitudes, beliefs and practices (KABP) regarding childhood obesity will help to implement or adjust the actions necessary to counteract obesity. Eligible studies were identified through a systematic database search for all available years to 2007. Articles were selected if they included data on primary care physicians' KABP regarding childhood obesity: 130 articles were assessed and eventually 11 articles covering the period 1987-2007 and responding to the inclusion criteria were analyzed. The included studies showed that almost all physicians agreed on the necessity to treat childhood obesity but they believed to have a low self-efficacy in the treatment and experienced a negative feeling regarding obesity management. There was a large heterogeneity in the assessment of childhood obesity between the different studies but the awareness of the importance of using body mass index increased over the years among physicians. Almost all studies noted that physicians recommended dietary advice, exercise or referral to a dietician. From this review, it is obvious that there is a need for education of primary care physicians to increase the uniformity of the assessment and to improve physicians' self-efficacy in managing childhood obesity. Multidisciplinary treatment including general practitioners, paediatricians and specialized dieticians appears to be the way to counteract the growing obesity epidemic and thus, primary care physicians have to initiate, coordinate and obviously participate in obesity prevention initiatives.

Economic arguments for the immediate management of moderate-to-severe obstructive sleep apnoea syndrome.

The objective of this study was to measure the impact of a 6-month delay in the diagnosis and treatment of patients with moderate obstructive sleep apnoea syndrome (OSAS) (apnoea/hypopnoea index (AHI) < 30) or severe OSAS (AHI > or = 30) on daytime sleepiness, cognitive functions, quality of life and healthcare expenditure (hospitalisations, medical visits, complementary tests, biological tests and drug prescriptions). In addition, this study aimed to analyse the incremental cost effectiveness ratios related to daytime sleepiness or quality of life following immediate introduction of treatment in these two populations. This study was conducted as a multicentre randomised controlled trial and carried out at two teaching hospitals in France. A total of 171 patients were followed for 6 months, with 82 patients randomised to group 1 "immediate polysomnography" and 89 in group 2 "polysomnography within 6 months". Patients with severe OSAS were deprived of a significant improvement of their daytime sleepiness (5.1 +/- 5.0 at the Epworth Sleepiness Scale score in group 1 versus 0.2 +/- 3.4 in group 2) and quality of life (12.4 +/- 13.3 at the Nottingham Health Profile score in group 1 versus 0.7 +/- 10.1 in group 2) during the waiting time. The impact of delayed management in subjects with less severe OSAS only concerned daytime sleepiness (1.1 +/- 3.3 in group 1 versus 0.3 +/- 4.3 in group 2). Delayed treatment did not affect cognitive functions or healthcare expenditure regardless of the severity of the disease. Incremental cost effectiveness ratios related to rapid introduction of treatment were significantly lower in the patients with more severe OSAS. These results provide fairly clear medical and economic arguments in favour of early management of patients with more severe forms of obstructive sleep apnoea syndrome.

Restructuring of the healthcare system and the diffusion of telemedicine.

This contribution focuses on the medical applications of new information and communication technologies (NICTs). We discuss the paradoxical nature of the spread of these technologies, related to the discrepancy between the promises held out by their use in a healthcare system searching for new mechanisms of coordination and their actual implementation, involving a series of experiments that to date have been short-lived. We then argue that solving this paradox requires understanding the complexity of the interaction process between NICTs and organisational changes. Thus while NICTs can facilitate the restructuring of provider networks, one of the principal challenges facing healthcare systems, they also reveal the tensions engendered by some new formal coordination mechanisms.

Equivalence versus pragmatic trials for the economic evaluation of information and communication technologies; the case of polysomnography under telesurveillance in the diagnosis of sleep apnea syndrome.

This article deals with the choice of the appropriate protocols for the early economic evaluation of information and communication technologies, equivalence trial versus pragmatic trial. The reasoning put forward here is based on a concrete interrogation relative to polysomnography (PSG), a key diagnostic test for sleep apnoea syndrome (SAS). Is PSG under tele-surveillance more efficient than ambulatory PSG to diagnose SAS? After analyzing and discussing both advantages and limits of these two kinds of trial, we showed that one or the other can be used to obtain appropriate results. But in this particular example, we concluded that a pragmatic trial should be preferred, knowing that it requires a smaller sample of patients along with a narrower range of uncertainty concerning the evaluation of costs.

The age and other factors in the evaluation of compliance with nasal continuous positive airway pressure for obstructive sleep apnea syndrome. A Cox's proportional hazard analysis.

Objective: To elucidate the predictive role of age and other pre-treatment, putative confounding factors on compliance with nasal continuous positive airway pressure (nCPAP) therapy.Patients and methods: This study was designed as a prospective cohort study in the setting of a sleep laboratory in a teaching hospital at Saint Antoine, Paris. One hundred and sixty-three patients referred to the sleep laboratory with complaints of snoring and excessive daytime sleepiness for whom nCPAP had been prescribed for obstructive sleep apnea syndrome (OSAS; defined as an apnea-hypopnea index (AHI) of >15/h of sleep during a polysomnographic recording) were followed for a median period of 887 days. The main outcome measure was the risk ratio for elderly patients associated with nCPAP compliance.Results: Four patients, who remained under treatment, died before the end of the study, and 50 patients stopped their nCPAP therapy for reasons other than death (insomnia, equipment too noisy, etc.). When compliance curves were compared by univariate analysis (log-rank test), the oldest group (57/163 patients, >60 years old) was significantly less compliant with nCPAP than the youngest (P=0.01). However, in the Cox's proportional hazards model, age did not exert any independent effect on compliance with nCPAP after controlling for confounding factors (adjusted relative risk, 1.09, 0.5-2; P=0.70). On the other hand, female sex (adjusted relative risk, 2.8, 1.4-5.4; P=0.002), a body mass index (BMI) of /=12 cmH(2)O (adjusted relative risk, 2.3, 1.2-4.4; P=0.011) were predictive factors for non-compliance.Conclusion: This study suggests that there is no independent effect of age on compliance with nCPAP therapy.

Predictive factors for the need for additional humidification during nasal continuous positive airway pressure therapy.

OBJECTIVE: To identify potential risk factors for the need for an additional cold or heated humidifier in nasal continuous positive airway pressure (nCPAP) circuitry. DESIGN: A prospective cohort study. SETTING: University hospital sleep-disorders center. PATIENTS: Eighty-two consecutive patients with obstructive sleep apnea syndrome were followed up for a median of 347 days (range, 3 to 530 days) after the initiation of nCPAP therapy. MEASUREMENTS AND RESULTS: In 46 patients (56%), the occurrence of upper-airway symptoms led to the addition of a cold humidifier after a median time of 39 days (range, 2 to 94 days). In 23 of the 46 patients, the persistence of the symptoms indicated the secondary use of a heated humidifier after a median time of 28 days (range, 5 to 70 days). nCPAP use (mean +/- SD) was not influenced by cold humidification (4.58 +/- 2.05 h/d vs 4.7 +/- 2.48 h/d; p = 0.75), but it increased significantly with heated humidification (5.38 +/- 2.26 h/d vs 3.51 +/- 2.53 h/d; p < 0.01). Anthropometric characteristics, drying medications, clinical findings such as deformity of the nasal septum, symptoms of a chronic mucosa disease (CMD), a previous uvulopalatopharyngoplasty (UPPP), and polysomnographic parameters had no significant effect on the need for a cold humidifier. Age > 60 years (odds ratio [OR], 5.58; 95% confidence interval [CI], 1.69 to 18.43), drying medications (OR, 6.59; 95% CI, 1.29 to 33.51), presence of CMD (OR, 4.11; 95% CI, 1.24 to 13.58), and previous UPPP (OR, 4.56; 95% CI, 1.18 to 17.6) were found as significant risk factors for the addition of a heated humidifier. CONCLUSION: Our results demonstrate that heated humidification significantly improves the nCPAP daily rate of use and that its need may be predicted.

A cost-minimization study of telemedicine. The case of telemonitored polysomnography to diagnose obstructive sleep apnea syndrome.

OBJECTIVES: In a context where sleep laboratories are overwhelmed by a growing demand to diagnose obstructive sleep apnea syndrome (OSAS), efficient substitutive solutions to in-laboratory polysomnography should be found. To compare the effectiveness and costs of home unattended polysomnography (Hpsg) and telemonitored polysomnography (TMpsg), a cost minimization study was performed. METHODS: In a crossover trial, 99 patients underwent on two consecutive nights TMpsg and Hpsg according to a randomized order. A legibility recording criterion was retained to measure effectiveness. A microcosting study of TMpsg and Hpsg was performed. The risks to adopt home strategy or telemonitored strategy, according to different scenario chosen to reach the diagnosis in case of failure of Hpsg or TMpsg, were analyzed. RESULTS: The recording was considered to be ineffective in 11.2% of TMpsg (95% CI, 4.9-17.4) and in 23.4% (95% CI, 19.12-27.68) of Hpsg. The effectiveness differential was 12.2% (95% CI, 1.8-22.6) (p = .02). Assuming that in case of failure PSGs would be re-realized in the same condition to reach the diagnosis, then TMpsg could be selected if Hc/TMc (cost of Hpsg/cost of TMpsg) > 0.97; Hpsg could be selected if Hc/TMc < 0.76. If 0.76 < or = Hc/TMc < or = 0.97, the choice of TMpsg would be ambiguous. TMc was estimated to be $244, while Hc was $153 (Hc/TMc = 0.63). CONCLUSION: Unless some specific geographical situations generate significant transport costs, the implementation of a strategy based on unattended polysomnography at home is cost-saving compared to a telemonitoring strategy.

Economic studies and 'technical' evaluation of telemedicine: the case of telemonitored polysomnography.

Information and communication technology (ICT) is not yet integrated into current medical practice and frequently, organizational patterns of health care production are held responsible for this situation. However, and quite paradoxically, measures recently taken in France indicate that a preferential role is granted to ICT in order to promote the development of healthcare networks. In this context, one should carefully examine which factors, other than organizational ones, can explain the very slow diffusion of telemedicine. Actually, medical assessment of telemedicine is very seldom and the medical community is unable to appreciate the extent that this technology would modify the quality of care provided. Furthermore, and as a consequence of the former, there is no economic evaluation of telemedicine applications and its effects, in terms of productivity, remain virtual. In this article, based on an early evaluation of telemonitored polysomnography to diagnose sleep apnea syndrome, we show that it is possible, even at an experimental stage, to produce appropriate and convincing clinical results stating the true technological effectiveness (choice of an adequate clinical trial, selection of appropriate endpoints). Specific attention is given to the technical conditions in which the technology is assessed, we also provide most of the data that should be taken into account to foresee the major organizational transformations of the production processes. Our results show that early clinical ad hoc evaluations of telemedicine applications can be conducted promptly, providing strong clinical results and useful data for any forthcoming economic evaluation.

Transaction costs economics as a conceptual framework for the analysis of barriers to the diffusion of telemedicine.

Telemedecine has been talked about for more than 20 years, without it entering daily use with any success. Based on transaction costs economics, the present analysis of the exchange relationships between health care producers highlights certain characteristics of the current technical and legislative context, which leads to transaction costs. It also demonstrates that the introduction of telemedicine shifts the costs associated with agents' opportunism from patients to health-care producers themselves. All these costs may be considered nowadays to thwart the use of telemedicine. It is argued here that the Public Authorities and professionals of health care could act upon telemedicine in two fields: (1) intervention in the institutional environment aims notably at better defining the property rights of telemedicine, and so constitutes an unavoidable means of encouraging health-care producers to invest in new technology; and (2) implementation of organisational forms and mechanisms susceptible to regulating such telemedical relationships between health care producers-given the present institutional environment-constitutes an essential means for overcoming the immediate barriers blocking the diffusion of telemedicine.

[Cost-effectiveness study of 2 long-term home oxygen therapy management systems]. / Etude coût-efficacité de deux structures de prise en charge de l'oxygéno-thérapie de longue durée à domicile.

In France, home oxygen therapy for patients with chronic obstructive pulmonary disease (COPD) is carried out by nonprofit associations (NP) or profit-making health organisations (PM). In a retrospective pragmatic approach we analysed the costs and the effectiveness of these 2 types of structures delivering oxygen at home. Between July 1985 and March 1994, 234 patients were involved in the survival study (chosen as an effectiveness indicator), 24% in PM and 76% in NP. The economic appraisal was performed, from the insurer's point of view, on a representative sample of 61 patients and analysed in detail all the ambulatory costs for respiratory care. Patient survival was similar in both types of structures (Cox model). Oxygen therapy represented the largest share of the total ambulatory cost (81.6% in PM and 72.1% in NP). The NP structures were less costly for reasons linked to their preference for concentrator (p = 0.004 in a Wilcoxon test), all the other direct costs being non-statistically different. NP structures had a significant influence on a low level of ambulatory costs (adjusted OR = 10.98, p = 0.0004) in logistic regression. As oxygen treatment plays an important role in the variation of costs, further pragmatic studies should help to better understand what are the real motivations to choose one mode of oxygen administration more than an other and should determine factors that may sometimes lead physicians not to comply with clinical guidelines (actually a quarter of the patients did not have a PaO2 < 60 mmHg).

The cost of treating COPD patients with long-term oxygen therapy in a French population.

OBJECTIVE: In greater Paris and its surrounding (as it is in all France), oxygen is home delivered by not-for-profit (NP) associations or profit-making (PM) health organizations. Both are financed by the national health insurance. This dual context and the current economic climate justify an economic evaluation of all respiratory care for patients with COPD receiving long-term oxygen therapy (LTO). This pragmatic approach identifies the variables that have the greatest impact on direct medical costs and estimates the annual cost for respiratory care per COPD patient. DESIGN: Retrospective study. SETTING: Health insurance scheme for self-employed professionals (CANAM). PATIENTS AND METHODS: Between July 1985 and March 1994, 234 patients registered in CANAM files began LTO, 24% in the PM sector, 76% in the NP sector, mainly using concentrator (78%), mean age of 74 +/- 10 years, male predominance (74%), PaO2 of 56.2 +/- 10.5 mm Hg, FEV1/FVC of 43 +/- 15%, and 51% having 1 or more severe illness(es) associated. The economic appraisal was performed on a representative sample of 61 patients and measured the total resources consumption for respiratory care per COPD patient and per year (physician visits and tests, drugs, physiotherapy, oxygen therapy, hospitalizations for acute respiratory failure, transport costs). RESULTS: A quarter of the patients in each sector did not meet the LTO prescription guidelines (PaO2 > 60 mm Hg). For patients having their oxygen delivered by NP sector, the total ambulatory cost for respiratory care was lower ($4,506 per patient and per year vs $5,399) because they mainly used concentrator, all the other direct ambulatory costs being equal. The total annual cost for respiratory care of a COPD patient receiving LTO amounted to $11,672 (NP and PM sectors merged). Oxygen therapy represented 73% of the total ambulatory cost. In a multiple linear regression model, hospitalization represented the largest share of cost, significantly higher when PaO2 was 55 mm Hg or less ($2,287 per patient per year vs $8,717). In contrast, none of the covariates (age, sex, PaO2, FEV1/FVC) influenced at a significant level the total cost of visits, tests, drugs, and physiotherapy, amounting to $1,507. CONCLUSION: As oxygen treatment plays an important role in the variation of costs, further pragmatic studies should help to better understand what are the real motivations to choose one mode of oxygen administration more than another and should determine factors that may lead physicians sometimes not to comply with clinical guidelines.