An economic evaluation of tranexamic acid to prevent postpartum haemorrhage in women with vaginal delivery: the randomised controlled TRAAP trial.

OBJECTIVE: To estimate the cost-effectiveness of tranexamic acid (TXA) use to prevent postpartum haemorrhage. DESIGN: A trial-based economic evaluation. SETTING: Fifteen French university maternity hospitals. POPULATION: Women enrolled in the TRAAP randomised controlled trial comparing TXA versus placebo in women with vaginal delivery. TRAAP failed to show a reduction in postpartum haemorrhage of at least 500 ml in the intervention arm but evidenced significant lower rates of secondary outcomes related to blood loss. METHODS & MAIN OUTCOME MEASURES: We estimated direct medical costs from within-trial hospital resources collected prospectively from the study report form. All resources were costed at their value to the hospital. We estimated incremental cost per incremental haemorrhage averted. RESULTS: Among the 4079 women in the TRAAP trial, data necessary to calculate costs were available for 3836 (94.0%). The average total costs in the TXA and control groups were €2278 ± 388 and €2288 ± 409 per woman, respectively (P = 0.79). In women with postpartum haemorrhage of at least 500 ml (trial primary endpoint), costs were €2359 ± 354 and €2409 ± 525 (P = 0.14); for provider-assessed clinically significant postpartum haemorrhage and postpartum haemorrhage of at least 1000 ml, costs were respectively €2316 ± 347 versus €2381 ± 521 (P = 0.22) and €2321 ± 318 versus €2411 ± 590 (P = 0.35) in the tranexamic and placebo groups, respectively. The probabilistic sensitivity analysis showed that the use of TXA had a 65-73% probability of saving costs and improving outcome. CONCLUSIONS: Our findings support the use of TXA, as both bleeding events and cost may be reduced three out of four times. TWEETABLE ABSTRACT: Tranexamic acid at vaginal delivery reduces both costs and bleeding events 3 times out of 4.

Hospitalization of HIV positive patients: Significant demand affecting all hospital sectors.

BACKGROUND: In a context of the evolution of severe morbidities in patients living with HIV (PLWH), the aim of this study was to describe reasons for hospitalization and the mode of care for the patients requiring hospitalization. METHODS: All admissions (≥24h) of PLWH to 10 hospitals in the south of Paris (COREVIH Ile-de-France Sud) between 1/1/2011 and 12/31/2011 were identified. The hospital database and the file of patients followed in the HIV referral department of each hospital were matched. Detailed clinical and biological data were collected, by returning to the individual medical records, for a random sample (65% of hospitalized patients). RESULTS: A total of 3013 hospitalizations (1489 patients) were recorded in 2011. The estimated rate of hospitalized patients was about 8% among the 10105 PLWH routinely managed in COREVIH Ile-de-France Sud in 2011. The majority (58.5%) of these hospitalizations occurred in a unit other than the HIV referral unit. Non-AIDS-defining infections were the main reason for admission (16.4%), followed by HIV-related diseases (15.6%), hepatic/gastrointestinal diseases (12.0%), and cardiovascular diseases (10.3%). The median length of stay was 5 days overall (IQR: 2-11), it was longer among patients admitted to a referral HIV care unit than to another ward. HIV infection had been diagnosed >10 years previously in 61.4% of these hospitalized patients. They often had associated comorbidities (coinfection HCV/HVB 40.5%, smoking 45.8%; hypertension 33.4%, dyslipidemia 28.8%, diabetes 14.8%). Subjects over 60 years old accounted for 15% of hospitalized patients, most of them were virologically controlled under HIV treatment, and cardiovascular diseases were their leading reason for admission. CONCLUSION: Needs for hospitalization among PLWH remain important, with a wide variety in causes of admission, involving all hospital departments. It is essential to prevent comorbidities to reduce these hospitalizations, and to maintain a link between the management of PLWH, that becomes rightly, increasing ambulatory, and recourse to specialized inpatient services.

Increasing ambulatory surgery potential by non-medicalized accommodation: matched comparison of the 2011 national hospital activity data to 66 local stays.

INTRODUCTION: Several policy and cultural factors still hinder the development of ambulatory surgery (AS) in France. Our surgery unit developed a day-surgery approach with extension of a non-medicalized post-operative stay in a hotel-like structure within the hospital, called an "ambulotel". The present study aims to evaluate the potential of this approach in increasing the possibilities of ambulatory surgery by comparing our stays to those of a nationwide database. PATIENTS AND METHODS: We matched 66 patients according to seven criteria in our one-day ambulotel program to the 2011 DRG national database and then compared their characteristics. RESULTS: Of the 10,428 patients in the database with one-night stays in a traditional surgery unit, more than half (52%) would probably have been eligible for ambulatory surgery with a potential theoretical savings estimated at €12,806,568. CONCLUSION: This estimated amount of savings represents a major medical and economic issue. The savings could contribute to increased ambulatory surgery activity in France by creating new dedicated Ambulatory Units, pooling conventional beds, or using night accommodation in non-hospital nursing homes, for example.

Generic drug prescriptions following hospital discharge: a prospective study in France.

AIMS: Systematic generic prescription at discharge could reduce confusion on drug-name usage, decrease commercial influence on medicine, and reduce drug-related expenditures. This study aimed to analyze generic drug prescriptions at discharge from hospital and to estimate the potential savings associated with a total substitution policy (substitution of every substitutable drug for its cheapest generic counterpart). METHODS: Drug prescriptions before admission and at discharge of all patients from three medical units of a university hospital were prospectively collected for five weeks without informing prescribers. RESULTS: Prescriptions from 85 patients were analyzed. On admission, 68 patients (80%) received 413 drugs; 141 were substitutable brand-name drugs and 23 (16%), which were directly prescribed as generics. At discharge, 488 drugs were prescribed to the 85 patients; 180 were substitutable drugs but only 5 (2.8%) were written as generics on prescription pads, a decrease of 78% (p<0.0001) compared to admission. In average, generics were 18% less expensive than brand-name drugs. Some common therapeutic classes offered even greater price difference, such as proton-pump inhibitors (42%), statins (32%), or antihypertensive agents (28%). Potential savings from a total substitution policy at discharge were estimated to €1512 per 1000 patients per week; for lifetime drugs, savings amounted to €18,960 per 1000 patients per year. CONCLUSIONS: Very few drugs are written as generics on medical forms at discharge in France. Hospital practitioners should be encouraged to prescribe generics, particularly in chronic diseases. A broad generic prescription policy at hospital discharge would result in substantial savings for health insurance.

[Cause of death in patients with cirrhosis]. / Causes de mortalité chez le cirrhotique.

PURPOSE: Since 1970, the rate of death from cirrhosis has decreased progressively, in part thanks to better handling of complications (preventive and curative treatment of gastric bleeding, prevention of infections and treatment of ascitis). The goal of this study was to examine the evolution in causes of death among cirrhotics. METHODS: We identified all of the patients who died among those cirrhotics hospitalized at the Alençon Hospital during the period covered by the study, from January 1, 1993 to December 31, 1998. We examined the age of death of these cirrhotics, their causes of death, and also studied and compared this data with causes of death cited in the literature of the 1980s. Finally, we examined the prevalence of each cause of death in relation to the age of death of each patient. RESULTS: Our results show that 347 cirrhotics were hospitalized at the Alençon Hospital during the period covered by the study, and 186 of these patients died. These deaths resulted from hepatocarcinoma in 22% of cases, gastric bleeding in 12% of cases, and liver cell failure at a terminal stage in 21% of cases. In 31% of cases, the cause was unrelated to cirrhosis, and in 13% of cases the cause was unknown. The death rate from hepatocarcinoma increased according to the patients' age, while the death rate from gastric bleeding decreased according to age. CONCLUSION: We have noted, in comparison with Saunders in 1981 that there was a significant increase in extrahepatic causes of death and a significant decrease in deaths from liver cell failure. Percentages of the other causes of death do not show any variation, in spite of new techniques of detection and treatment.

[Study with flow cytometry of the peritumoral mucosa adjacent to colorectal cancers]. / Etude en cytométrie en flux de la muqueuse péritumorale adjacente aux cancers colorectaux.

Tumour and peritumoral mucosa were analyzed using flow cytometry in 21 consecutive patients operated on for colorectal carcinoma. Thirteen tumours were DNA aneuploid. No foci of aneuploidy bordering the tumours were detected, regardless of the tumour type. On the other hand, a significant decrease in the proliferative index was observed adjacent to the DNA aneuploid tumours. This study provides an additional argument for segmentary excision in colorectal cancers. Complementary studies are still required to specify the mechanisms of proliferation inhibition in the area of the DNA aneuploid tumours.