[Public free anonymous HIV testing centers: cost analysis and financing options]. / Centre de dépistage anonyme et gratuit : étude de coût et des modes de financement.

The services of general interest provided by hospitals, such as free HIV clinics, have been funded since 2005 by a lump sum covering all costs. The allocation of the budget was initially determined based on historical and declarative data. However, the French Ministry of Health (MoH) recently outlined new rules for determining the allocation of financial resources and contracting hospitals for each type of services of general interest provided. The aim of this study was to estimate the annual cost of a public free anonymous HIV-testing center and to assess the budgetary implications of new financing systems. Three financing options were compared: the historic block grant; a mixed system recommended by the MoH associating a lump sum covering the recurring costs of an average center and a variable part based on the type and volume of services provided; and a fee-for-services system. For the purposes of this retrospective study, the costs and activity data of the HIV testing clinic of a public hospital located in the North of Paris were obtained for 2007. The costs were analyzed from the perspective of the hospital. The total cost was estimated at 555,698 euros. Personnel costs accounted for 31% of the total costs, while laboratory expenses accounted for 36% of the total costs. While the estimated deficit was 292,553 euros under the historic system, the financial balance of the clinic was found to be positive under a fee-for-services system. The budget allocated to the HIV clinic under the system recommended by the MoH covers most of the current expenses of the HIV clinic while meeting the requirements of free confidential care.

[Elderly people, precariousness, social handicap and length of stay: pilot study at the Lariboisière-Fernand Widal Hospital Group in Paris]. / Personnes âgées, précarité, handicap social et durée de séjour: étude pilote au groupe hospitalier Lariboisière-Fernand Widal de Paris.

OBJECTIVES: To administer a social handicap questionnaire associated with French DRGs (PMSI) to determine the social handicaps of a population hospitalized in a public health establishment and to measure the cost implications for the establishment due to increased length of stay (DMS). METHOD: A prospective pilot study has been carried out in the Lariboisière-Fernand Widal Hospital Group in Paris targeting users 50 or more years old hospitalized for short stays in medicine, surgery and obstetrics. Data of the PMSI and answers to the questionnaire for hospitalisations longer than 24 hours have been exploited. RESULTS: Two hundred twenty-two stays from 8 to 23 November 2005 have been analyzed: 140 pertained to patients aged 50-69 years (27.8%) and 82 to patients aged 70 or more years (16.3%). Three-fourths of the persons aged 50-69 and 70 or over presented a social handicap: 45% showed a strong handicap and a third an average handicap. The three indicators "renter/owner", "interior comfort" and "family relations" were the major determinants of social handicap for those aged 70 or more, 50-69 and 50 or more years. For the patients 70 years and over and those 50-69 years, with an average handicap, the indicator was "income" with the domain "patrimony." For strong handicaps, it was the indicator "scolarisation" for the 70 or more years and the indicator "income" for the 50-69 years old. When all classes and populations were pooled, the DMS was significantly lower than that of the ENC (p<0.001 for the 70 years and over; p<0.05 for the 50-69 years). With again all classes and populations pooled, patients 70 and over stayed in hospital 6.50 days less on average compared to data published by the ENC; those 50-69 years stayed 3.57 days less. Persons aged 50 and over with a social handicap remained hospitalized on average more than 2.5 days: 2.2 days for the 70 and over and 3.1 days for the 50-69 years group. In terms of hospital days that produces an increase of 18%, corresponding to a supplementary expenditure attributable to social handicap of approximately 5.9 million euros. CONCLUSION: This pilot study with a questionnaire disability social PMSI proposing specific aid, but also reducing the DMS, provides several promising information but also indicates the limits of our approach. Among these, we note in particular: (a) its regular feasibility requires constant supervision, wider and well-trained, (b) that the measurement of our tool can only be affirmed after its use in many patients, and (c) the classification of disability in social class could even be discussed again. We still wanted to explore whether through this initiative without much logistical, markers of interest had emerged, which seems to be the case.

Access to care of patients with chronic hepatitis C virus infection in a university hospital: Is opioid dependence a limiting condition?

BACKGROUND: We aimed to examine access to care of opioid-dependent patients with chronic hepatitis C. METHODS: A standardized form was used to conduct a retrospective survey from 1999 to 2003 in a French university hospital. All HCV RNA positive in- or outpatients who had not had a liver biopsy or anti-HCV treatment were included. Opioid-dependence was defined as active opioid drug use or being on opioid substitution treatment. RESULTS: The survey included 580 patients; 137 (23.6%) were opioid-dependent. Fewer patients with than without current opioid dependence had had genotyping (40.1% versus 67.7%, p<0.001), liver biopsy (51.8% versus 62.8%, p=0.022), and anti-HCV treatment (8.8% versus 18.3%, p=0.008). Genotyping was independently, negatively, associated with: (1) current opioid-dependence (OR=0.3, 95%CI=0.2-0.5), (2) former opioid-dependence (OR=0.5, 95%CI=0.3-0.9), (3) unemployment (OR=0.5, 95%CI=0.3-0.7), and (4) HCV infection discovered by screening (OR=0.5, 95%CI=0.3-0.7). Access to liver biopsy was independently, negatively associated with current opioid-dependence (OR=0.6, 95%CI=0.4-0.9), but positively associated with alcohol consumption (OR=2.0, 95%CI=1.2-3.4) and abnormal ALT level (OR=2.2, 95%CI=1.5-3.2). Access to anti-HCV treatment was independently, negatively associated with HCV infection discovered by screening (OR=0.5, 95%CI=0.3-0.9), but positively associated with moderate hepatitis (OR=6.8, 95%CI=2.8-16.8), extensive fibrosis or cirrhosis (OR=12.3, 95%CI=5.5-27.5), abnormal ALT level (OR=2.1, 95%CI=1.3-3.6) and age (40-64 years) (OR=1.9, 95%CI=1.0-3.4). CONCLUSIONS: Genotyping and liver biopsies were performed less frequently on current opioid dependent patients. Absence of genotyping was also independently associated with unemployment and former opioid-dependence. Alcohol consumption or abnormal ALT levels favored access to biopsy. Histological grade strongly conditioned access to anti-HCV treatment.