[Economic repercussions of cardiac insufficiency in France]. / Répercussion économique de l'insuffisance cardiaque en France.

The aim of the article is to review economic and public health consequences of congestive heart failure in France. This disease with an increasing prevalence induces for the social security system and the society a high cost; 85 to 93% of this cost are bound to hospitalizations, most of them avoidable. New modalities of care are to be chosen in order to improve the management of heart failure and to contain costs. In this context, multidisciplinary interventions based on patients' education are experimented taking care to assure a greater role to health actors working in the ambulatory sector (GPs, private cardiologists, nurses).

[Economic assessments of head and neck cancers: a review]. / Evaluations economiques des cancers de la tête et du cou: un etat des lieux.

The aim of this study is to perform a review of the literature on economic studies in the area of head and neck cancer (including the cancers of the buccal cavity, the larynx, and the pharynx). French and international literature (as reported on Medline and OHE-IFPMA databases) has been reviewed. This research demonstrated the lack of economic data in this field. In France, only one study was found, assessing the cost of the treatment of head and neck cancer in hospital to 29 billions French Francs including 2.3 billions linked to head and neck cancer. This relative indifference is possibly due to the heterogeneity and the low incidence of the studied pathologies. In addition, the research highlighted the great interest of dealing with quality of life in such physically and psychologically disabling illnesses. To facilitate the decision making and to allow optimal resource allocation in the area of costly health strategies, we should develop in France an economic evaluation of the head and neck cancer, while taking care of integrating the notion of quality of life into the analysis.

Economic assessment of the secondary prevention of ischaemic events with lysine acetylsalicylate.

OBJECTIVE: To analyse the economic benefits, in comparison with placebo, of the secondary prevention of ischaemic stroke and myocardial infarction (MI) with lysine acetylsalicylate (Kardégic) in patients with a history of ischaemic stroke, MI or stable and unstable angina pectoris. DESIGN AND SETTING: This was a modelling study from the perspectives of direct medical costs, the social security system and society in France. METHODS: Efficacy data for the secondary prevention of ischaemic events were derived from the Antiplatelet Trialists' Collaboration meta-analysis on antithrombotics. The rates and costs of ischaemic disease and of serious gastrointestinal adverse affects arising from long term aspirin treatment, as well as the costs of treatment with lysine acetylsalicylate, were taken from published sources, using French data where possible. RESULTS: From the social security perspective, the estimated cost-effectiveness ratios show that the prevention of MI in patients with a history of unstable angina (with a 1-year follow-up) is a cost-saving strategy, with net benefits ranging from $US5703 (1996 prices) per avoided MI for lysine acetylsalicylate 300 mg/day to $US5761 per avoided MI for lysine acetylsalicylate 75 mg/day. The prevention of MI and stroke is also a cost-saving strategy in patients with prior MI [net benefits in a 2-year follow-up (5% discount rate) ranging from $US15 to $US494 per avoided MI and from $US37 to $US1170 per avoided stroke]. This was also true in patients with prior ischaemic stroke (net benefits in a 3-year follow-up ranging from $US610 to $US2082 per avoided MI and from $US176 to $US599 per avoided stroke). Finally, a 4-year follow-up in patients with a history of stable angina pectoris shows that prophylactic treatment with lysine acetylsalicylate is associated with net costs per avoided MI, ranging from $US4375 to $US3608 per avoided event. Sensitivity analysis confirmed that prophylaxis with lysine acetylsalicylate in patients at high risk of cardiovascular and cerebrovascular events results in savings in social security expenditure. CONCLUSIONS: Our results underline the high economic benefit of using lysine acetylsalicylate to prevent secondary ischaemic stroke and MI in patients at high risk of cardiovascular and/or cerebrovascular events, leading to savings for the social security system and society.

[Advanced breast cancer: an evaluation of the cost of recurrence]. / Cancer du sein au stade avancé: évaluation du coût de la récidive.

In the context of a medicoeconomic study of the adjuvant treatment of breast cancer, we evaluated the cost of the recurrence. This cost was assessed from the medical records of 146 patients having presented either distant metastases, or a local recurrence followed or not by metastases between 1983 and 1990. We checked according to published data that the frequency of the metastatic risk is negligible if beyond 5 years after the local recurrence. Costs are expressed in 1995 French Francs (FF), with the French Social Security point of view. From the medical records, we calculated the mean cost of each type of recurrence using medical costs (visits, drugs and treatments, assessments, tests, hospital care, outpatient services.) and non medical costs (patient transportation). The costs are 175,168 FF (standard deviation or SD: 127,972) for metastatic recurrence, and respectively 287,582 FF (SD: 142,280) and 115,705 FF (SD: 78,677) for local recurrence followed or not by metastases. There is a significant difference between these figures (p < 0.001). The hospitalization costs are around 66% of the total cost of each type of recurrences and they are significantly higher (p < 0.005) when metastatic disease occurs after a local recurrence. The mean cost of isolated local recurrence added to metastatic recurrence, 290,873 FF, is not different from that of local recurrence followed by metastases, 287,582 FF (p = 0.15). These results will be integrated in a model in order to evaluate the long-term economic consequences of an adjuvant strategy in the treatment of breast cancer and presented in other publications.

[Socioeconomic and quality of life repercussions of arterial hypertension]. / Les répercussions socio-économiques et de qualité de vie de l'hypertension artérielle.

This article reports on the economic, social and quality-of-life issues relating to hypertension. Although it does not claim to be a comprehensive review of the many studies available in this field, it does attempt to highlight the main areas of interest. From both a macro- and a micro-economic viewpoint, hypertension and its associated cardiovascular and renal diseases are characterized by high costs. Treatment costs can, for certain persons, represent a considerable obstacle and result in limited access to any form of care. Nevertheless, providing access to care does not necessarily ensure that an individual patient receives effective treatment. Socioeconomic factors can have varying degrees of influence on the success of any therapy, and can affect, for example, treatment compliance. An individual's awareness of his/her hypertension (the labelling effect) and the initiation of any form of long term treatment can have specific effects on quality of life; yet, in order to ensure adequate patient compliance, treatment should not impair quality of life. Evaluation of quality of life depends not only on the dimensions under investigation but also on the use of reliable, legitimate, sensitive and previously validated questionnaires. The use of such questionnaires has enabled the complex links between quality of life and blood pressure to be recognised. This in turn has led to an assessment of various drug treatments. Results would appear to indicate that hypertension and its treatment do indeed affect patients' quality of life, a factor that ultimately influences the approach to disease management and the choice of long term treatment.

[Adjuvant treatment of cancer of the breast: cost assessment of the protocol used]. / Traitement adjuvant du cancer du sein: évaluation du coût de la stratégie mise en oeuvre.

In this study a cost analysis of therapeutics used in the adjuvant treatment of breast cancer has been performed. Four strategies were considered: chemotherapy (FEC, 6 courses), hormone therapy (tamoxifen, 20 mg/day during 3 years), the association of chemotherapy and hormone therapy, or standard follow-up with neither chemotherapy nor hormone therapy. The costs of these strategies were analysed according to the payer's perspective (social security system). In order to complete the economic data, specific investigations were performed at the Centre Oscar-Lambret (COL), a Cancer Center located in Lille (France). The study shows a high cost for chemotherapy (63,767 FF at 5 years) and a high cost for the association (68,891 FF), in comparison to the cost of hormone therapy alone (45,540 FF) or to the follow-up without adjuvant therapy (38,416 FF). These costs could be confronted to the efficacy data of these different strategies and to the cost of avoided relapses. Cost-effectiveness and cost-benefit ratios of these adjuvant strategies could then be assessed.

[Medico-economical assessment in cancerology]. / Evaluation médico-économique en cancérologie.

In recent studies, the economic criteria has begun to be integrated to the appraisal in cancerology. The question asked by the economist can be framed as follows: what incremental cost should the collectivity or the health insurance system consent, in order to improve the care of cancer patients? This involves first that the cost of the strategies, foreseen or already implemented, can be appraised, then, that indicators can be defined to capture health improvement, and finally, that this health improvement can be quantified. In this article, we present the process of integrated appraisal (cost/result approach). We specifically analyze costs in cancerology, their source and their evolution. We demonstrate the meaning of the integration of economic costs and medical results. We emphasize on the fact that part of the costs, especially those supported by the patient and his close relations, are most of the time excluded from the analysis. Two main points should be carefully analyzed, when proceeding to an appraisal in cancerology: the measurement of the patient's QoL, which represents an expression of the results of the strategy of care; the financing modalities, for the same type of care, if we consider the specificity of the structures involved and the organization of the care. We conclude by mentioning how difficult this task is and under which conditions it should be developed.

[Socio-economic consequences and quality of life in hypertension and its management: a review of the literature]. / Conséquences socio-économiques et de qualité de vie de l'hypertension artérielle et de sa prise en charge: revue de la littérature.

A macro-economic approach to the cost of hypertension showed that, due to its high prevalence in industrialised countries and the increase in the costs of its treatment, the management of this condition is a preoccupation for the community. The micro-economic approach revealed an inequality between individuals concerning its management, especially with respect to social class. Ambulatory blood pressure recording provides a method of reliable assessment of the blood pressure of an individual. Its cost could be compensated on the macro-economic scale by the economies of treatment, especially as erroneous diagnosis of normal subjects as hypertensive may lead to both psychosocial and economic complications (increased professional absenteeism), the so-called "labelling effect" in Anglo-Saxon countries.

The introduction of economic criteria into the management of arterial disease: an illustration with regard to the socioeconomic consequences of peripheral occlusive arterial disease of the lower limbs.

A survey of studies was used to investigate the economic repercussions of arterial disease; these repercussions included the cost of the disease and its management, and cost/efficacy, cost/utility, and cost/benefit studies of preventive, diagnostic, and therapeutic strategies. The study presented is an evaluation of the socio-economic consequences of peripheral occlusive arterial disease of the lower limbs (POADLL). The cost of health care was measured by means of a prospective 6-month study of 85 patients recruited in 6 centers. The average cost over the 6-month period was 15,735 FF (1991 francs) ($2,760 U.S.). The 85 patients were classified by age, sex, risk factors, concomitant disease, and how the illness was managed, notably in terms of hospitalization and vascular surgery. The four-group classification was used to calculate an annual management cost for POADLL, which ranged from 9,500 FF ($1,667 U.S.) for a stage II patient (mean age, 66 years) with no major risk factors and not presenting any complication requiring admission to hospital, to 35,000 FF ($6,140 U.S.) for patients (mean age, 62 years) who presented major risk factors and who required vascular surgery during the year.

[Changes in bones of the foot and development of inserting tendons of the lower leg musculature in tibial aplasia]. / Untersuchungen über Veränderungen im Fussskelet und im Verlauf der Ansatzsehnen der Unterschenkelmuskulatur bei Tibiaaplasie.

Skeleton, muscles and tendons were investigated in 3 lower legs with aplasia of the tibia. The tibiofibular joint appears to be rather a syndesmosis than a diarthrosis. In all 3 cases, talus and calcaneus are connected by a synostosis. Also in the other parts of the skeleton of the feet, synarthroses with different extensions are found. The muscles, normally originating from the tibia, have shifted their origin to the fibula. The proximal part of the inserting tendons under the retinacula is quite normal. Also, their distal part in the region of the metatarsalia and of the digits exhibits no alterations. In the region of the tarsus in which already alterations in bone formation are found, the tendons of the flexor muscles of the toes exhibit some variations. Often the muscles show a new, strong insertion into the bones of the tarsus. The normal connection between the proximal and distal parts of the tendons is sometimes still indicated by a thin bundle of collagenous fibers. In all 3 cases, the tibialis anterior muscle inserts into the distal part of the tendons of the flexor muscles of the toes, indicating that there are also connections between tendons of muscles from different blastemas.