Admission into healthcare education in France: Half-baked reform that further complicates the system.

France has undertaken the most ambitious reform of healthcare education in more than 10 years. It has resulted in a hybrid system with multiple pathways, granting admission into the healthcare professions after competitive exams. The reform continues the trend to increase the quotas limiting the number of second year healthcare students, and also creates new local access options to healthcare education. However, the heterogeneity in implementation has led, in conjunction with the difficulties caused by the Covid-19 pandemic, to great dismay among students and parents. This article seeks to outline the historical underpinnings of the reform program(s) and argues that the core question - selecting students from the very high number of candidates in a fair and effective manner - remains largely unresolved.

Why are there so many hospital beds in Germany?

The place of hospitals in health systems is undergoing rapid change worldwide due to the high cost of hospital care and the changing health needs of the population. The Covid-19 pandemic has recently drawn public attention towards hospital capacity and has added new urgency to discussions on the future role of hospitals. In this context, recent experience in Germany provides valuable information for health systems seeking to manage hospital capacity. Despite reform efforts to reduce hospital capacity, Germany has the highest rates of intensive care beds among high-income countries and the highest overall hospital capacity in Europe. The capacity of the German hospital system can be explained in large part by the high number of elderly in-patients. This, in turn, is driven by (1) a fragmented ambulatory care system; (2) physicians admitting and maintaining elderly patients in hospital at a high rate; (3) a hospital market adding incentives to admit patients; and (4) a political commitment to egalitarian access and universal care. Additionally, recent policies to reduce hospital capacity have had limited impact because hospitals have not responded to financial incentives in the expected manner. Countries looking to learn from Germany's hospital capacity must therefore consider systemic features, political commitments, and unintended policy consequences.

Born in the USA? A Comparison of "Inspired" Health Care Reforms in Germany and France.

CONTEXT: Despite numerous examples of health policy transfer in Western health systems, the nature of such "inspired" reforms has received little detailed attention. The aim of this article is to apply and refine a specific theoretical angle for the analysis of these reforms using the theoretical frameworks of transfer and translation. METHODS: The design is based on a comparative case study: the introduction of disease management programs (DMPs) for diabetes in Germany in 2002 and in France in 2008, drawing on a literature review and semistructured interviews. FINDINGS: In introducing its DMP, Germany chose and combined several components in a process of selective borrowing, while France opted for copying a specific foreign program and adapting it. Such differences in process are linked to distinct system structures, in particular the setup of health insurance and the representation of physicians. Furthermore, the displayed versus actual degree of inspiration varied significantly, with a branding strategy in Germany (high display of foreign influence) and the inverse picture in France (high degree of actual inspiration). CONCLUSIONS: This analysis has applied the dual perspective of transfer and translation. Both perspectives proved complementary and necessary, and translation appeared as a main determinant of implementation success.

Tools of power: pay-for-performance in French and German health reforms.

PURPOSE: Pay-for-performance (P4P) as an innovation for improved health care has been introduced in many health systems worldwide. The aim of this article is to apply and refine a specific theoretical angle for the analysis of these reforms, the theoretical frameworks of public policy instruments and programmatic actors, in order to highlight differences between countries. DESIGN/METHODOLOGY/APPROACH: This analysis is based on a comparative case study of the introduction of P4P in France and Germany in the ambulatory sector for the period from 2007 until 2017. This included a literature review and semi-structured interviews with 23 actors between 2013 and 2015. FINDINGS: The introduction of a supposedly clear-cut policy instrument - P4P in health care - is distinctly shaped by the intertwined configuration of institutional architecture and the policy programme of key system actors. This can be understood as a continuation of long-term transformations, most importantly the increasingly direct influence of the state and a weakening of the representation of the medical profession, as well as an internal fragmentation of the latter. ORIGINALITY/VALUE: This analysis illustrates the applicability of the policy instrument approach to the heath sector. In addition, the authors have applied the dual perspective of policy instruments and programmatic actors. Both proved complementary and appropriate for the study of a highly technical instrument such as P4P.

Pemetrexed-Based Chemotherapy Is Inferior to Pemetrexed-Free Regimens in Thyroid Transcription Factor 1 (TTF-1)-Negative, EGFR/ALK-Negative Lung Adenocarcinoma: A Propensity Score Matched Pairs Analysis.

INTRODUCTION: Thyroid transcription factor 1 (TTF-1) is a prognostic biomarker in lung adenocarcinoma; however, TTF-1-positive patients also display more favorable factors like actionable target mutations. In contrast, TTF-1-negative cancer is a poorly described entity. We performed a retrospective study to characterize a TTF-1-negative phenotype and to evaluate outcome depending on the chemotherapy regimen applied in the EGFR/ALK-negative population. PATIENTS AND METHODS: Phenotypic traits were analyzed in 741 patients with evaluable TTF-1 expression status, among them 529 patients with platinum-based first-line chemotherapy, with disease diagnosed between 2009 and 2016 at a tertiary referral university hospital. The influence of TTF-1 and several cofactors on progression-free survival and overall survival (OS) were analyzed using a 1:1 propensity score matching model, depending on the platinum doublet chemotherapy's incorporating pemetrexed or not, with subsequent Cox regression. RESULTS: TTF-1 negativity implied a distinct cancer phenotype with the predominance of male sex, worse Eastern Cooperative Oncology Group performance status, greater metastatic burden at primary diagnosis, and more adrenal gland metastases. These patients had improved progression-free survival (hazard ratio, 0.42; P = .001) and OS (hazard ratio, 0.40; P < .001) when gemcitabine-, taxane-, or vinorelbine-based regimens were provided instead of pemetrexed. None of the regimens was superior in TTF-1-positive patients with regard to OS. Overall, TTF-1 expression was strongly prognostic with a substantial increase in progression-free survival (hazard ratio, 0.54; P < .001) and OS (hazard ratio, 0.53; P < .001). CONCLUSION: TTF-1 negativity is associated with a distinct cancer phenotype. Incorporation of this biomarker may be helpful when choosing an appropriate therapy regimen.

European mental health research resources: Picture and recommendations of the ROAMER project.

As part of the Roamer project, we sought to have a picture of the available mental health research (MHR) funding, capacity-building and infrastructures resources and to establish consensus-based recommendations that would allow an increase of European MHR resources and enable better use and accessibility to them. The methods fell into three sections (i) a review of the literature, (ii) a mental health-related keywords search within the Cordis®, On-Course® and Meril® databases which contain information on European research funding, training and infrastructures. These reviews provided an overview that was presented to (iii) two experts workshops with 28 participants drawn from academic which identified gaps and produced recommendations. The literature review illustrates the debates in the scientific community on funding, training and infrastructures. The database searches estimated the fraction of health research resources available for mental health. Eight overarching goals for MHR resources were identified by the workshops; each of them was carried out with several practical recommendations. Resources for MHR are scarce considering the burden of mental disorders, the high rate of return of MHR and the under-investment of the field. The recommendations are urgently warranted to increase resources and their optimal access and use.

Local ablative treatment for synchronous single organ oligometastatic lung cancer-A propensity score analysis of 180 patients.

INTRODUCTION: Local ablative treatment (LAT) improves outcome in lung cancer with oligometastatic disease (OMD) and potentially leads to long term survival. The aim of this retrospective study was to evaluate and quantify the additional benefit of LAT in synchronous OMD and to further identify prognostic factors for survival. PATIENTS AND METHODS: A propensity score-matched pairs analysis was performed on a set of patient and disease variables in 180 patients, treated for synchronous single organ OMD including non small-cell and neuroendocrine lung cancer with ≤4 metastases between 2000 and 2016 in 3 lung cancer centers in Berlin, Germany. Patients either received LAT for all sites of disease (intervention group) by means of surgery or stereotactic radiotherapy, or standard chemotherapy, if necessary combined with a local treatment with palliative intent (control group). RESULTS: Median follow-up time was 32.2 and 18.8 months for the intervention and control group, respectively. Substantial benefits in median progression-free survival (PFS, 25.1 vs. 8.2 months; HR, 0.30; 95% CI, 0.21-0.43; p < 0.001) and overall survival (OS, 60.4 vs. 22.5 months; HR, 0.42; 95% CI, 0.28-0.62; p < 0.001) were associated with LAT. Histology of adenocarcinoma and T1a primaries also predicted a favorable prognosis concerning PFS and OS. More favorable nodal stage (N0-2 vs. 3) and solitary metastases were associated with an extended PFS, whereas initial ECOG-PS (0-1 vs. 2) predicted OS. CONCLUSIONS: LAT was the strongest predictor for PFS and OS in OMD with ≤4 metastases. Survival in the control group identifies OMD as a subset of lung cancer with a generally more favorable prognosis.

Management of end-stage heart failure patients with or without ventricular assist device: an observational comparison of clinical and economic outcomes.

OBJECTIVES: Heart transplantation (HT) and ventricular assist devices (VAD) for the management of end-stage heart failure have not been directly compared. We compare the outcomes and use of resources with these 2 strategies in 2 European countries with different allocation systems. METHODS: We studied 83 patients managed by VAD as the first option in Bad Oeynhausen, Germany (Group I) and 141 managed with either HT or medical therapy, as the first option, in Paris, France (Group II). The primary end-point was 2-year survival. Kaplan-Meier analyses were performed after the application of propensity score weights to mitigate the effects of non-random group assignment. The secondary end-points were resource utilization and costs. Subgroup analyses were performed for patients undergoing HT and patients treated with inotropes at the enrolment time. RESULTS: The Group I patients were more severely ill and haemodynamically compromised, and 28% subsequently underwent HT vs 55% primary HT in Group II, P < 0.001. The adjusted probability of survival was 44% in Group I vs 70% in Group II, P <0.0001. The mean cumulated 2-year costs were €281 361 ± 156 223 in Group I and €47 638 ± 35 061 in Group II, P < 0.0001. Among patients who underwent HT, the adjusted probability of survival in Group I (n = 23) versus Group II (n = 78) was 76% versus 68%, respectively (0.09), though it differed in the inotrope-treated subgroups (77% in Group I vs 67% in Group II, P = 0.04). CONCLUSIONS: HT should remain the first option for end-stage heart failure patients, associated with improved outcomes and better cost-effectiveness profile. VAD devices represent an option when transplant is not possible or when patient presentation is not optimal.

Attitudes towards digital treatment for depression: A European stakeholder survey.

BACKGROUND: The integration of digital treatments into national mental health services is on the agenda in the European Union. The E-COMPARED consortium conducted a survey aimed at exploring stakeholders' knowledge, acceptance and expectations of digital treatments for depression, and at identifying factors that might influence their opinions when considering the implementation of these approaches. METHOD: An online survey was conducted in eight European countries: France, Germany, Netherlands, Poland, Spain, Sweden, Switzerland and The United Kingdom. Organisations representing government bodies, care providers, service-users, funding/insurance bodies, technical developers and researchers were invited to participate in the survey. The participating countries and organisations reflect the diversity in health care infrastructures and e-health implementation across Europe. RESULTS: A total of 764 organisations were invited to the survey during the period March-June 2014, with 175 of these organisations participating in our survey. The participating stakeholders reported moderate knowledge of digital treatments and considered cost-effectiveness to be the primary incentive for integration into care services. Low feasibility of delivery within existing care services was considered to be a primary barrier. Digital treatments were regarded more suitable for milder forms of depression. Stakeholders showed greater acceptability towards blended treatment (the integration of face-to-face and internet sessions within the same treatment protocol) compared to standalone internet treatments. Organisations in countries with developed e-health solutions reported greater knowledge and acceptability of digital treatments. CONCLUSION: Mental health stakeholders in Europe are aware of the potential benefits of digital interventions. However, there are variations between countries and stakeholders in terms of level of knowledge about such interventions and their feasibility within routine care services. The high acceptance of blended treatments is an interesting finding that indicates a gradual integration of technology into clinical practice may fit the attitudes and needs of stakeholders. The potential of the blended treatment approach, in terms of enhancing acceptance of digital treatment while retaining the benefit of cost-effectiveness in delivery, should be further explored. FUNDING: The E-COMPARED project has received funding from the European Union Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 603098.

Mental health research priorities for Europe.

Mental and brain disorders represent the greatest health burden to Europe-not only for directly affected individuals, but also for their caregivers and the wider society. They incur substantial economic costs through direct (and indirect) health-care and welfare spending, and via productivity losses, all of which substantially affect European development. Funding for research to mitigate these effects lags far behind the cost of mental and brain disorders to society. Here, we describe a comprehensive, coordinated mental health research agenda for Europe and worldwide. This agenda was based on systematic reviews of published work and consensus decision making by multidisciplinary scientific experts and affected stakeholders (more than 1000 in total): individuals with mental health problems and their families, health-care workers, policy makers, and funders. We generated six priorities that will, over the next 5-10 years, help to close the biggest gaps in mental health research in Europe, and in turn overcome the substantial challenges caused by mental disorders.

Research priorities for public mental health in Europe: recommendations of the ROAMER project.

BACKGROUND: The ROAdmap for MEntal health Research in Europe project aimed to create an integrated European roadmap for mental health research. Leading mental health research experts across Europe have formulated consensus-based recommendations for future research within the public mental health field. METHODS: Experts were invited to compile and discuss research priorities in a series of topic-based scientific workshops. In addition, a Delphi process was carried out to reach consensus on the list of research priorities and their rank order. Three web-based surveys were conducted. Nearly 60 experts were involved in the priority setting process. RESULTS: Twenty priorities for public mental health research were identified through the consensus process. The research priorities were divided into summary principles-encompassing overall recommendations for future public mental health research in Europe-and thematic research priorities, including area-specific top priorities on research topics and methods. The priorities represent three overarching goals mirroring societal challenges, that is, to identify causes, risk and protective factors for mental health across the lifespan; to advance the implementation of effective public mental health interventions and to reduce disparities in mental health. CONCLUSIONS: The importance of strengthening research on the implementation and dissemination of promotion, prevention and service delivery interventions in the mental health field needs to be emphasized. The complexity of mental health and its broader conceptualisation requires complementary research approaches and interdisciplinary collaboration to better serve the needs of the European population.

Evaluating structured care for diabetes: can calibration on margins help to avoid overestimation of the benefits? An illustration from French diabetes provider networks using data from the ENTRED Survey.

OBJECTIVE: While there is growing evidence on the effectiveness of structured care for diabetic patients in trial settings, standard population level evaluations may misestimate intervention benefits due to patient selection. In order to account for potential biases in measuring intervention benefits, we tested the impact of calibration on margins as a novel adjustment method in an evaluation context compared with simple poststratification. RESEARCH DESIGN AND METHODS: We compared the results of a before-after evaluation on HbA1c levels after 1 year of enrollment in a French diabetes provider network (DPN) using an unadjusted sample and samples adjusted by simple poststratification to results obtained after adjustment via calibration on margins to the general diabetic population's characteristics using a national cross-sectional sample of diabetic patients. RESULTS: Both with and without adjustment, patients in the DPN had significantly lower HbA1c levels after 1 year of enrollment. However, the reductions in HbA1c levels among the adjusted samples were 22-183% lower than those measured in the unadjusted sample, regardless of the poststratification method and characteristics used. Compared with simple poststratification, estimations using calibration on margins exhibited higher performance. CONCLUSIONS: Evaluations of diabetes management interventions based on uncontrolled before-after experiments may overestimate the actual benefit for patients. This can be corrected by using poststratification approaches when data on the ultimate target population for the intervention are available. In order to more accurately estimate the effect an intervention would have if extended to the target population, calibration on margins seems to be preferable over simple poststratification in terms of performance and usability.

ROAMER: roadmap for mental health research in Europe.

Despite the high impact of mental disorders in society, European mental health research is at a critical situation with a relatively low level of funding, and few advances been achieved during the last decade. The development of coordinated research policies and integrated research networks in mental health is lagging behind other disciplines in Europe, resulting in lower degree of cooperation and scientific impact. To reduce more efficiently the burden of mental disorders in Europe, a concerted new research agenda is necessary. The ROAMER (Roadmap for Mental Health Research in Europe) project, funded under the European Commission's Seventh Framework Programme, aims to develop a comprehensive and integrated mental health research agenda within the perspective of the European Union (EU) Horizon 2020 programme, with a translational goal, covering basic, clinical and public health research. ROAMER covers six major domains: infrastructures and capacity building, biomedicine, psychological research and treatments, social and economic issues, public health and well-being. Within each of them, state-of-the-art and strength, weakness and gap analyses were conducted before building consensus on future research priorities. The process is inclusive and participatory, incorporating a wide diversity of European expert researchers as well as the views of service users, carers, professionals and policy and funding institutions.

[Care for patients with chronic illness - concepts, assessment and foreign experiences]. / Prise en charge des patients atteints de maladies chroniques. concepts, évaluations et enseignements internationaux.

The growing number of people with chronic diseases is a major challenge for health care systems in terms of morbidity, mortality, quality of care and financial impact. A range of organizational concepts for structured chronic disease care have been developed to address this challenge. The purpose of this literature review is to identify the key concepts, results and success factors of recent initiatives in this area. Four main concepts related to the broader notion of integrated care were identified: case management, disease management, the chronic care model and population management. The available evidence suggests that the expected results in terms of health gains and cost reductions have only been partially achieved, but that the quality of care has improved. The study identified several critical success factors for initiatives aimed at improving chronic care: the integration of patient education, the implementation of a patient identification system, provider feedback, primary care performance and financial incentives. Improved care for patients with chronic illness requires a range of interdependent measures. However, it is important to note that initiatives in this area are not usually associated with shortterm savings, but represent an investment for the future.

Cost of transcatheter aortic valve implantation and factors associated with higher hospital stay cost in patients of the FRANCE (FRench Aortic National CoreValve and Edwards) registry.

BACKGROUND: Currently, several anatomical approaches and intervention sites can be used to perform transcatheter aortic valve implantations (TAVIs), often with no clinical indications for choosing one or another. While these choices can have an impact on resource consumption, no costing study is available in the European context to provide information on resource use and assist decision-making. AIMS: To provide comparative data on the cost of the TAVI procedure, depending on anatomical approach and intervention site used, from a hospital perspective, and to analyze factors associated with cost of hospital stay. METHODS: Multicentre national registry data were collected in 16 centres between January and October 2009. For 287 patients, a descriptive costing study and a multivariable analysis of hospital stay cost were performed. RESULTS: The mean cost of the TAVI procedure was €22,876 and the mean initial hospital stay cost was €35,164. The procedure cost, excluding valve cost, did not differ between anatomical approaches and was highest in the hybrid room and lowest in the catheterization laboratory. Factors associated with higher hospital stay cost were transapical approach, Society of Thoracic Surgeons score>10%, warfarin use at inclusion, complications during procedure and pacemaker implantation following valve implantation. CONCLUSIONS: If clinical considerations do not interfere, hospital staff may find it economically favorable to opt for the catheterization laboratory and against the hybrid room. The mean hospital stay cost is higher than the tariff paid in 2011, a difference that has grown since the change in tariff in 2012, representing an economic disincentive for the uptake of TAVI in France.

Is Europe putting theory into practice? A qualitative study of the level of self-management support in chronic care management approaches.

BACKGROUND: Self-management support is a key component of effective chronic care management, yet in practice appears to be the least implemented and most challenging. This study explores whether and how self-management support is integrated into chronic care approaches in 13 European countries. In addition, it investigates the level of and barriers to implementation of support strategies in health care practice. METHODS: We conducted a review among the 13 participating countries, based on a common data template informed by the Chronic Care Model. Key informants presented a sample of representative chronic care approaches and related self-management support strategies. The cross-country review was complemented by a Dutch case study of health professionals' views on the implementation of self-management support in practice. RESULTS: Self-management support for chronically ill patients remains relatively underdeveloped in Europe. Similarities between countries exist mostly in involved providers (nurses) and settings (primary care). Differences prevail in mode and format of support, and materials used. Support activities focus primarily on patients' medical and behavioral management, and less on emotional management. According to Dutch providers, self-management support is not (yet) an integral part of daily practice; implementation is hampered by barriers related to, among others, funding, IT and medical culture. CONCLUSIONS: Although collaborative care for chronic conditions is becoming more important in European health systems, adequate self-management support for patients with chronic disease is far from accomplished in most countries. There is a need for better understanding of how we can encourage both patients and health care providers to engage in productive interactions in daily chronic care practice, which can improve health and social outcomes.

Reported barriers to evaluation in chronic care: experiences in six European countries.

INTRODUCTION: The growing movement of innovative approaches to chronic disease management in Europe has not been matched by a corresponding effort to evaluate them. This paper discusses challenges to evaluation of chronic disease management as reported by experts in six European countries. METHODS: We conducted 42 semi-structured interviews with key informants from Austria, Denmark, France, Germany, The Netherlands and Spain involved in decision-making and implementation of chronic disease management approaches. Interviews were complemented by a survey on approaches to chronic disease management in each country. Finally two project teams (France and the Netherlands) conducted in-depth case studies on various aspects of chronic care evaluation. RESULTS: We identified three common challenges to evaluation of chronic disease management approaches: (1) a lack of evaluation culture and related shortage of capacity; (2) reluctance of payers or providers to engage in evaluation and (3) practical challenges around data and the heterogeity of IT infrastructure. The ability to evaluate chronic disease management interventions is influenced by contextual and cultural factors. CONCLUSIONS: This study contributes to our understanding of some of the most common underlying barriers to chronic care evaluation by highlighting the views and experiences of stakeholders and experts in six European countries. Overcoming the cultural, political and structural barriers to evaluation should be driven by payers and providers, for example by building in incentives such as feedback on performance, aligning financial incentives with programme objectives, collectively participating in designing an appropriate framework for evaluation, and making data use and accessibility consistent with data protection policies.