Potential determinants of unfavourable healthcare utilisation trajectories during the last year of life of people with incident Alzheimer Disease or Related Syndromes: a nationwide cohort study using administrative data.

BACKGROUND: people approaching the end-of-life frequently face inappropriate care. With Alzheimer Disease or Related Syndromes (ADRS), end-of-life is characterised by progressive decline, but this period remains difficult to identify. This leads to a lack of anticipation and sometimes with unfavourable healthcare utilisation trajectories (HUTs). OBJECTIVE: to quantify unfavourable HUTs during the last year of life and identify their potential determinants in both community and nursing-home settings. DESIGN: nationwide cohort study using administrative database. SETTING: French community and nursing-home residents. SUBJECTS: incident ADRS people identified in 2012, who died up to 31 December 2017. METHODS: we used multidimensional clustering to identify 15 clusters of HUTs, using 11 longitudinal healthcare dimensions during the last year of life. Clusters were qualitatively assessed by pluri-disciplinary experts as favourable or unfavourable HUTs. Individual and contextual potential determinants of unfavourable HUTs were studied by setting using logistic random-effect regression models. RESULTS: 62,243 individuals died before 31 December 2017; 46.8% faced unfavourable end-of-life HUTs: 55.2% in the community and 31.8% in nursing-homes. Individual potential determinants were identified: younger age, male gender, ADRS identification through hospitalisation, shorter survival, life-limiting comorbidities, psychiatric disorders, acute hospitalisations and polypharmacy. In the community, deprivation and autonomy were identified as potential determinants. Contextual potential determinants raised mostly in the community, such as low nurse or physiotherapist accessibilities. CONCLUSIONS: Nearly half of people with ADRS faced unfavourable HUTs during their last year of life. Individual potential determinants should help anticipate advance care planning and palliative care needs assessment. Contextual potential determinants suggest geographical disparities and health inequalities.

Induction of labor at term with vaginal misoprostol or a prostaglandin E2 pessary: a noninferiority randomized controlled trial.

BACKGROUND: Induction of labor is among the most common procedures for pregnant women. Only a few randomized clinical trials with relatively small samples have compared misoprostol with dinoprostone. Although their efficacy seems similar, their safety profiles have not been adequately evaluated, and economic data are sparse. OBJECTIVE: This study aimed to test the noninferiority of vaginal misoprostol (prostaglandin E1) (25 µg) to a slow-release dinoprostone (prostaglandin E2) pessary (10 µg) for induction of labor with an unfavorable cervix at term. STUDY DESIGN: This was an open-label multicenter randomized noninferiority trial at 4 university hospitals of the Research Group in Obstetrics and Gynecology between 2012 and 2015. We recruited women who underwent induction of labor for medical reasons, those with a Bishop score of ≤5 at ≥36 weeks' gestation, and those with a cephalic-presenting singleton pregnancy with no previous cesarean delivery. Women were randomly allocated to receive either vaginal misoprostol at 4-hour intervals (25 µg) or a 10-mg slow-release dinoprostone pessary. The primary outcome was the total cesarean delivery rate. Noninferiority was defined as a difference in the cesarean delivery rates between the groups of no more than 5%. Secondary outcomes included neonatal and maternal morbidity, vaginal delivery at <24 hours after starting the induction of labor process, and maternal satisfaction. RESULTS: The study included 1674 randomized women. The per-protocol analysis included 790 women in each group. The total cesarean delivery rates were 22.1% (n=175) in the misoprostol group and 19.9% (n=157) in the dinoprostone group, a difference of 2.2% (with an upper-bound 95% confidence limit of 5.6%) (P=.092). Results in the intention-to-treat analysis were similar. Neonatal and maternal morbidity rates were similar between groups. Vaginal delivery within 24 hours was significantly higher in the misoprostol group (59.3% vs 45.7%; P<.001) as was maternal satisfaction, assessed in the postpartum period by a visual analog scale (mean score, 7.1±2.4 vs 5.8±3.1; P<.001). CONCLUSION: The noninferiority of a 25-µg dose of vaginal misoprostol every 4 hours to the dinoprostone pessary for cesarean delivery rates after induction of labor at term could not be demonstrated, although the confidence limit of the difference barely exceeded the noninferiority margin. Nonetheless, given the small difference between these cesarean delivery rates and the similarity of neonatal and maternal morbidity rates in this large study, the clinical risk-to-benefit ratio justifies the use of both drugs.

How to assess patient satisfaction regarding physician interaction: A systematic review.

Patient satisfaction is an important health care quality indicator. This is particularly relevant in chronic diseases, such as, many dermatological diseases. The purpose of the current systematic review was to assess the validated tools measuring patient satisfaction with physician interaction. We performed a systematic review search in Pubmed, Cochrane Library, and EMBASE. The psychometric properties of the instruments and the domains explored were assessed. Overall, 2229 articles were extracted from the literature search. Of these, 146 articles were eligible for inclusion, 55 were included, and 22 scores were selected. A total of 13 instruments reported cross-cultural validation and the EUROPEP score highlighted the most diverse cross-cultural validation involving 11 different countries. All scores were assessed for content validity, construct validity, factor analysis, reliability, and responsiveness to change. The extent of the validation varied between scores with a few assessing practicability. The following domains were explored: listening skills, empathy, caring/compassion, confidentiality, honesty, behavior, competency/technical skills, satisfaction with the information provided, time given, availability, the environment, trust in the physician, ability to comply with the recommendations, and readiness to recommend the physician to other patients. We identified a total of 22 validated instruments. The major gaps in the validation process appear to be the practicability of the scores and the cross-cultural validation. Major domains evaluated by the scores are communication skills that can be improved by specific training. There is a need to improve evaluation of the quality of the patient-physician relationship in dermatology using validated instruments.

Omalizumab in the treatment of adult patients with mastocytosis: A systematic review.

BACKGROUND: Mastocytosis is associated with mast cell (MC) mediator-related symptoms for which limited therapies are available. OBJECTIVE: Our aim was to assess the efficacy and safety of omalizumab in the treatment of MC mediator-related symptoms in adult patients with mastocytosis. RESULTS: We identified one multi-centre retrospective cohort study (39 patients), one retrospective cohort study (13 patients), 4 case series and 10 case reports. No published controlled randomized study was identified. We included 69 patients (13 patients with cutaneous mastocytosis and 56 with systemic mastocytosis). The mean age was 48 years. Omalizumab maintenance dose was 300 mg for the majority of patients. The mean duration of treatment was 17 months. Treatment led to a tolerability of venom immunotherapy and to a complete resolution of severe reactions in all patients with post-honeybee sting anaphylaxis. Complete resolution of idiopathic anaphylaxis episodes was noted in 84% of the patients. Complete resolution of palpitations, gastrointestinal, cutaneous, neuropsychiatric, respiratory and musculoskeletal symptoms was observed at a rate of 43%, 29%, 27%, 11%, 9% and 0%, respectively. Efficacy was maintained for the entire duration of the treatment in all but four responders. Adverse events were reported for 13 patients. CONCLUSIONS AND CLINICAL RELEVANCE: Omalizumab appears to prevent some life-threatening reactions associated with mastocytosis and may be a good option to treat the associated symptoms. However, the evidence relied upon is observational, uncontrolled and from a small number of patients. A randomized controlled trial is needed to better understand the place of omalizumab in mastocytosis treatment.

Evidence of practice gaps in emergency psychiatric care for borderline personality disorder: how can this be explained?

BACKGROUND: Recent research has highlighted that patients with borderline personality disorder (BPD) could experience symptomatic remissions. This led to the production of guidelines concerning the most appropriate care. In addition, as BPD patients frequently present at an emergency department (ED), specific recommendations concerning how they should be cared for there have also been developed. The recommendations include the referral of patients to inpatient, outpatient or specific crisis care. However, an issue that has not been addressed is the capacity of ED services to apply the care recommendations. The objective of our study, therefore, was to identify the factors limiting their use in the ED of Toulouse University Hospital. METHODS: A panel of psychiatrists specializing in BPD care examined the medical files of 298 patients with a BPD diagnosis to determine which referrals were consistent or not, according to the care recommendations. A logistic regression was then performed to identify which sociodemographic, clinical, organizational or professional-training factors were associated with inconsistent referrals. RESULTS: 32% of patients experienced an inconsistent referral. Consultations performed during an on-call or day-off schedule were linked with inconsistent referrals, while an active follow-up was associated with the provision of consistent care. CONCLUSION: Changing how evaluations of BPD patients in the ED are organized during on-call and day-off schedules could improve the application of the care recommendations regarding the most appropriate referrals.

The specific branches leading to the genioglossus muscle: three-dimensional localisation using skin reference points.

INTRODUCTION: Supra-selective stimulation of the branches destined for the horizontal part of genioglossus muscle (GGh) could be a target of choice in the treatment of mild-to-severe obstructive sleep apnea syndrome. The main aim of our study was to assess a percutaneous method for the three-dimensional localisation of the terminal branches destined to GGh. MATERIALS AND METHODS: Twenty cadaveric hypoglossal nerves were dissected and included in the injection protocol. The distance between the posterior edge of the mandibular symphysis and the hyoid bone on the sagittal midline as the approximated distance of the geniohyoid muscle (dGH) was measured before any dissection. Methylene blue mixed with a thickening agent, was injected. The injection point was defined in relation to dGH, in an orthonormal coordinate system. For each dissection, we recorded the theoretical and the real (X, Y, Z) coordinates of GGh motor points and measured their distance to each other. RESULTS: X was accurately estimated. Y and Z were overestimated by + 5.34 ± 5.21 mm ([Formula: see text]) and + 4.79 ± 3.99 mm ([Formula: see text]) on average, respectively. We found a more significant difference between the theoretical and real Y and Z coordinates in the subgroup BMI < 25 kg/m2 (8.6 ± 4.5 mm and 6.9 ± 2.5 mm, respectively, p = 0.0009), and of Z in subgroup with dGH ≥ 50 mm (6.89 ± 3.26 mm, p = 0.0494). CONCLUSIONS: X can be estimated accurately using the relationship [Formula: see text]. Y seems to be related to BMI and Z may be estimated with the relationship [Formula: see text]. This three-dimensional localisation could be very helpful to facilitate placement of cuff electrodes to manage refractory sleep apnea.

Anticholinergic exposure and cognitive decline in older adults: effect of anticholinergic exposure definitions in a 3-year analysis of the multidomain Alzheimer preventive trial (MAPT) study.

AIM: The aim of the present study was to assess the association between anticholinergic (atropinic) burden and cognitive decline in older adults over the course of 3 years. METHODS: We used data from Multidomain Alzheimer Preventive Trial (MAPT) study participants aged ≥70 years and at risk of cognitive decline. Cognitive function was assessed with a composite score [Mini-Mental State Examination (MMSE) orientation, Free and Cued Selective Reminding Test, Category Naming Test, Digit Symbol Substitution Test] at 12, 24 and 36 months. Participants declining by more than 0.236 points on the composite score (representing the lowest quintile of 1-year cognitive change) during any 1-year period were considered to have undergone cognitive decline. Anticholinergic exposure was defined by four methods for each of four anticholinergic scales (Anticholinergic Drug Scale, Anticholinergic Cognitive Burden, Anticholinergic Risk Scale, the Durán list). The association between cognitive decline and time-varying anticholinergic exposure [primary analysis using the Durán list and maximal anticholinergic score (0, 1 or 3)] was assessed using Cox proportional hazards models. Other cognitive decline definitions were used in sensitivity analyses. RESULTS: At baseline, among 1396 patients included, 7.4-23.5% were exposed to anticholinergic agents, depending on the anticholinergic scale used. Sixty-four per cent of participants experienced cognitive decline during follow-up. Regardless of the anticholinergic scale/exposure measurement used, no significant association was observed with cognitive decline {primary analysis: compared with non-anticholinergic agent users, hazard ratio [HR] = 1.14 [95% confidence interval (CI) = 0.95, 1.38] for anticholinergic score = 1; HR = 0.92 [95% CI = 0.65, 1.30] for score = 3}. Results were stable in sensitivity analyses. CONCLUSION: We found no significant association between anticholinergic exposure and cognitive decline in older adults using anticholinergic scales and definitions of exposure.

Association between anticholinergic (atropinic) drug exposure and cognitive function in longitudinal studies among individuals over 50 years old: a systematic review.

PURPOSE: With increasing age, adults are often exposed to anticholinergic drugs and are prone to potential adverse drug reaction, among which cognitive impairment. If the short-term cognitive effects of anticholinergic drugs are well established, their long-term cognitive effects have less been studied. OBJECTIVE: To provide a systematic review of longitudinal studies which assessed the effect of anticholinergic exposure on cognition in individuals over 50 years. MATERIALS: We searched the MEDLINE database for studies with a minimal 6-month follow-up, assessing anticholinergic exposure through a biological measure or a clinical list and reporting at least one cognitive outcome. We used the modified Newcastle-Ottawa scale and additional criteria regarding the anticholinergic exposure to assess studies' methodological quality. Given the heterogeneity of the studies, we performed a systematic review. RESULTS: Among the 1574 references retrieved, 25 studies were included. Anticholinergic medications were mostly defined through the Anticholinergic Cognitive Burden Scale (n = 14/25). Six studies evaluated baseline drug collection, 14 used longitudinal aggregated measure, and 5 multiple drug exposure measures over time. Seventeen studies assessed anticholinergic burden. Cognitive function was assessed by mild cognitive impairment/dementia incidence (n = 15) or neuropsychological tests (n = 14). Most studies were of poor quality and retrieved discordant results. However, studies with good quality (n = 4) suggested a relationship between anticholinergic drug exposure and/or burden and cognitive function. CONCLUSION: Our review suggests a deleterious effect of anticholinergic exposure on mid/long-term cognitive function but should be confirmed in studies with improved methodology. Meanwhile, prescription of anticholinergic drugs should remain cautious.

Evaluating the clinical relevance of a cognitive composite outcome measure: An analysis of 1414 participants from the 5-year GuidAge Alzheimer's prevention trial.

INTRODUCTION: Composite cognitive scores have been developed as primary outcome measures for preclinical/prevention trials for Alzheimer's disease (AD), mainly using observational data and with little consideration of clinical relevance. METHODS: Secondary analysis of placebo group data from a 5-year AD prevention trial. The composite score was the average of the following z scores: MMSE orientation items, Free and Cued Selective Reminding Test, Category Fluency, Trail Making Test-part B. RESULTS: Composite score change from baseline differed significantly by age, APOE genotype, and CDR progression and AD dementia status. A 1 point decrease in baseline score was highly predictive of 5-year AD dementia risk (HR = 3.51, 95% CI, 2.62-4.71, P < .001). The 1 year minimum clinically important difference was estimated at -0.3 points and predicted AD dementia. DISCUSSION: We explored the clinical relevance of a composite score in a prevention trial setting. This type of analysis facilitates the interpretation of composite scores and informs power calculations.

The influence of drug use in university hospitals on the pharmaceutical consumption in their surrounding communities.

AIM: To investigate the influence of hospital drug choices on pharmaceutical consumption for nine competitive classes in the surrounding community. METHODS: Ecological study. Data from the national survey on drugs in hospitals were used to extract quantities purchased by 25 French university hospitals for three 'hospital classes' (EPOs, LMWHs and setrons) and six 'ambulatory classes' (PPIs, ACEIs and ARBs, statins, α-adrenoreceptor antagonists (AAAs) and selective serotonin re-uptake inhibitors SSRIs). Re-imbursed quantities for patients living in the hospital's catchment area were extracted from the national health insurance database. The relationship between the use of a brand in hospitals and their catchment areas was assessed using multivariate linear regressions with instrumental variables. RESULTS: An increase of 1 day of treatment with one brand in the hospital was associated with a significant increase of 2.8 days of treatment with the same brand in the catchment area. However, results strongly varied according to classes. An increase of 1 day of treatment in the hospital was significantly associated with an increase of 0.21 day for 'hospital classes' and 21.8 days for 'ambulatory classes' in the catchment area. Strong variations were seen across 'ambulatory classes'. The effect was maximal for cardiovascular classes and not significant for AAAs and SSRIs. The size of the effect also varied with hospital characteristics: small and proximity university hospitals exerted the greatest influence. CONCLUSIONS: Hospital consumption influences the use of drugs in the community. A significant effect was found, especially for competitive classes used on a long-term basis. The economic consequences of these findings need to be addressed.

Drug selection in French university hospitals: analysis of formularies for nine competitive pharmacological classes.

AIM: To give a panorama of the selectivity and agreement of French university hospitals' drug formularies (HDF) for nine competitive classes. METHODS: All university hospitals were asked to send their HDF and selection criteria as of January 2009 for nine competitive pharmacological classes (proton pump inhibitors, serotonin antagonists, low molecular weight heparins, erythropoietins, angiotensin converting enzyme inhibitors, angiotensin II receptor antagonists, statins, α-adrenoreceptor antagonists and selective serotonin re-uptake inhibitors). Selectivity of HDF was estimated by the percentage of drug entities selected by the hospital within the pharmacological class. Agreement between hospitals was assessed with modified kappa coefficients for multi-raters. RESULTS: Twenty-one out of the 29 hospitals agreed to participate. These hospitals selected between 34% and 63% of the drug entities available for the nine classes, which represented 18 to 35 agents. Regarding the nature of chosen drug entities, the overall level of agreement was 'fair' and varied with pharmacological classes. Selection criteria were sent by only 12 hospitals. The technical component was the most important element in all hospitals. The weight of the economic component varied between 20% and 40% in the tender's grade. DISCUSSION: Large variations were seen in the number and nature of drugs selected by university hospitals which can be attributable to two successive decision-making processes (evaluation by the Drug and Therapeutics Committee followed by the purchasing process).

Slow-release oral morphine for opioid maintenance treatment: a systematic review.

This review article summarizes the results of all available clinical trials considering the use of slow-release oral morphine (SROM) for opioid maintenance treatment (OMT). All studies published up to October 2010 and assessing SROM for OMT in adult patients are included. Three independent reviewers assessed the selected articles using a standardized checklist. Study design, study length and number of subjects included were recorded. Data about retention rate (proportion of participants remaining under maintenance treatment at the end of the study), quality of life, withdrawal symptoms, craving, additional drug consumption, driving capacity and adverse events were collected. We identified 13 articles corresponding to nine clinical trials considering the use of SROM for OMT. Among them, only one was a randomized trial and one was a controlled not randomized trial. All other studies were uncontrolled. Retention rates were good (from 80.6 to 95%) with SROM maintenance, but similar retention rates were obtained with methadone. Most of the studies showed that quality of life, withdrawal symptoms, craving and additional drug consumption improved with SROM. However, there was no comparison with other maintenance drugs. As most of the studies assessing SROM efficacy were uncontrolled, there is no definite evidence that SROM is an effective alternative to methadone for OMT.

Abnormalities in distal first metatarsal joint surface orientation: Distal Metatarsal Articular Angle and Distal Metatarsal-2 Articular Angle.

BACKGROUND: Hallux valgus (HV) in adults is an acquired pathology related to 1st metatarsal (M1) abduction. In children, it is related to abnormal M1 joint surface orientation. HYPOTHESIS: HV deformities in children and adults differ. OBJECTIVE: Descriptive study of radiologic abnormalities in a pediatric population of symptomatic HV, with comparison to a population without symptomatic HV. MATERIALS AND METHODS: Weight-bearing X-rays were studied in pediatric patients undergoing surgery for HV and in a control population. Measurements comprised M1P1, M1M2, DMAA, DM2AA, MPAA, and sesamoid subluxation index. RESULTS: Twenty-five patients (42 feet) were included in the HV group, and 16 patients (29 feet) in the control group. Mean age was 13 years in both. Interobserver reproducibility was excellent for M1P1, and good for M1M2, DMAA and DM2AA. In HV, 71% of feet showed M1M2 angle>12° and 98% DMAA>10°; DM2AA was>0°, except in 1 foot. DISCUSSION: Normal values are the same in children and adults: M1P1<15°, DMAA<10° and M1M2<12°. In the HV group, DMAA was systematically pathological, while M1M2 was pathological in only 71% of cases. Childhood HV is related to abnormal DMAA, sometimes associated with increased M1M2 angle, especially in severe forms. DM2AA assesses distal M1 joint surface orientation with respect to the M2 axis; in the HV group, it was systematically>0° (except in 1 foot). Thus, in case of concomitant DMAA and M1M2 abnormalities, DMAA is more severely abnormal than M1M2 (DM2AA=DMAA-M1M2). CONCLUSION: Childhood HV is mainly due to abnormal M1 joint surface orientation, sometimes associated with increased 1st metatarsal abduction. DM2AA reflects the balance between 1st metatarsal abduction and M1 joint surface orientation abnormality. LEVEL OF EVIDENCE: III.

Monitoring adolescent idiopathic scoliosis by measuring ribs prominence using surface topography device.

Due to the danger of repeated exposure to X-rays for patients with Adolescent Idiopathic Scoliosis (AIS), reducing the number of radiographs is necessary. By using Surface Topography (ST), trunk asymmetry evaluation could be used. The number of radiographs required can be reduced by 30% when the radio is used only for patients with worsening ST. HYPOTHESIS: ST is a reliable technique for deformity monitoring in AIS. DESIGN: Observational prospective study. INTRODUCTION: The risk of curve progression in AIS is high during a growth spurt and necessitates regular radiographic follow-up, despite the adverse effects of repeated exposure to X-rays. AIM: The aim of this study was to determine a simple and reproducible parameter for deformity monitoring using ST in AIS patients. MATERIAL AND METHODS: Consecutive AIS patients with a Cobb angle between 10° and 40° were included. Every 6 months, X-ray and ST acquisitions were performed. Radiographic parameters and the ribs prominence curve calculated from ST were collected. This curve was deduced from the axial rotation of the 100 axial sections of the trunk. We analyzed correlations between the evolution of Cobb angle and the curve. RESULTS: 123 patients were included, 111 girls, 12 boys, mean age 12 years. The measurement of the curve had a good reproducibility (ICC: 0.816). ST differentiated patients with or without increased Cobb. (p = 0.0294). CONCLUSION: ST is useful for monitoring AIS. This device could reduce the number of radiographs by 30%. LEVEL OF EVIDENCE: II.

Developing and Testing a Local Expert-Based Reading Process for Use to Examine Discrepancies Between Guidelines and Current Clinical Practices.

The use of relevant guidelines is critical in psychiatric clinical practice to ensure the homogeneity of the global care provided. Consequently, it is important to identify whether they are utilized successfully and, if not, why. This would enable pragmatic solutions to be agreed to improve the organization of care and the removal of any barriers to the guidelines' implementation. The first step in this process, before any exploration of the limitations of the guidelines themselves, involves a determination of whether they are actually applied in clinical practice. We therefore evaluated discrepancies between the guidelines relating to patients with borderline personality disorder and current practices in the psychiatric Emergency Department at Toulouse University Hospital. This was achieved using a reading process involving a panel of eight local experts who analyzed relevant medical files extracted from a database. They were guided by, and instructed to answer, six standardized questions in relation to each file to determine the method's feasibility. A total of 333 files were analyzed to determine whether, in the local experts' judgment, the care provided reflected current guidance. This reading process revealed substantial agreement (0.85%; Fleiss Kappa -0.69), which is a promising outcome and suggests that such methods could be used in future protocols. Moreover, the process is practical and reliable and requires very few materials.

Development and Validation of a Model to Identify Alzheimer's Disease and Related Syndromes in Administrative Data.

BACKGROUND: Administrative data are used in the field of Alzheimer's Disease and Related Syndromes (ADRS), however their performance to identify ADRS is unknown. OBJECTIVE: i) To develop and validate a model to identify ADRS prevalent cases in French administrative data (SNDS), ii) to identify factors associated with false negatives. METHODS: Retrospective cohort of subjects ≥ 65 years, living in South-Western France, who attended a memory clinic between April and December 2013. Gold standard for ADRS diagnosis was the memory clinic specialized diagnosis. Memory clinics' data were matched to administrative data (drug reimbursements, diagnoses during hospitalizations, registration with costly chronic conditions). Prediction models were developed for 1-year and 3-year periods of administrative data using multivariable logistic regression models. Overall model performance, discrimination, and calibration were estimated and corrected for optimism by resampling. Youden index was used to define ADRS positivity and to estimate sensitivity, specificity, positive predictive and negative probabilities. Factors associated with false negatives were identified using multivariable logistic regressions. RESULTS: 3360 subjects were studied, 52% diagnosed with ADRS by memory clinics. Prediction model based on age, all-cause hospitalization, registration with ADRS as a chronic condition, number of anti-dementia drugs, mention of ADRS during hospitalizations had good discriminative performance (c-statistic: 0.814, sensitivity: 76.0%, specificity: 74.2% for 2013 data). 419 false negatives (24.0%) were younger, had more often ADRS types other than Alzheimer's disease, moderate forms of ADRS, recent diagnosis, and suffered from other comorbidities than true positives. CONCLUSION: Administrative data presented acceptable performance for detecting ADRS. External validation studies should be encouraged.

Clustering 5-Year Multidimensional Health Care Trajectory Patterns in Alzheimer's Disease and Related Syndromes.

OBJECTIVE: After diagnosis of Alzheimer's disease and related syndromes (ADRS), personalized care adapted to each patient's needs is recommended to provide a care plan and start symptomatic treatments according to guidelines. Over the past decade, dedicated structures and care have been implemented in various settings. Equal access to ADRS care, health care providers and services is crucial to ensure potential health benefits for everyone. However, the extent of use of recommended services and favorable health care utilization trajectories (HUT) may vary according to individual and contextual characteristics. The aim of this article was to (1) describe HUT patterns after multidimensional clustering of similar trajectories, (2) assess the proportion of individuals presenting favorable HUTs, and (3) identify factors associated with favorable HUTs. DESIGN: Cohort study. SETTING AND PARTICIPANTS: A cohort of 103,317 people newly diagnosed with ADRS identified in the French health reimbursement system (SNDS) was followed for 5 years with their monthly utilization on 11 health care dimensions. METHODS: For 3 age groups (65-74, 75-84, ≥85 years), 15 clusters of patients were identified using partitioning around medoids applied to Levenshtein distances. They were qualitatively assessed by pluridisciplinary experts. Individual and contextual determinants of clusters denoting favorable trajectories were identified using mixed random effects multivariable logistic regression models. RESULTS: Clusters with favorable HUTs denoting slow, progressive trajectories centered on at-home care, represented approximatively 25% of the patients. Determinants of favorable HUTs were mostly individual (age, female gender, absence of certain comorbidities, circumstances of ADRS identification, lower deprivation). Contextual determinants were also identified, in particular accessibility to nurses and nursing homes. Inter-territories variance was small but significant in all age groups (from 0.9% to 1.8%). CONCLUSION AND IMPLICATIONS: Favorable HUTs remain the minority and many efforts can still be made to improve HUTs. Qualitative studies could help understanding underlying barriers to favorable HUTs.

[Decreased hospital spending as a result of antibiotic prescriptions dispensed in community pharmacies. Results from the Midi-Pyrenees region.]. / Limites de l'intéressement financier proposé par l'accord-cadre relatif au bon usage des antibiotiques dans les établissements de santé. Illustration en Midi-Pyrénées.

A contract between French hospitals and national health authorities was signed in early 2006 to improve the rational use of antibiotics in hospitals. The contract offers a financial reward in the event of decreased spending as a result of hospital prescriptions dispensed in community pharmacies compared to the previous year. The article describes the limitations relating to the financial rewards defined by the contract, particularly those concerning the measurement and relevance of the chosen indicator. Since no national data are currently available, quantitative results drawn from the Midi-Pyrénées region are used to illustrate the analysis.

Benzodiazepine exposure in subjects with incident Alzheimer's disease and related syndromes in France: a longitudinal study 2011-2017.

Benzodiazepines are commonly used for behavioral and psychiatric symptoms of dementia, despite their numerous adverse effects and the lack of evidence regarding their efficacy in this context. We studied longitudinal benzodiazepines exposure in incident cases of Alzheimer's disease and related syndromes (ADRS) in France. We used a cohort of incident ADRS patients identified in 2012 within the national health data system. Benzodiazepines exposure was measured 1 year before, to 5 years after ADRS identification. Quarterly benzodiazepines prevalence and incidence were computed. We identified factors associated with long half-life benzodiazepines initiation. A total of 106 508 subjects were included. Quarterly benzodiazepines prevalence was stable (around 25%) but we saw an important decrease in long half-life benzodiazepines compensated by an increase in short half-life benzodiazepines. In most benzodiazepine initiations, the first episode lasted less than 3 months. Factors associated with initiating a long half-life benzodiazepine were young age, male gender, no registration with ADRS as a long-term disease, having consulted an ADRS specialist, antipsychotic reimbursement before the index date, no admission in nursing home. Prevalence of benzodiazepines use remains high in subjects with ADRS despite guidelines for their avoidance. However, indicators regarding benzodiazepine initiations (duration, benzodiazepine type) suggest some caution in their use.

Benzodiazepine Dispensing to Persons With Dementia in France, 2011-2016: A Nationwide Study.

OBJECTIVE: To study temporal trends of benzodiazepine exposure among incident Alzheimer's disease and related dementia (ADRD) cohorts between 2011 and 2016. DESIGN: Repeated cross-sectional study. SETTING AND PARTICIPANTS: Three nationwide incident ADRD cohorts (community-dwelling and institutionalized subjects) were identified in 2011, 2013, and 2016 through the French health insurance database. Subjects were followed 4 semesters around ADRD identification [Semester -2 (S-2) to Semester 2 (S2)]. MEASURES: Odds ratios (ORs) for semestrial prevalent exposure, initiation, and adherence to benzodiazepine prescription recommendations (prescription duration <3 months, single reimbursement) were computed using multivariate logistic regressions for each cohort and according to benzodiazepine half-life. RESULTS: Among 262,024 community-dwelling subjects, as compared to 2011, overall benzodiazepine prevalence risk decreased slightly immediately after ADRD identification [S1: aOR2013 = 0.93 (0.91-0.95), aOR2016 = 0.95 (0.93-0.97)] and did not differ during S2. Among 72,013 institutionalized subjects, it increased over time [S2: aOR2013 = 1.16 (1.11-1.21), aOR2016 = 1.26 (1.21-1.32)]. Long half-life benzodiazepine prevalence risk decreased in the 4 semesters among recent cohorts, for both populations [S2: community-dwelling: aOR2013 = 0.77 (0.74-0.79), aOR2016 = 0.61 (0.59-0.64); institutionalized: aOR2013 = 0.74 (0.68-0.80), aOR2016 = 0.58 (0.54-0.63)]. Short half-life benzodiazepine prevalence risk increased [S2: community-dwelling: aOR2013 = 1.13 (1.10-1.16), aOR2016 = 1.22 (1.20-1.25); institutionalized: aOR2013 = 1.26 (1.21-1.32), aOR2016 = 1.44 (1.38-1.50)]. The same patterns were observed for benzodiazepine initiation. Adherence to benzodiazepine prescription recommendations (based on French prescription duration) worsened over years [prescription duration <3 months: aOR2013 = 0.90 (0.86-0.95), aOR2016 = 0.90 (0.85-0.95), single reimbursement: aOR2013 = 0.95 (0.91-1.00), aOR2016 = 0.94 (0.90-0.99)]. CONCLUSIONS AND IMPLICATIONS: Long half-life benzodiazepine exposure was reduced whereas short half-life benzodiazepine exposure increased, and adherence to recommendations worsened (prescription duration longer than 3 months and more than a single reimbursement in recent cohorts). Efforts from prescribers and authorities are required in order to restrict psychotropic exposure among the ADRD population. Further research among institutionalized ADRD subjects could provide useful data to disentangle the effects of changes in prescribing practices and in patients' characteristics.