[Health has a cost]. / La santé a un coût.

Health has a cost, and in the face of declining purchasing power, many French people are forced to cut back on their healthcare spending, at the risk of damaging their health. For example, a chiropodist feels that some patients with a deforming forefoot pathology are depriving themselves of essential chiropody care, or are coming for consultations but at the expense of other leisure expenses. In this article, we present a study protocol designed to objectivize this phenomenon.

[Human rights and transgender surgery]. / Droits de la personne humaine et chirurgie de la transidentité.

René Sève recalls that Contemporary Law in the Western World is based on autonomy of equal subjects, mutually recognizing the right to each carry out their own life project. The LGBTQIA+ person therefore exercises their ability to be their own species, according to Kirkegaard's word. It remains that "life project" also implies a constraint of stability and rationality. The author then shows, using Canadian and French statistical data, the difficulties of achieving this ideal for minors and, for adults, the other medical, paramedical and social conditions required. The rights of LGBT people cannot be considered independently of the physical and financial limits of the health system and therefore of the public debate on its priorities.

[The associative approach, a force for progress in a context of Covid-19]. / La démarche associative, force d'avancées dans un contexte de Covid-19.

The pioneering national association "TousPartenairesCovid" dedicated to Covid long has the singularity of operating in 2.0 and cultivating transversality. In two years, it has built up an unprecedented database based on online surveys, worked with the French National Authority for Health and regional health agencies, and designed digital tools including the "Covid long" adult, child and adolescent referral algorithm in partnership with the French National Health Insurance Fund. Very early on, it proposed positioning the coordination support systems- territorial support platforms as post-Covid cells. Today, its flexibility allows it to address other issues, such as facilitating the return to work of patients with long-standing Covid, or modeling care in medical deserts through hybridization between healthcare professionals and emerging e-health tools.

Waiting for common-law solutions for the most vulnerable populations' healthcare access.

BACKGROUND: The state of populations' health is linked to their access to quality healthcare. Best achieving this primary condition - a health, social and humanitarian condition - is an ongoing public policy objective. Although significant effort goes into this, do public policies sufficiently take into account the state of health of the most vulnerable populations? In France, reducing the non-take-up (NTU) of healthcare is a priority in current national health insurance policy. Under the local plans to tackle non-take-up, lack of understanding and exit from the system (PLANIR), national health insurance is currently rolling out a regional and partnership-based intervention framework in order to prevent NTU of healthcare by welfare clients. This social investment is unprecedented, yet the impact of the framework on the most vulnerable populations still seems to be limited. METHOD: The study of this example is based on monitoring of the framework's general implementation. This task was entrusted to the research team co-founded by the author, ODENORE (Observatory for the Non-take-up of Social Rights and Public Services). It is organized in four parts: quantitative monitoring of the detection and addressing of non-take-up situations (n=160,000 questionnaires); analysis of the results through qualitative interviews with beneficiaries and individuals who rejected the framework (n=365 interviews); analysis of the framework's implementation, using qualitative interviews and participant observations at the services in charge of the framework's implementation (n=18 collective interviews across three sites), and an analysis of the partnership through collective interviews with all the actors in the areas involved in the framework (three sites). RESULTS: The analysis shows that the integration of the most vulnerable populations' state of health into a common-law framework for intervention is hindered by three limitations: the framework's neutrality regarding public decisions and non-decisions that exacerbate social and regional health inequalities; its organizational design, which does not take into account the need for long-term medical-psycho-social care; and the absence of regulation capable of bringing together and coordinating the actors working towards healthcare access locally but with different populations. CONCLUSION: The difficulties of integrating the most vulnerable populations into a common-law framework such as the one proposed by the national health insurance do not seem insurmountable-provided, that is, that the regulatory authority (the regional health agencies) are willing and able to make it a strategic organizational objective at local level.

Disparities in out-of-pocket inpatient expenditures in rural Shaanxi Province, western China from 2011 to 2014: a time series analysis.

OBJECTIVE: To investigate the long-term trend of disparity of monthly average out-of-pocket inpatient expenditures (OOP) between areas with different developing levels since the new healthcare reform. METHODS: Time series regression was used to assess the trend of disparities of OOP and monthly average inpatient expenditures (AIE) between areas with different developing levels in rural Shaanxi Province, western China. The data of OOP and AIE in primary health institutions, secondary hospitals, tertiary hospitals and also all levels of the hospital were analysed separately covering the period 2011 through to 2014. RESULTS: The disparity of AIE at all levels of hospitals was increasing (coefficient = 0.003, P = 0.029), and only the disparity of AIE in secondary hospitals was statistical significant (coefficient = 0.003, P = 0.012) when separately considering different levels of the hospital. The disparity of OOP in all levels of the hospital was increasing (coefficient = 0.007, P = 0.001), and the OOP in primary hospitals contributed most of the disparity (coefficient = 0.019, P = 0.000), followed by OOP in secondary (coefficient = 0.008, P = 0.003) and tertiary hospitals (coefficient = 0.004, P = 0.091). CONCLUSIONS: A statistically significant absolute increase in the trend of disparities of OOP and AIE at all levels of hospital was detected after the new healthcare reform in Shaanxi Province, western China. The increase rate of disparity of OOP was bigger than that of AIE. A modified health insurance plan should be proposed to guarantee equity in the future.

Value of a national administrative database to guide public decisions: From the système national d'information interrégimes de l'Assurance Maladie (SNIIRAM) to the système national des données de santé (SNDS) in France.

In 1999, French legislators asked health insurance funds to develop a système national d'information interrégimes de l'Assurance Maladie (SNIIRAM) [national health insurance information system] in order to more precisely determine and evaluate health care utilization and health care expenditure of beneficiaries. These data, based on almost 66 million inhabitants in 2015, have already been the subject of numerous international publications on various topics: prevalence and incidence of diseases, patient care pathways, health status and health care utilization of specific populations, real-life use of drugs, assessment of adverse effects of drugs or other health care procedures, monitoring of national health insurance expenditure, etc. SNIIRAM comprises individual information on the sociodemographic and medical characteristics of beneficiaries and all hospital care and office medicine reimbursements, coded according to various systems. Access to data is controlled by permissions dependent on the type of data requested or used, their temporality and the researcher's status. In general, data can be analyzed by accredited agencies over a period covering the last three years plus the current year, and specific requests can be submitted to extract data over longer periods. A 1/97th random sample of SNIIRAM, the échantillon généraliste des bénéficiaires (EGB), representative of the national population of health insurance beneficiaries, was composed in 2005 to allow 20-year follow-up with facilitated access for medical research. The EGB is an open cohort, which includes new beneficiaries and newborn infants. SNIIRAM has continued to grow and extend to become, in 2016, the cornerstone of the future système national des données de santé (SNDS) [national health data system], which will gradually integrate new information (causes of death, social and medical data and complementary health insurance). In parallel, the modalities of data access and protection systems have also evolved. This article describes the SNIIRAM data warehouse and its transformation into SNDS, the data collected, the tools developed in order to facilitate data analysis, the limitations encountered, and changing access permissions.

[The French medecine pricing committee]. / Le Comité économique des produits de santé et la politique économique du médicament.

The French medicine pricing committee (CEPS) has to reconcile several major constraints, including optimal patient access to medicines and a good control of expenditures on reimbursable medicines. From 2013 to 2015, drug price decreases and discounts obtained by CEPS contributed more than € 5 billion to the balance of the health insurance accounts. As for price setting, there is a significant drop in the prices of medicines in France once they are registered for reimbursement. France is affected by a limited, but costly, flow of innovative medicines, whose prices are higher than those of previous generations, a reflection of an international gradient to which France is obviously subject, despite prices that remain at the low end of the range in Western Europe. The provision of innovative medicines for all patients who need them has been ensured in France over the last fifteen years at a controlled cost. But with the arrival of new expensive products, a resolute policy of control of expenditures must take over from the fall in prices, and original financing channels will have to be explored.

Effective reimbursement rates of the rural health insurance among uncomplicated tuberculosis patients in China.

OBJECTIVE: China has established universal health coverage for 830 million rural residents through the rapid expansion of the New Cooperative Medical Scheme (NCMS). This study accesses the effective reimbursement rates of NCMS among patients with tuberculosis (TB) who lived in counties where their schemes covered costs within TB dispensaries and those who did not. METHODS: We randomly selected 50 patients with uncomplicated TB from each of the eight counties in two provinces. We reviewed all patient clinical charts and conducted face-to-face surveys. Effective reimbursement was measured as the proportion of patients who received reimbursement from NCMS and the average reimbursement rate of total medical costs. RESULTS: A total of 393 patients with TB were included with 186 from Zhejiang and 206 from Sichuan. In the covered group, only 41% of patients with TB received reimbursements for medical costs in TB dispensary in Zhejiang as compared to 84% in Sichuan, because patients in Zhejiang needed to keep their bills and claim later, while Sichuan had patient medical costs automatically deducted at the point of care. Patients in the covered group had a significantly higher average reimbursement rate compared with those in the uncovered group (13% vs. 8% in Zhejiang and 17% vs. 12% in Sichuan). For all patients, the biggest cost was due to hospitalisation, and their overall reimbursement rates were low. CONCLUSION: New Cooperative Medical Scheme has not relieved the financial burden of TB-related medical costs. NCMS should cover costs in TB dispensaries. Measures are also needed to minimise unnecessary hospitalisation, and lower the barriers to claims.

Is the Quebec provincial administrative database a valid source for research on chronic non-cancer pain?

PURPOSE: The objective of this study was to evaluate the validity of diagnostic codes recorded in the Régie de l'assurance maladie du Québec (RAMQ) administrative database for identifying patients suffering from various types of chronic non-cancer pain. METHODS: The validity of published International Classification of Diseases, Ninth Revision, coding algorithms for identifying patients with particular chronic pain syndromes in the RAMQ database was tested using pain specialist-established diagnostic data of 561 patients enrolled in the Quebec Pain Registry, which was used as the reference standard. Modified versions of these algorithms (i.e., adaptation of the number of healthcare encounters) were also tested. For each algorithm, sensitivity, specificity, positive/negative predictive values, and their respective 95% confidence intervals (95%CI) were calculated. RESULTS: In the RAMQ database, some previously published algorithms and modified versions of these algorithms were found to be valid for identifying patients suffering from chronic lumbar pain (sensitivity: 0.65, 95%CI: 0.59-0.71; specificity: 0.83, 95%CI: 0.79-0.87), chronic back pain (sensitivity: 0.70, 95%CI: 0.64-0.76; specificity: 0.73, 95%CI: 0.68-0.78), and chronic neck/back pain (sensitivity: 0.71, 95%CI: 0.65-0.76; specificity: 0.78, 95%CI: 0.72-0.82). Algorithms to identify patients with other types of chronic pain showed low sensitivity: complex regional pain syndrome (≤0.07), fibromyalgia (≤0.42), and neuropathic pain (≤0.39). CONCLUSIONS: Our study provides evidence supporting the value of the RAMQ administrative database for conducting research on certain types of chronic pain disorders including back and neck pain. Users should, however, be cautious about the limitations of this database for studying other types of chronic pain syndromes such as complex regional pain syndrome, fibromyalgia, and neuropathic pain.

[Relevance of the health insurance databases to study spatial disparities in asthma prevalence: A study in southeastern France]. / Intérêt des données de remboursement de l'assurance-maladie pour l'étude des disparités territoriales de la prévalence de l'asthme : une étude en Provence-Alpes-Côte d'Azur.

BACKGROUND: Data on asthma prevalence at a small-area level would be useful to set up and monitor French local public health policies. This study, based on drug reimbursement databases in southeastern France, aimed to (1) compare asthma-like disorders prevalence estimated by using three different indicators; (2) study sociodemographic characteristics associated with these indicators; (3) verify whether these indicators are equivalent to study geographical disparities of the asthma-like disorders prevalence at a small-area level. METHODS: The study was conducted among the beneficiaries of the National Health Insurance Fund aged 18-44 years residing in southeastern France in 2010 (n=1,371,816). Using data on asthma drugs reimbursements (therapeutic class R03), we built three indicators to assess asthma-like disorders prevalence: at least 1, 2 or 3 purchase(s) in 2010. We analyzed sociodemographic characteristics associated with these indicators, and their geographical disparities at a small-area level using multilevel logistic regression models. RESULTS: The crude asthma-like disorders prevalence varied between 2.6 % and 8.4 % depending on the indicator. It increased with age, was higher for women than for men, and among low-income people for all three indicators. We measured significant geographical disparities. Areas with high prevalence rates were the same regardless of the indicator. CONCLUSION: The indicators built in this study can be useful to identify high prevalence areas. They could contribute to launch discussion on environmental health issues at the local level.

Comparative effectiveness of rosuvastatin versus simvastatin in primary prevention among new users: a cohort study in the French national health insurance database.

PURPOSE: Using the French claims database (Système National d'Information Inter-Régimes de l'Assurance Maladie) linked to the hospital discharge database (Programme de Médicalisation des Systèmes d'Information), this observational study compared the effectiveness of rosuvastatin and simvastatin prescribed at doses with close LDL-cholesterol-lowering potency on all-cause mortality and cardiovascular and cerebrovascular diseases (CCDs) in primary prevention. METHODS: This historical cohort included patients with no prior CCD, aged 40-79 years, who initiated statin therapy with rosuvastatin 5 mg or simvastatin 20 mg in 2008-2009 in general practice. Follow-up started after a 1-year period used to select patients who regularly received the initial treatment. In an intention-to-treat analysis, patients were followed up to December 2011. In a per-protocol analysis, they were censored prematurely when they discontinued their initial treatment. Adjustment for baseline covariates (age, deprivation index, comedications, comorbidities, prior hospital admissions) was carried out by a Cox proportional hazards model. In the per-protocol analysis, estimation was done by "inverse probability of censoring weighting" using additional time-dependent covariates. Analyses were gender-specific. RESULTS: A total of 106941 patients initiated statin therapy with rosuvastatin 5 mg and 56860 with simvastatin 20 mg. Mean follow-up was 35.8 months. For both genders and both types of analyses, the difference in incidence rates of mortality and/or CCD between rosuvastatin 5 mg and simvastatin 20 mg users was not statistically significant after adjustment (e.g., for CCD and/or mortality in men, in intention-to-treat analysis HR=0.94 [95% CI=0.85-1.04], in per-protocol analysis HR=0.98 [0.87-1.10]). CONCLUSIONS: The results of this real-life study based on medico-administrative databases do not support preferential prescription of rosuvastatin compared to simvastatin for primary prevention of CCD.

[Health Care Insurance in France: its impact on income distribution between age and social groups]. / Redistribution des revenus opérée par l'assurance maladie entre groupes d'âge et groupes sociaux.

Our study, based on microsimulation models, evaluates the redistributive impact of health care insurance in France on income distribution between age and social groups. This work sheds light on the debate concerning the respective role of the public health care insurance (PHI) and the private supplemental health care insurance (SHI) in France. The analysis points out that the PHI enables the lowest-income households and the pensioners a better access to health care than they would have had under a complete private SHI. Due to the progressivity of taxes, low-income households contribute less to the PHI and get higher benefits because of a weaker health. Pensioners have low contributions to public health care finance but the highest health care expenditures.

[Towards real progress for advanced practice nurses thanks to Rider 9]. / Vers de réelles avancées pour les infirmiers en pratique avancée grâce à l'avenant 9.

The national agreement for nurses organizes the relationship between these professionals and the Health Insurance. An amendment was signed on July 27, 2022, leading to the implementation of a new billing system on March 23, 2023. Two types of pathways are now possible: "Patients followed" and "Occasional patients" with, for each, two types of billing. After a few months of implementation, the production and analysis of quantitative and qualitative data will be necessary for possible readjustment.

[Real-world study of the consumption between 2017 and 2020 of anti-cancer medications that inhibit cyclin- dependent kinases 4 and 6]. / Étude en vie réelle de la consommation de médicaments anticancéreux inhibiteurs des kinases cycline-dépendantes 4 et 6 entre 2017 et 2020.

The real-world study of data from the Système National des Données de Santé (French System of Health Data) in relation to therapeutic indications that give entitlement to having Assurance Maladie (Health-Insurance Fund) pay for, or reimburse the cost of, inhibitors of cyclin-dependent kinases 4 and 6 (iCDK4/6) shows that the target population defined by the Haute Autorité de santé (HAS-National Health Authority) has been significantly exceeded ; in addition, there is a gap with respect to reimbursable indications and therapeutic strategy. The HAS has set the upper limit of the eligible population at 5 320 new patients per year, but in 2019, Assurance Maladie reimbursed iCDK4/6-related costs for 10 894 patients, i.e. double the number. Therapeutic strategies are found that do not comply with the opinions of the commission de la transparence (transparency commission) in 30 % of cases, and that do not comply with reimbursable therapeutic indications in 22 % of cases. Patient profiles are not in line with reimbursable indications in terms of age (women aged under 50 and, a priori, non-menopausal) and sex (men) in 14 % of cases. Furthermore, treatment seems to be started at an advanced stage of the disease, based on the number of deaths observed after treatment is started: 13% of patients died in the year following the start of treatment, including 26 % in the first three months. There is a significant volume of treatment being started, but there is also a significant volume of stoppage. One third of patients for whom treatment was started in 2019 had their treatment stopped after less than one year, including half after less than three months.

Health and health insurance in Tunisia: the challenges of the 2004 reform.

Background: In 2004, Tunisia has implemented health insurance reform in order to remedy several problems related to alarming inequity, insufficient health coverage, and exponential growth in health costs and out of pocket spending. Aims: This paper aimed at sharing a critical vision and qualitative assessment of health insurance reform implemented during 2004 in Tunisia. Methods: Using several sources of information such as the national health insurance fund and the national institute of statistics, we identified the major problems of the health insurance system, the objectives outlined by the reform in relation to these problems, the implementation of measures taken and the level of achievement of these objectives. Results: 17% of the population remains without health coverage. In 2015, the out-of-pocket health expenditures was 39.8%, which does not avoid the risk of catastrophic expenditure. Almost all (91%) of out-of-pocket health expenditures are spent for private sector related healthcare services. Coverage for chronic disease control remains insufficient. The health expenditure contribution of supplementary schemes is estimated at 3.3%. The fragmentation of the health coverage accentuates the inequalities in access to healthcare. Conclusion: In general, the measures taken by the health insurance reform were not found to be sufficiently efficient to achieve its objectives. Out-of-pocket health expenditures remain high. For better social health protection, policy makers have to restructure health coverage, promote the public health sector and guarantee access to medicines, particularly for chronic diseases.

[Role and responsibility of the pharmacist in the implementation of the Compulsory Health Insurance policy in Mali]. / Role et responsabilite du pharmacien dans la mise en œuvre de la politique de L'assurance Maladie Obligatoire au Mali.

OBJECTIVE: To study the role and responsibility of the pharmacist who can contribute to the sustainability of compulsory health insurance in Mali. MATERIALS AND METHODS: This was a descriptive cross- sectional study that took place in Bamako from October 1, 2016 to December 31, 2017. We conducted a literature review and interviews with 36 pharmacists, 400 policyholders, 90 prescribers, and 04 resource personsfrom delegated management organizations. Analysis of the interview data was done using SPSS 20. RESULTS: A total of 2 Acts and 6 Orders in Council enshrine the legislative and regulatory provisions of the AMO. Most insured persons (90%) thought the pharmacist was a drug specialist. More than 80% of the medications on the care sheets were fully available. Among their tasks in implementing the AMO, 38.9 % of pharmacists mentioned the availability of medicines, 27.70 % the application of good dispensing practices and 16.7 % the right to substitution. CONCLUSION: Substitution of unavailable drugs is a factor that can contribute to reducing health care costs for patients and to their satisfaction.

OBJECTIF: Etudier le rôle et la responsabilité du pharmacien pouvant contribuer à assurer la pérennité de l'Assurance Maladie Obligatoire (AMO) au Mali. MATÉRIEL ET MÉTHODES: Il s'agissait d'une étude transversale descriptive qui s'est déroulée à Bamako du 1 er octobre 2016 au 31 décembre 2017. Nous avons réalisé une analyse documentaire et des entrevues avec 36 pharmaciens, 400 assurés, 90 prescripteurs et 04 personnes ressources des organismes délégués de gestion. L'analyse des données des entrevues a été faite par le logiciel SPSS 20. RÉSULTATS: Au total 2 lois et 6 décrets consacrent les dispositions législatives et réglementaires de l'AMO. La majorité des assurés (90 %) pensaient que le pharmacien est un spécialiste du médicament. Plus de 80 % des médicaments figurant sur les feuilles de soins étaient intégralement disponibles. Parmi leursmissions dans le cadre de la mise en œuvre de l'AMO, 38,9% des pharmaciens ont cité la disponibilité des médicaments, 27,70 l'application des bonnes pratiques de dispensation et 16,7% le droit de substitution. CONCLUSION: La substitution des médicaments non disponibles est un facteur pouvant contribuer à la réduction des dépenses de santé pour les patients et à leur satisfaction.

[Evaluation of ambulance transport relevance of dialysis patients in the PACA region (France), and estimation of savings by the Health Insurance]. / Évaluation de la pertinence des transports par ambulance des patients dialysés en région PACA, et estimation des économies réalisables par l'Assurance maladie.

INTRODUCTION: Patient transport represents the second largest item of cost of dialysis after hospitalization. A significant proportion of patients transported by ambulance are self-sufficient for walking. DESCRIPTION: A study was carried out in the PACA region (France) to analyse the profile of patients transported by ambulance and self-sufficient for walking and then to evaluate the savings for the Health Insurance. METHODS: A triangulation of data was carried out using data from haemodialysis patients recorded in the French REIN Registry in 2017 and data from two surveys: one of a sample of patients transported by ambulance and autonomous in walking, and the other of 62 nephrologists. RESULTS: The data from the REIN register allowed us to estimate that 44 % of patients transported by ambulance are self-sufficient for walking. Our study allowed us to estimate that 2/3 of patients transported by ambulance, self-sufficient for walking, have a reason for being transported by ambulance; for the third without a reason, the health insurance savings would amount to €2 million per year with a reclassification of their transport as seated transport. The survey of prescribers showed that there are exemptions justified by a temporary deterioration in health and/or housing conditions, but also by the lack of seated transport. CONCLUSION: One third of the patients, transported by ambulance and self-sufficient for walking, would have an inappropriate transport. This would be explained by the fluctuating state of health of the patients and would also linked to the lack of seated transportation. Savings are possible and depend in part on improved management of the supply.

[Factors associated to the implementation of compulsory health insurance at the CHC level in Kalaban Coro, Kati, Mali]. / Lies a la mise en œuvre de l'assurance maladie obligatoire au niveau des cscoms a Kalaban Coro, Kati, Mali.

OBJECTIVE: To identify the factors influencing the implementation of compulsory health insurance in two community health centers (CHC) in the health district of Kalaban Coro in Kati. MATERIAL METHODS: It was a cross-sectional descriptive study from July 1, 2017 to October 31, 2018 in both CHC of Koulouba and Kalaban Coro central. We conducted a literature review and in-depth interviews with 20 people. A content analysis was done manually using deductive and inductive logic. RESULTS: Out of all the services in 2017, those insured by the compulsory health insurance benefited from 5% of deliveries, 7% of the first antenatal cares and 8% of curative cares at the CHC of Koulouba against 0.1%, 0,3% and 3% respectively in CHC of Kalaban Coro central. The implementation of the compulsory health insurance and the reimbursement mechanisms have been facilitated through the establishment of information and communication channels, the training of members of the Federations of Community Health Associations at national, regional and local levels and other forms of support for CHC. The reimbursement period was 1-3 months in Koulouba against an absence since 2017 in Kalaban Coro central. Governance, monitoring and evaluation and staff motivation systems were weak or nonexistent. They resulted in financial and drug supply difficulties. CONCLUSION: Among the factors identified, the reimbursement mechanism posed the most problem for CHC and delegated management organizations.

OBJECTIF: Identifier les facteurs influençant la mise en œuvre de l'assurance maladie obligatoire dans deux centres de santé communautaire du district sanitaire de Kalaban Coro dans le Cercle de Kati. MATÉRIEL MÉTHODES: il s'agissait d'une étude transversale descriptive couvrant la période du 1er juillet 2017 au 31 octobre 2018 dans les CSComs de Koulouba et Kalaban Coro central. Nous avons réalisé une analyse documentaire et des entrevues individuelles approfondies de 20 personnes. Une analyse de contenu a été faite manuellement selon les logiques déductive et inductive. RÉSULTATS: Sur l'ensemble des prestations en 2017, les assurés de l'AMO ont bénéficié de 5% des accouchements, 7% des premières consultations prénatales et 8% des consultations curatives au niveau du CSCom de Koulouba contre respectivement 0,1%, 0,3% et 3% à Kalaban Coro central. La mise en œuvre de l'AMO et les mécanismes de remboursement ont été facilités grâce à la mise en place des canaux d'informations et de communications, à la formation des membres des Fédérations des ASACO au niveau national, régional et local et à d'autres formes d'appuis aux CSComs. Le délai de remboursement était de 1-3mois à Koulouba contre une absence depuis 2017 à Kalaban Coro central. Les systèmes de gouvernance, de suivi et évaluation et de motivations du personnel étaient insuffisants, voire inexistant. Ils avaient pour conséquences, des difficultés financières et d'approvisionnement en médicaments. CONCLUSION: Parmi les facteurs identifiés, le mécanisme de remboursement des prestations posait le plus de problème aux CSComs et organismes gestionnaires délégués.

[Screening for diabetic retinopathy in the Centre-Val de Loire region: A study based on the French national healthcare database]. / Suivi ophtalmologique des patients diabétiques en région Centre-Val de Loire : une étude issue du Système national des données de santé (SNDS).

INTRODUCTION: The main objective of this study was to investigate the rate of ophthalmological screening for diabetic retinopathy in diabetic individuals in the Centre-Val de Loire (CVDL) region. This study secondarily aimed to identify factors associated with regular ophthalmological screening. MATERIAL AND METHODS: Data were extracted from the French national healthcare database (SNDS). Individuals were identified on the basis of reimbursements for antidiabetic medications. Patients who were identified as having at least one reimbursed eye examination between 2015 and 2016 were considered as having regular follow-up. RESULTS: In total, 118,181 diabetic individuals residing in CVDL were identified in the SNDS, and 74,048 had undergone ophthalmological screening. The rate of eye examination was 62.7% between 2015 and 2016 and was highly variable within the region (from 65.6% in Loiret to 54.0% in Cher). The main factors associated with regular eye screening were: follow-up with an established primary care physician (OR=2.88), regular follow-up with a diabetologist (OR=2.14), and regular follow-up with an internist (OR=1.57). CONCLUSION: This study suggests that ophthalmological screening for diabetic retinopathy in individuals with diabetes in the CVDL region could be significantly improved, particularly in rural areas. Factors influencing compliance with follow-up are multiple but appear mainly related to the patients' quality of overall medical management. These findings highlight the need for public health policies to improve detection and prevention of diabetic retinopathy by promoting comprehensive medical care for diabetic individuals.

Care quality for rheumatoid arthritis patients in Quebec.

AIM: The aims of this study were to: (a) measure the proportion of CARTaGENE rheumatoid arthritis (RA) patients fulfilling pre-specified quality indicators (ie disease-modifying antirheumatic drug [DMARD] use, regular follow up, use of folate supplementation, use of vitamin D and calcium, exercise and smoking status); and (b) examine variation in DMARD use with respect to patient age, sex, education and income. METHODS: A cohort of RA patients was constructed based on the CARTaGENE survey and health administrative database. CARTaGENE is a large, established, population-based study which recruited 19 995 participants from four metropolitan regions in Quebec. Six quality indicators (QI) were assessed; four pertained to RA management and treatment received (use of DMARD therapy, annual medical visits, use of folate supplementation with methotrexate therapy, and use of calcium and vitamin D in steroid-exposed patients) and two pertained to lifestyle factors (physical activity and smoking cessation). QI were reported in terms of proportion of patients fulfilling them. Bayesian logistic regression analyses were preformed to investigate potential variation with DMARD use. RESULTS: Our cohort included 142 RA patients. The QI that pertain to RA pharmacotherapy and medical management ranged 60-80%. Regarding the QI focusing on lifestyle factors, 55% of patients reported performing moderate physical activity and only 16.6% reported current smoking. Results from the Bayesian logistic regression showed no definite associations between DMARD use and patient characteristics (age, education, income and sex). CONCLUSION: Our findings suggest a seemingly modest performance of Quebec's health-care system for RA patients, with respect to these QI.