Proposing a health-specific organizational impact framework to evaluate organizational impacts in health technology assessments

OBJECTIVES

Health technology assessments (HTAs) have traditionally included clinical and cost-effectiveness evaluation of new health technologies (HTs). However, new HTs can generate important organizational impacts (OIs) that influence their overall value. OIs are currently not clearly identified and evaluated in HTA procedures and tools are limited. To address this issue, a comprehensive framework that allows to assess OIs of new HTs in HTAs is proposed.

METHODS

A working and methodological group identified the Oslo Manual 2018, 4th edition, OECD/Eurostat, on the objectives and outcomes of commercial innovations as the basis for the OIs framework for HTAs. The Oslo Manual was translated to the healthcare sector and adapted to HTA procedures through a three-step process.

RESULTS

The framework is composed of three main parts. Part I tackles the context of the evaluation, Part II the categories of impacts and the specific impacts - in total, 16 OIs were identified - and Part III the stakeholders involved. The central part of the framework is Part II, and consists of three categories of impacts: (i) on the care process, (ii) on the stakeholders' capabilities and skills, and (iii) on society or the community.

CONCLUSIONS

This framework provides a comprehensive and structured basis to document OIs of new HTs. It thus contributes to the extension of HTA evaluation criteria to other dimensions than clinical and economic aspects, that is, organizational aspects. Some of its intrinsic limitations and the questions they raise in the field for policy-makers, practitioners, and researchers are discussed.

Stroke Care in Brazil and France: National Policies and Healthcare Indicators Comparison

Objective

To identify the commonalities and discrepancies between national health policies to combat stroke in France and Brazil.

Justification

Both healthcare systems were structured as universal access and comprehensive care attention, hierarchized by the level of care, politically and administratively decentralized. France is an industrialized, high-income country, with health care involving copayment and reimbursement of expenses, and spontaneous demand for services. Brazil is a member of the BRICs, of upper middle income with totally free health care, with an active search for hypertension and diabetes in the general population.

Methods

Data regarding policies, risk factors, and health indicators about stroke care, from 2010 to 2017, were obtained from both countries (publicly accessible information or on request) from the respective Ministries of Health or international agencies.

Results

About acute stroke hospitalizations, on average, Brazil has 0.75 per 1000 annual population hospitalizations versus 1.54 per 1000 in France. Brazil has 0.21 per 1000 population deaths per year versus 0.40 per 1000 in France. The in-hospital mortality rate in Brazil has 139 per 1000 hospitalized people versus 263 in France. The average length of stay of acute hospitalizations was 7.6 days in Brazil versus 12.6 in France. The prevalence of strokes by age group shows from 0 to 39 years old (this rate is stable); 40–59 years (it is increasing in both countries); and 60–79 and 80+ years (this rate has been increasing in France and decreasing in Brazil).

Conclusion

No major differences were found about the health policies and the National Health Plans related to stroke. However, the data directly linked to the period of hospitalization differed substantially between countries. Subsequent studies can be implemented to identify the explanatory factors, notably among the risk factors and actions in primary care, and the moments after hospital care, such as secondary prevention and palliative care.

The vaccination coverage in dispensaries on Mayotte Island is lacking for natives and migrants alike

OBJECTIVE

Assessing the vaccination coverage rate in Mayotte dispensaries.

PATIENTS AND METHODS

Prospective study in three dispensaries from June to July 2019.

RESULTS

Of the 162 patients included, 78% (126/162) were natives of the island and 19% (30/162) were from the Comoros Islands. Twenty-three percent (37/162) were up-to-date on their mandatory vaccinations, 45% (73/162) were not and 32% (52/162) had unknown vaccination status. There was no difference in relation to their origin. Some vaccinations were strictly followed (MMR, Hepatitis B…) others were not (HiB, meningitides…). The vaccination coverage rate and its traceability are altogether lacking whatever the age or origin of patients. Efforts must be made in order to increase the vaccination coverage rate among people who, from our experience, do not oppose vaccination in any way.

Y-a-t’il eut une intelligence collective face à l’émergence du SRAS-Cov2 en France ?

Introduction

Dès le début de l’arrivée du virus en France, la transmission d’information entre médecins s’est transformée avec la mise en place spontanée de nouveaux réseaux de communication entre médecins face à l’épidémie. L’objectif de ce travail est d’étudier la réalité de l’intelligence collective médicale au cours de la pandémie de Covid-19 en analysant l’émergence et la diffusion de quatre informations médicales nouvelles durant la quarantaine.

Matériels et méthodes

Nous avons étudié les différents messages d’information circulant entre médecins puis leur reprise dans la presse écrite nationale durant l’épidémie de COVID-19 en France pendant la période de confinement pour quatre informations médicales : anosmie/agueusie, l’atteinte dermatologique, le lien entre tabagisme et COVID19 et enfin l’intérêt du traitement par hydroxychloroquine. Le corpus était constitué des messages d’alertes COVID du 14 mars 2020 au 11 mai 2020, reçus par SMS, messages WhatsApp, mails, publications des sociétés savantes et enfin, les publications scientifiques. Les articles de presse écrite ont été recherchés par le moteur de recherche Europresse et les articles scientifiques par PubMed.

Résultats

(a) Lésions dermatologiques liée au COVID : onze alertes ont circulé entre médecins dès le 2 avril 2020 (3 mails, 5 messages WhatsApp et 3 articles scientifiques le premier publié le 15/04/20). Un seul article évoque cette alerte dans la presse généraliste française publié le 8 avril 2020 dans le Point. (b)Symptômes d’anosmie agueusie : 21 alertes entre médecins ont circulé dès le 20 mars 2020 (4 mails, 1 SMS, 1 message WhatsApp, 11 articles scientifiques dont le 1^er publié le 26/03/20) et 28 articles dans la presse nationale généraliste dès le 20 mars 2020. (c) Lien entre tabac et COVID : 7 alertes ont circulées entre médecins (7 articles scientifiques dès le 02/04/20 dont 1 article d’une équipe française mis en ligne sur une plateforme en accès libre le 21 avril 2020) suivis par 25 articles dans la presse écrite nationale dès le 13 avril 2020. (d) Traitement par chloroquine : nombreuses alertes entre médecins ont été publiées (4 mails, 918 articles scientifiques), 3278 articles y sont consacrés dans la presse écrite nationale dont le premier publié le 18 février 2020 dans le Monde. À titre comparatif une recherche dans la presse nationale généraliste avec les mots clés « Anticorps monoclonaux », « Tocilizumab », « azithromycine », « Remdesivir » donnent respectivement, 61, 123, 281 et 493 résultats.

Conclusion

Au vu de cette analyse, les réseaux sociaux ont relayé avec efficacité les messages d’alerte pendant l’épidémie, à un moment où les médecins n’avaient pas forcément du temps de lire la littérature scientifique quotidienne. Néanmoins, si la diffusion a été large par ces canaux, le gain de temps a été faible puisque les messages ont presque tous été relayés de manière simultanée dans la presse généraliste et scientifique à quelques jours d’intervalle.

Risk profile, quality of life and care of patients with moderate and advanced CKD: The French CKD-REIN Cohort Study

Background

The French Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort study was designed to investigate the determinants of prognosis and care of patients referred to nephrologists with moderate and advanced chronic kidney disease (CKD). We examined their baseline risk profile and experience.

Methods

We collected bioclinical and patient-reported information from 3033 outpatients with CKD and estimated glomerular filtration rates (eGFRs) of 15-60 mL/min/1.73 m2 treated at 40 nationally representative public and private facilities.

Results

The patients' median age was 69 (60-76) years, 65% were men, their mean eGFR was 33 mL/min/1.73 m2, 43% had diabetes, 24% had a history of acute kidney injury (AKI) and 57% had uncontrolled blood pressure (BP; >140/90 mmHg). Men had worse risk profiles than women and were more likely to be past or current smokers (73% versus 34%) and have cardiovascular disease (59% versus 42%), albuminuria >30 mg/mmol (or proteinuria > 50) (40% versus 30%) (all P < 0.001) and a higher median risk of end-stage renal disease within 5 years, predicted by the kidney failure risk equation {12% [interquartile range (IQR) 3-37%] versus 9% [3-31%], P = 0.008}. During the previous year, 60% of patients reported one-to-two nephrologist visits and four or more general practitioner visits; only 25% saw a dietician and 75% were prescribed five or more medications daily. Physical and mental quality of life (QoL) were poor, with scores <50/100.

Conclusions

The CKD-REIN study highlights high-risk profiles of cohort members and identifies several priorities, including improving BP control and dietary counselling and increasing doctors' awareness of AKI, polypharmacy and QoL.

Trial registration

ClinicalTrials.gov identifier: NCT03381950.

Cerebellopontine angle subdural empyema in a 2-years old patient with bilateral mastoiditis - a life-threatening condition. Case presentation and review of literature

Infratentorial subdural empyema is a life-threatening condition, the common source being an ear infection. We present a 2-year old boy treated for bilateral mastoiditis, with infratentorial-left cerebellopontine angle subdural empyema. Clinical presentation encompassed a systemic febrile illness, headaches, and a stiff neck. Empyema was diagnosed with computed tomography and magnetic resonance imaging. The patient was successfully treated with surgery and appropriate antibiotics. Empyema should be considered in patients with ENT infection associated with neurological signs that suggest a posterior fossa lesion.

The French Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort study

BACKGROUND

While much has been learned about the epidemiology and treatment of end-stage renal disease (ESRD) in the last 30 years, chronic kidney disease (CKD) before the end-stage has been less investigated. Not enough is known about factors associated with CKD progression and complications, as well as its transition to ESRD. We designed the CKD-renal epidemiology and information network (REIN) cohort to provide a research platform to address these key questions and to assess clinical practices and costs in patients with moderate or advanced CKD.

METHODS

A total of 46 clinic sites and 4 renal care networks participate in the cohort. A stratified selection of clinic sites yields a sample that represents a diversity of settings, e.g. geographic region, and public versus for-profit and non-for-profit private clinics. In each site, 60-90 patients with CKD are enrolled at a routine clinic visit during a 12-month enrolment phase: 3600 total, including 1800 with Stage 3 and 1800 with Stage 4 CKD. Follow-up will continue for 5 years, including after initiation of renal replacement therapy. Data will be collected from medical records at inclusion and at yearly intervals, as well as from self-administered patient questionnaires and provider-level questionnaires. Patients will also be interviewed at baseline, and at 1, 3 and 5 years. Healthcare costs will also be determined. Blood and urine samples will be collected and stored for future studies on all patients at enrolment and at study end, and at 1 and 3 years in a subsample of 1200.

CONCLUSIONS

The CKD-REIN cohort will serve to improve our understanding of the biological, clinical and healthcare system determinants associated with CKD progression and adverse outcomes as well as of international variations in collaboration with the CKD Outcome and Practice Pattern Study (CKDopps). It will foster CKD epidemiology and outcomes research and provide evidence to improve the health and quality of life of patients with CKD and the performances of the healthcare system in this field.

The context of available options affects health care decisions: a generalization study

BACKGROUND

When a given option is presented along with 2 alternatives, similar to each other, health care professionals choose it more often than when it is presented with just one of the alternatives. This inconsistent decision pattern may depend on the conflict generated from choosing between 2 highly similar options.

OBJECTIVE

To generalize the effect by using realistic scenarios that involve 2 alternatives displaying various degrees of similarity.

METHODS

One hundred fifty-five psychiatrists, 149 gynecologists, and 89 nurse managers had to indicate the treatment they would recommend in clinical scenarios containing either 3 options or just 2 of them. The similarity between the 2 alternatives varied across scenarios, ranging from a very high (psychiatric scenario) to an only moderately high (nursing management scenario) to a limited level (gynecological scenario).

RESULTS

Professionals chose the focal option more often when both alternatives were available. The paradoxical effect occurred for all scenarios--namely, when the alternatives were medication variants (psychiatric scenario), when most of the features they shared produced their effect at a different extent in the 2 cases (nursing management scenario), and some of their consequences were at variance (gynecological problem).

CONCLUSIONS

The context of available options affects professionals' choices when the alternatives are similar but also when they present diverging features. Professionals need to be aware of such a source of practice variability and are encouraged to consider each option per se before they compare the available options.

New aeromagnetic and gravity compilations from Norway and adjacent areas: methods and applications

The Geological Survey of Norway (NGU) has produced new aeromagnetic and gravity maps from Norway and adjacent areas, compiled from ground, airborne and satellite data. Petrophysical measurements on core samples, hand specimens and onin situbedrock exposures are essential for the interpretation of these maps. Onshore, the most prominent gravity and magnetic anomalies are attributed to lower crustal rocks that have been brought closer to the surface. The asymmetry of the gravity anomalies along the Lapland Granulite Belt and Kongsberg–Bamble Complex, combined with the steep gradient, points to the overthrusted high-density granulites as being the main source of the observed anomalies. The Kongsberg–Bamble anomaly can be traced southwards through the Kattegat to southern Sweden. This concept of gravity field modelling can also be applied to the Mid-Norwegian continental shelf and could partially explain the observed high-density rocks occurring below the Møre and Vøring basins and in the Lofoten area. Extrapolations of Late-Caledonian detachment structures occurring on the mainland can be traced on aeromagnetic and gravimetric images towards the NW across the continental margin. Subcropping Late Palaeozoic to Cenozoic sedimentary units along the mid-Norwegian coast produce a conspicuous magnetic anomaly pattern. The asymmetry of the low-amplitude anomalies, with a steep gradient and a negative anomaly to the east and a gentler gradient to the west, relates the anomalies to gently westward dipping strata. Recent aeromagnetic surveys in the Barents Sea have revealed negative magnetic anomalies associated with shallow salt diapirs. Buried Quaternary channels partly filled with gravel and boulders of crystalline rocks generate magnetic anomalies in the North Sea. The new maps also show that the opening of the Norwegian–Greenland Sea occurred along stable continental margins without offsets across minor fracture zones, or involving jumps in the spreading axis. A triple junction formed at 48 Ma between the Lofoten and Norway Basins.

Potential mechanisms for the genesis of Cenozoic domal structures on the NE Atlantic margin: pros, cons and some new ideas

The mild compressional structures of Cenozoic age on the passive margins bordering Norway, the UK, the Faroes and Ireland have been the subject of much discussion in the literature. Nevertheless, their origin remains enigmatic. Candidate mechanisms must be able to explain the generation of sufficient stress to cause deformation, the episodic nature of the structures and why they developed where they did. We examine these mechanisms and conclude that multiple causes are probable, while favouring body force as potentially the most important agent.

The geometry and setting of the structures are incompatible with gravitational sliding and toe-thrusting, probably the commonest ‘compressive’ structuring around the Atlantic margins. A passive mode of origin featuring drape or flank sedimentary loading probably emphasized some of the structures, but cannot be invoked as a primary mechanism. Likewise, reactivation of basement structure probably focused deformation but did not initiate it. Far-field orogenic stress from Alpine orogenic phases and from the West Spitsbergen–Eurekan folding and thrusting is also examined. This mechanism is attractive because of its potential to explain episodicity of the compressional structures. However, difficulties exist with stress transmission pathways from these fold belts, and the passive margin structures developed for much of their existence in the absence of any nearby contemporaneous orogeny. Breakup and plate spreading forces such as divergent asthenosheric flow have potential to explain early post-breakup compressional structuring, for example on the UK–Faroes margin, but are unlikely to account for later (Neogene) deformation.

Ridge push, generally thought to be the dominant body force acting on passive margins, can in some circumstances generate enough stress to cause mild deformation, but appears to have low potential to explain episodicity. It is proposed here that the primary agent generating the body force was development of the Iceland Insular Margin, the significant bathymetric-topographic high around Iceland. Circumstantially, in Miocene times, this development may also have coincided with the acme of the compressional structures. We show that, dependent on the degree of lithosphere–asthenosphere coupling, the Iceland Plateau may have generated enough horizontal stress to deform adjacent margins, and may explain the arcuate distribution of the compressional structures around Iceland.

Assuming transmission of stress through the basement we argue that, through time, the structures will have developed preferentially where the basement is hotter, weaker and therefore more prone to shearing at the relatively low stress levels. This situation is most likely at the stretched and most thermally-blanketed crust under the thickest parts of the young (Cretaceous–Cenozoic) basins. Although several elements of this model remain to be tested, it has the potential to provide a general explanation for passive margin compression at comparatively low stress levels and in the absence of nearby orogeny or gravitational sliding.

[Epidemiology and clinical characteristics of childhood parapneumonic empyemas]

Several studies have reported an increasing incidence of childhood parapneumonic empyemas in various countries.

AIM OF THE STUDY

The aim of our study was to estimate the annual incidence of complicated community-acquired pneumonias in children during a 9-year period in a French area and to describe the epidemiological and clinical characteristics of these complications.

POPULATION AND METHODS

We have listed the children from 28 days to 15 years old, hospitalized in the 2 children hospitals of the Isere district for a community-acquired pneumonia complicated with a pleural empyema or a pulmonary abscess from 1995 to 2003.

RESULTS

During the study period, 90 children were hospitalized for a complicated pneumonia including 83 pleural empyemas and 7 isolated lung abscess. The average number of cases was 4 per year from 1995 to 1998 then increased since 1999 to reach 34 cases in 2003, according to a linear model (P<0,001). The incidence of the complicated pneumonia, plotted to the paediatric population of the area has gone up from 0.5 per 100000 to 13 per 100000 children between 1995 and 2003.

CONCLUSION

The incidence of the complicated pneumonias in children increased since 1999 in a French area. Additional investigations are necessary to identify the causes of this increase.

Bénéfice de l'utilisation saisonnière d'un test de diagnostic rapide (TDR) de la grippe aux urgences pédiatriques

Influenza virus infections are current in viral infections of childhood. The quick test is now available and we want to assess its clinical and economical benefit through an unicentric study and during two seasons of influenza pandemic. An hospitalization avoided due to a quick test is equivalent to 20 to 30 general practitioner fixes fees. For social security, it is equivalent to 55 to 83 quick tests per child per hospitalization avoid. We plead for free test during influenza pandemic.

[Non-compaction of the myocardium in childhood]

Non compaction of the ventricular myocardium is a rare and severe myocardiopathy with numerous trabeculations and deep intertrabecular recesses directly connected with the ventricular cavity. Many complications may occur: heart failure, arrythmia, thrombotic events. However, phenotypic and genotypic presentations vary. Non compaction affects infants in almost half of the cases. A pediatric national cohort study (directed by the filiale de cardiologie pédiatrique de la société française de cardiologie) should allow to analyse the clinical and epidemiological characteristics of the patients as well as to accurate both non compaction's diagnosis and prognosis. Inclusion criteria of this retrospective multicenter study were: age lesser than 18, echographic and/or histologic criteria of non compaction, no congenital heart disease such as pulmonary atresia. This population included 38 patients: 21 were asymptomatic at diagnosis. Ten familial forms were detected. The ECG was abnormal in 77% of the cases, the chest-X ray in 80%. Echocardiography remains the usual technique for diagnosis. However, previously reported quantitative criteria are not easy to use in a retrospective study. Treatment was symptomatic as the etiology of non compaction is unknown. The prognosis is severe: 31.5% of the patients died or had a cardiac transplantation. Only 30% of the patients were free of cardiac events for a 2-year period. Inclusion of new patients must go on to set up a prospective study and biomolecular analysis in informative families.

Risk factors for self-injurious behaviours among 222 young children with autistic disorders

The aim of this study was to identify risk factors for self-injurious behaviours (SIBs) in children with autistic disorders. The occurrence of SIB was examined in comparison with the following variables: chronological age, sex, adaptive skills, speech level, associated medical condition, degree of autism and parental social class. The subjects were 222 children aged under 7 years and all of them fulfilled the ICD-10 criteria for infantile autism. Retrospective data were collected on demographic characteristics and medical condition. Children were assessed in terms of speech, degree of autism and adaptive skills in communication, socialization and daily living skills domains. Results indicated that 50% of the children experienced SIB and 14.6% had severe SIBs. Lower chronological age, associated perinatal condition, a higher degree of autism and a higher daily living skills delay were risk factors of SIBs but parental class, sex and epilepsy were not.

Development of a reversed-phase ion-pairing liquid chromatographic assay of daunorubicin for pharmacopoeial use

A liquid chromatographic method is described for the determination of daunorubicin using octyldecylsilyl columns and sodium dodecyl sulphate as ion-pairing agent. The method based on previous publication [M. A. van Lancker et. al., J. Chromatogr., 254 (1983) 45] is specific for daunoribicin and separates it from likely impurities, e.g., the aglycone, duborimycin and related anthracyclines, doxorubicin and epirubicin. Several commercial batches have been examined in a number of laboratories employing various types of stationary phases. The intralaboratory reproducibilities varied from 1.0 to 1.6% and the interlaboratory reproducibility between 0.63 and 1.0% (based on the means of duplicate determinations), while with the preferred mobile phase the coefficient of variation was 0.3% (n = 4). The method is robust and is proposed for inclusion in a monograph on daunorubicin which is currently under consideration by the European Pharmacopoeia.

Antibacterial activities of erythromycins A, B, C, and D and some of their derivatives

The MICs of erythromycins A, B, C, and D and some of their derivatives were determined against 21 gram-positive and 15 gram-negative microorganisms. Antibacterial activity was confined to gram-positive and very few gram-negative bacteria. Erythromycin B was somewhat less active than erythromycin A, and erythromycin C and D showed about half that activity or even less. Most other derivatives had negligible activity. Determination of potency by diffusion and turbidimetric assays were in line with MICs. The examination of the results of these assays, however, revealed that there are differences between the data of different laboratories, depending on the microorganisms and conditions used.

Nosiheptide, a sulfur-containing peptide antibiotic isolated from Streptomyces actuosus 40037

Nosiheptide (9671 R.P.) isolated from Streptomyces actuosus 40037 (NRRL 2954) is a sulfur-containing polypeptidic antibiotic, quite different from all the other members of this family. Very active in vitro against gram-positive bacteria, it is inactive in vivo in experimentally infected mice. Not toxic, even at high dose, it may be used as a feed additive for chickens and pigs and it shows a favourable effect on the growth and conversion index.

Primary in vitro antibody response in human cord blood lymphocytes

Human cord blood lymphocytes were stimulated with trinitrophenyl--polyacrylamide beads (TNP--PAA) in order to induce a primary IgM anti-TNP response. With few exceptions, no anti-TPN response was obtained, whereas peripheral blood lymphomonocytic cells (PBL) from 18-mth-old children were able to respond to TNP-PAA. The addition of lipopolysaccharide (LPS) or of mitomycin-treated adult PBL to cultures of cord blood lymphocytes significantly enhanced their anti-TNP response, thus showing that functional anti-TNP B cell precursors are present in the human neonate.

[Exploration of humoral immunity in man using blood lymphocytes cultures (author's transl)]

New methods allow the study of humoral immunity in man using blood lymphocyte cultures. A primary in vitro antibody response can be induced, characterized by the appearance of antibody forming cells, and its pattern is as follows: stringent culture requirements, which have been so far obtained in few laboratories; the kinetics of the response, with a peak on day 7--8; and exclusively IgM response; a T-cell requirement. Among these methods, the model we have described has the advantage of allowing a reproductible response in a given individual. The in vitro study of humoral immunity has limitations, the most apparent of which is that it addresses itself to only one lymphoid population, that in peripheral blood, easily accessible. It presents several advantages, as compared to an in vivo study after injection of an antigen: absence of ethical problem; the necessity of only one blood sample, at a given time, avoiding the interference of a treatment started after the test; the possibility of performing successive primary stimulations for a longitudinal study.