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d’Elbée M, Harker M, Mafirakureva N, Nanfuka M, Huyen Ton Nu Nguyet M, Taguebue JV, Moh R, Khosa C, Mustapha A, Mwanga-Amumpere J, Borand L, Nolna SK, Komena E, Cumbe S, Mugisha J, Natukunda N, Mao TE, Wittwer J, Bénard A, Bernard T, Sohn H, Bonnet M, Wobudeya E, Marcy O, Dodd PJ. Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis in six high tuberculosis incidence countries: a mathematical modelling study. EClinicalMedicine 2024; 70:102528. [PMID: 38685930 PMCID: PMC11056392 DOI: 10.1016/j.eclinm.2024.102528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/23/2024] [Accepted: 02/21/2024] [Indexed: 05/02/2024] Open
Abstract
Background The burden of childhood tuberculosis remains high globally, largely due to under-diagnosis. Decentralising childhood tuberculosis diagnosis services to lower health system levels could improve case detection, but there is little empirically based evidence on cost-effectiveness or budget impact. Methods In this mathematical modelling study, we assessed the cost-effectiveness and budget impact of decentralising a comprehensive diagnosis package for childhood tuberculosis to district hospitals (DH-focused) or primary health centres (PHC-focused) compared to standard of care (SOC). The project was conducted in Cambodia, Cameroon, Côte d'Ivoire, Mozambique, Sierra Leone, and Uganda between August 1st, 2018 and September 30th, 2021. A mathematical model was developed to assess the health and economic outcomes of the intervention from a health system perspective. Estimated outcomes were tuberculosis cases, deaths, disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs). We also calculated the budget impact of nationwide implementation. The TB-Speed Decentralization study is registered with ClinicalTrials.gov, NCT04038632. Findings For the DH-focused strategy versus SOC, ICERs ranged between $263 (Cambodia) and $342 (Côte d'Ivoire) per DALY averted. For the PHC-focused strategy versus SOC, ICERs ranged between $477 (Cambodia) and $599 (Côte d'Ivoire) per DALY averted. Results were sensitive to TB prevalence and the discount rate used. The additional costs of implementing the DH-focused strategy ranged between $12.8 M (range 10.8-16.4) (Cambodia) and $50.4 M (36.5-74.4) (Mozambique), and between $13.9 M (12.6-15.6) (Sierra Leone) and $134.6 M (127.1-143.0) (Uganda) for the PHC-focused strategy. Interpretation The DH-focused strategy may be cost-effective in some countries, depending on the cost-effectiveness threshold used for policy making. Either intervention would require substantial early investment. Funding Unitaid.
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Affiliation(s)
- Marc d’Elbée
- University of Bordeaux, National Institute for Health and Medical Research (Inserm) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux, France
- Ceped UMR 196, Université Paris Cité, Research Institute for Sustainable Development (IRD), Inserm, Paris, France
| | - Martin Harker
- TB Modelling Group, TB Centre, and Global Centre for Health Economics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Mastula Nanfuka
- MU-JHU Care Ltd, MUJHU Research Collaboration, Kampala, Uganda
| | - Minh Huyen Ton Nu Nguyet
- University of Bordeaux, National Institute for Health and Medical Research (Inserm) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux, France
| | | | - Raoul Moh
- Teaching Unit of Dermatology and Infectiology, UFR of Medical Sciences, Félix-Houphouët Boigny University, Abidjan, Côte d’Ivoire
- Programme PAC-CI, CHU de Treichville, Abidjan, Côte d’Ivoire
| | - Celso Khosa
- Instituto Nacional de Saúde, Marracuene, Mozambique
| | | | | | - Laurence Borand
- Epidemiology and Public Health Unit, Clinical Research Group, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Eric Komena
- Programme PAC-CI, CHU de Treichville, Abidjan, Côte d’Ivoire
| | | | | | | | | | - Jérôme Wittwer
- University of Bordeaux, National Institute for Health and Medical Research UMR 1219, Bordeaux, France
| | - Antoine Bénard
- CHU Bordeaux, Service d'information Médicale, USMR & CIC-EC 14-01, Bordeaux, France
| | | | - Hojoon Sohn
- Seoul National University College of Medicine, Seoul, South Korea
| | - Maryline Bonnet
- TransVIHMI, University of Montpellier, IRD /INSERM, Montpellier, France
| | - Eric Wobudeya
- MU-JHU Care Ltd, MUJHU Research Collaboration, Kampala, Uganda
| | - Olivier Marcy
- University of Bordeaux, National Institute for Health and Medical Research (Inserm) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux, France
| | - Peter J. Dodd
- School of Health & Related Research, University of Sheffield, Sheffield, United Kingdom
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Wallerich L, Fillol A, Rivadeneyra A, Vandentorren S, Wittwer J, Cambon L. Environment and child well-being: A scoping review of reviews to guide policies. Health Promot Perspect 2023; 13:168-182. [PMID: 37808945 PMCID: PMC10558968 DOI: 10.34172/hpp.2023.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/18/2023] [Indexed: 10/10/2023] Open
Abstract
Background Acting on social determinants is the most effective, efficient, and fairest strategy to improve population health and health equity. Because of their vulnerability and dependence, children are particularly exposed to the deleterious effects of their living environment. Taking these issues into account in the development of public policies and identifying levers for action are crucial. The objective of this scoping review of reviews is to identify the main environmental determinants on children's health and development, and their mechanisms of effect, to be addressed by public policies. Methods We conducted a scoping review of reviews in accordance with the method developed by Arksey and O'Malley, and Levac and colleagues' methodology advancement and the PRISMA guideline. Inclusion criteria were identified with the PICos (population-phenomena of interest-context-study design) framework. We used the PubMed database and conducted a thematic analyze. Results Forty-seven articles were selected. Their analysis allowed us to identify five categories of interdependent environmental determinants of child health: i) urban design ii) contaminants, iii) parenting environment, iv) social conditions, v) climate change. Together and in a systemic way, they act on the health of the child. Conclusion The review carried out allows us to propose a pragmatic framework for clarifying the effects of the physical, social, and economic environment on children's health and wellbeing.
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Affiliation(s)
- Louise Wallerich
- University of Bordeaux, INSERM, BPH, U1219, Mérisp/PHARES, Equipe Labellisée Ligue Contre le Cancer, CIC 1401, F-33000 Bordeaux, France
| | - Amandine Fillol
- University of Bordeaux, INSERM, BPH, U1219, Mérisp/PHARES, Equipe Labellisée Ligue Contre le Cancer, CIC 1401, F-33000 Bordeaux, France
| | - Ana Rivadeneyra
- Institute of Public Health, Epidemiology and Development, Bordeaux, France
- Equipe PHARes, Bordeaux Population Health, Bordeaux, France
| | - Stéphanie Vandentorren
- French Public Health Agency, F-94415 Saint-Maurice, France
- University of Bordeaux, Centre INSERM U1219 Bordeaux Population Health Research Center, Bordeaux, France
| | - Jérôme Wittwer
- University of Bordeaux, Centre INSERM U1219 Bordeaux Population Health Research Center, Bordeaux, France
| | - Linda Cambon
- University of Bordeaux, INSERM, BPH, U1219, Mérisp/PHARES, Equipe Labellisée Ligue Contre le Cancer, CIC 1401, F-33000 Bordeaux, France
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Boespflug N, Wittwer J, Bénard A. Factors associated with the author-reported cost-effectiveness threshold in high-income countries: systematic review and multivariable modelling. Eur J Health Econ 2023:10.1007/s10198-023-01613-7. [PMID: 37433889 DOI: 10.1007/s10198-023-01613-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/16/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE The cost-effectiveness threshold (CET) is a key parameter to guide objective reimbursement decisions, yet very few countries have defined a reference CET, and there is no reference method for defining it. Our objective was to determine the factors explaining the author-reported CETs in the literature. METHODS Our systematic review targeted original articles referenced in EMBASE and published between 2010 and 2021. Selected studies had to use Quality-Adjusted Life-Year (QALY), and being conducted in high-income countries. Our explanatory variables were: estimated cost-effectiveness ratio (ICER), region of the world, source of funding, type of intervention, disease, year of publication, justification of the author-reported Cost-Effectiveness Threshold (ar-CET), economic perspective, and declaration of interest. Multivariable linear regression models implemented on R software were used, guided by a Directed Acyclic Graph. RESULTS Two hundred and fifty four studies were included. The mean ar-CET was €63,338/QALY (standard deviation (SD) 34,965) overall, and €37,748/QALY (SD 20,750) in studies conducted in the British Commonwealth. The ar-CET increased slightly with the ICER (+ 66€/QALY for each additional 10,000€/QALY in the ICER, 95% confidence interval (IC) [31-102], p < 0.001), was higher in the United States (+ 36,225€/QALY; IC [25,582; 46,869]) and Europe (+ 10,352€/QALY; IC [72; 20,631]) compared to the British Commonwealth (p < 0.001), and was higher when the ar-CET was not defined a priori (+ 22,393€/QALY; [5809; 38,876]) compared to state recommendations defined ar-CET (p < 0.001). CONCLUSIONS Our results underline the virtuous role of state recommendations in the choice of a low and homogeneous CET. We also highlight the need to integrate the a priori justification of the CET into good publishing guidelines.
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Affiliation(s)
- Nicolas Boespflug
- CHU Bordeaux, Service d'information Médicale, USMR & CIC-EC 1401, 33000, Bordeaux, France
| | - Jérôme Wittwer
- INSERM, Bordeaux Population Health, UMR 1219, 33000, Bordeaux, France
| | - Antoine Bénard
- CHU Bordeaux, Service d'information Médicale, USMR & CIC-EC 1401, 33000, Bordeaux, France.
- INSERM, Bordeaux Population Health, UMR 1219, 33000, Bordeaux, France.
- Université de Bordeaux, Case 75, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France.
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Krier D, de Boer B, Hiligsmann M, Wittwer J, Amieva H. Evaluation of Dementia-Friendly Initiatives, Small-Scale Homelike Residential Care, and Dementia Village Models: A Scoping Review. J Am Med Dir Assoc 2023; 24:1020-1027.e1. [PMID: 37121264 DOI: 10.1016/j.jamda.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/16/2023] [Accepted: 03/16/2023] [Indexed: 05/02/2023]
Abstract
OBJECTIVES Numerous initiatives are emerging to improve the care management of persons suffering from Alzheimer's disease or related disorders (ADRD). The aim of this review is to identify research evaluations of initiatives in long-term care facilities and those making society more inclusive. DESIGN Scoping review with systematic search of PubMed. SETTING AND PARTICIPANTS Reviewed articles focused on the impact of (1) dementia-friendly initiatives (DFIs), (2) small-scale homelike (SSHL) facilities, and (3) dementia/Alzheimer villages. The intervention targets people (or their carers) with dementia or cognitive impairment. METHODS A scoping review was performed on PubMed, including papers published up to November 2022. Further hand-searching from reference lists and the gray literature was carried out. RESULTS A total of 477 articles were identified initially, and finally 12 more specifically related to the impact of DFI (n = 4) and SSHL facilities (n = 8) were selected. They included preliminary effectiveness analyses on DFI-related training and awareness intervention and comparative studies on an SSHL model. Scarce but promising results were found on the physical functioning, social participation, and quality of life for older adults living in SSHL facilities compared to those living in conventional nursing homes. No quantitative evaluation on dementia villages was published. CONCLUSIONS AND IMPLICATIONS The article highlights the lack of studies providing data on the efficacy of such innovative facilities on clinical, economic, and social outcomes. Such data are essential to better characterize these models and assess their potential efficiency and reproducibility.
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Affiliation(s)
- Damien Krier
- Bordeaux Population Health, U1219, University of Bordeaux, Bordeaux, Nouvelle-Aquitaine, France.
| | - Bram de Boer
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, Limburg, the Netherlands
| | - Mickaël Hiligsmann
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, Limburg, the Netherlands
| | - Jérôme Wittwer
- Bordeaux Population Health, U1219, University of Bordeaux, Bordeaux, Nouvelle-Aquitaine, France
| | - Hélène Amieva
- Bordeaux Population Health, U1219, University of Bordeaux, Bordeaux, Nouvelle-Aquitaine, France
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Lipenguet GM, Ngoungou EB, Ibinga E, Amani PG, Engohang-Ndong J, Bivigou EA, Nsounda AA, Wittwer J. Assessment of the direct hospital cost of medical care for patients hospitalized for a stroke in Gabon. Pan Afr Med J 2023; 45:95. [PMID: 37692986 PMCID: PMC10491710 DOI: 10.11604/pamj.2023.45.95.35702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/01/2023] [Indexed: 09/12/2023] Open
Abstract
While the incidence of stroke is increasing in developing countries, resulting in an extremely high economic burden, very few costing studies have been carried out to date. This study aims to measure the direct hospital costs of stroke management in Gabon. The study adopts a retrospective approach, based on a review of patient records in the Neurology and Cardiology Departments of the University Hospital of Libreville (CHUL) between January 2018 and December 2019. It focuses on all patients received for stroke at the CHUL during the study period, regardless of the outcome, analyzing direct hospital costs. Three hundred and thirteen (313) patients were admitted during the period in question, 72.52% in neurology and 27.48% in cardiology. The average age was 58.44 (±13.73 years). Fifty-six percent (56.23%) had health coverage. Ischemic stroke was more common than hemorrhagic stroke, at 79.55% and 20.45%, respectively. The average expenditure per patient was estimated at 619,633 CFA francs (€944.62). From the point of view of social security coverage, the average out-of-pocket expense per patient was 147,140 CFA francs (€224.31), for a reimbursement of 422,883 CFA francs (€644.68). The average direct cost of stroke is very high for both patients and administrations. This argues for the implementation of prevention programs for the disease. The results of this study may be useful for work on the efficiency of such programs.
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Affiliation(s)
- Gaëtan Moukoumbi Lipenguet
- Bordeaux Health Population, Inserm U1219 University of Bordeaux, 33076 Bordeaux Cedex, France
- Research Unit in Epidemiology of Chronic Diseases and Environmental Health (UREMCSE), University of Health Sciences, Libreville, Gabon
- Department of Epidemiology, Biostatistics and Medical Informatics (DEBIM), University of Health Sciences, Faculty of Medicine, Libreville, Gabon
| | - Edgard Brice Ngoungou
- Research Unit in Epidemiology of Chronic Diseases and Environmental Health (UREMCSE), University of Health Sciences, Libreville, Gabon
- Department of Epidemiology, Biostatistics and Medical Informatics (DEBIM), University of Health Sciences, Faculty of Medicine, Libreville, Gabon
| | - Euloge Ibinga
- Research Unit in Epidemiology of Chronic Diseases and Environmental Health (UREMCSE), University of Health Sciences, Libreville, Gabon
- Department of Epidemiology, Biostatistics and Medical Informatics (DEBIM), University of Health Sciences, Faculty of Medicine, Libreville, Gabon
| | - Prudence Gnamien Amani
- Bordeaux Health Population, Inserm U1219 University of Bordeaux, 33076 Bordeaux Cedex, France
| | - Jean Engohang-Ndong
- Department of Epidemiology, Biostatistics and Medical Informatics (DEBIM), University of Health Sciences, Faculty of Medicine, Libreville, Gabon
- Department of Biological Sciences, Kent State University at Tuscarawas, New Philadelphia, United States of America
| | - Elsa Ayo Bivigou
- Department of Cardiology, Centre Hospitalier Universitaire de Libreville, Libreville, Gabon
| | - Andréa Annick Nsounda
- Department of Neurology, Centre Hospitalier Universitaire de Libreville, Libreville, Gabon
| | - Jérôme Wittwer
- Bordeaux Health Population, Inserm U1219 University of Bordeaux, 33076 Bordeaux Cedex, France
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Moukoumbi Lipenguet G, Ngoungou EB, Roberts T, Ibinga E, Amani Gnamien P, Engohang-Ndong J, Wittwer J. Evaluation of the intention to use the electronic medical record (EMR) by health professionals in healthcare facilities of Libreville and Owendo in Gabon. JAMIA Open 2022; 5:ooac096. [PMCID: PMC9680664 DOI: 10.1093/jamiaopen/ooac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 09/19/2022] [Accepted: 11/08/2022] [Indexed: 11/24/2022] Open
Abstract
Abstract
Introduction
Health systems in several countries have integrated information and communication technologies into their operations. Electronic medical records (EMRs) are at the core of patient care. The working of these EMRs requires their acceptance and use by medical and paramedical personnel. The objective of this study was to empirically evaluate the intention of health professionals to use these EMRs.
Materials and Methods
A questionnaire on the intention of health professionals to use the EMR was developed following a Likert scale. The survey was done via in-person interviews of health professionals in major health facilities in the cities of Libreville and Owendo in Gabon. The technology acceptance model (TAM) was tested using a step-down logistic regression analysis to identify the main factors explaining the intention of health professionals to use the EMR.
Results
A total of 218 health professionals responded to the questionnaire. Thirty-eight percent (38%) of respondents were male. The average age was 41.33 years (±8.98 years) and the average length of service at work in the system was 12.02 years (±8.47 years). The integrated model showed that the intention to use the EMR was significantly associated with the perceived usefulness, the subjective standard, and experience. No socio-demographic variables explained the intention to use the EMR.
Conclusion
The perceived ease, familiarity with the computer, and motivation are not associated with the intention to use the EMR. Actions should be taken to raise awareness and train health professionals to motivate them to accept and use EMRs in their medical practices.
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Affiliation(s)
- Gaëtan Moukoumbi Lipenguet
- EMOS Team—BPH U1219, University of Bordeaux , Bordeaux, France
- Department of Epidemiology–Biostatistics and Medical Informatics (DEBIM), Faculty of Medicine, University of Health Sciences , Libreville, Gabon
| | - Edgard-Brice Ngoungou
- Department of Epidemiology–Biostatistics and Medical Informatics (DEBIM), Faculty of Medicine, University of Health Sciences , Libreville, Gabon
- Inserm U1094, IRD U270, Univ. Limoges, CHU Limoges, EpiMaCT—Epidemiology of Chronic Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, OmegaHealth , Limoges, France
- Research Unit in Epidemiology of Chronic Diseases and Environmental Health (UREMCSE), University of Health Sciences , Libreville, Gabon
| | - Tamara Roberts
- EMOS Team—BPH U1219, University of Bordeaux , Bordeaux, France
| | - Euloge Ibinga
- Department of Epidemiology–Biostatistics and Medical Informatics (DEBIM), Faculty of Medicine, University of Health Sciences , Libreville, Gabon
- Research Unit in Epidemiology of Chronic Diseases and Environmental Health (UREMCSE), University of Health Sciences , Libreville, Gabon
| | | | - Jean Engohang-Ndong
- Department of Epidemiology–Biostatistics and Medical Informatics (DEBIM), Faculty of Medicine, University of Health Sciences , Libreville, Gabon
- Research Unit in Epidemiology of Chronic Diseases and Environmental Health (UREMCSE), University of Health Sciences , Libreville, Gabon
- Department of Biological Sciences, Kent State University at Tuscarawas , New Philadelphia, Ohio, USA
| | - Jérôme Wittwer
- EMOS Team—BPH U1219, University of Bordeaux , Bordeaux, France
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Boespflug N, Wittwer J, Benard A. Facteurs associés au choix du seuil d'efficience dans les évaluations médico-économiques: revue systématique et méta-régression. Rev Epidemiol Sante Publique 2022. [DOI: 10.1016/j.respe.2022.03.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Gaillard A, Garcia-Lorenzo B, Renaud T, Wittwer J. Manuscript Title: Does integrated care mean fewer hospitalizations? An evaluation of a French Field Experiment. Health Policy 2022; 126:786-794. [DOI: 10.1016/j.healthpol.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 04/09/2022] [Accepted: 05/19/2022] [Indexed: 11/04/2022]
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Salmi LR, Roberts T, Renaud T, Buffeteau S, Cueille S, Fourneyron E, Gaillard A, Abraham M, Arditi N, Castry M, Daniel F, N'gom NF, Guéry O, L'Horty Y, Pincemail S, Purgues S, Thiessard F, Ramel V, Langlois E, Saillour-Glénisson F, Sibé M, Wittwer J. An evaluation of five regional health information technology-based programmes to improve health and social care coordination: A quasi-experimental controlled before/after mixed design. J Health Serv Res Policy 2022; 27:122-132. [DOI: 10.1177/13558196211065704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Health information technology (HIT) can help coordinate health and social actors involved in patients’ pathways. We assess five regional HIT-based programmes (‘ Territoires de Soins Numériques’ or TSN) introduced in France, covering the period 2012–2018. Methods This was a quasi-experimental controlled before/after mixed design. We used data from the French National Health Insurance database, qualitative and quantitative surveys, and information extracted from project documents and databases. We assessed the impact of TSN using four main impact indicators: emergency room visits, unplanned hospitalizations, avoidable hospitalizations and rehospitalization within 30 days. We also collected qualitative and secondary quantitative data covering perceived needs, knowledge, use, satisfaction, adoption and understanding of projects, pathway experience, impact on professional practices and appropriateness of hospitalizations. Results TSN implemented a heterogeneous mix of HIT. Implementation was slower than expected and was not well documented. Users perceived the HIT as having a positive but weak overall effect. There were no significant differences in trends for the main impact indicators, nor on the appropriateness of hospitalizations, but favourable trends on secondary polypharmacy indicators. Conclusions If similar innovations take place in future, they should be based on a logical framework that defines causal, measurable links between services provided and expected impacts.
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Affiliation(s)
- Louis-Rachid Salmi
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- Univ. Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Tamara Roberts
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Thomas Renaud
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Sophie Buffeteau
- Fédération nationale des observatoires de la santé, Paris, France
| | | | - Emmanuelle Fourneyron
- Univ. Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Aurélie Gaillard
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Maelys Abraham
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Nora Arditi
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Mathieu Castry
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Fabien Daniel
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - N'deye Fatou N'gom
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Orlane Guéry
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Yannick L'Horty
- Fédération nationale des observatoires de la santé, Paris, France
| | - Stéphane Pincemail
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Sonia Purgues
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Franz Thiessard
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- Univ. Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Viviane Ramel
- Univ. Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Emmanuel Langlois
- Univ. Bordeaux/Sciences Po Bordeaux, Centre Emile Durkheim, Bordeaux, France
| | - Florence Saillour-Glénisson
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- Univ. Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Matthieu Sibé
- Univ. Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Jérôme Wittwer
- Univ. Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
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Francis-Oliviero F, Cambon L, Wittwer J, Marmot M, Alla F. [Theoretical and practical challenges of proportionate universalism: a reviewAnálise dos desafios teóricos e práticos de universalismo proporcional]. Rev Panam Salud Publica 2021; 45:e102. [PMID: 34703455 PMCID: PMC8529998 DOI: 10.26633/rpsp.2021.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/23/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it. The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues. METHODS We searched for all articles published until 6th of February 2020, mentioning "Proportionate Universalism" or its synonyms "Targeted universalism" OR "Progressive Universalism" as a topic in all Web of Science databases. RESULTS This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs. CONCLUSION This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.
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Affiliation(s)
| | - Linda Cambon
- University of BordeauxBordeauxFranciaUniversity of Bordeaux, Bordeaux, Francia.
| | - Jérôme Wittwer
- University of BordeauxBordeauxFranciaUniversity of Bordeaux, Bordeaux, Francia.
| | - Michael Marmot
- Institute of Health Equity at the University College LondonLondresReino UnidoInstitute of Health Equity at the University College London, Londres, Reino Unido.
| | - François Alla
- University of BordeauxBordeauxFranciaUniversity of Bordeaux, Bordeaux, Francia.
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11
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Raimond V, Kaltenbach E, Adam C, Lazzarotto S, Le Galès C, Perrier L, Wittwer J. Challenges raised by the economic evaluation of CAR-T-cell therapies. The review by the French National Authority for Health. Bull Cancer 2021; 108:1162-1169. [PMID: 34629167 DOI: 10.1016/j.bulcan.2021.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 08/27/2021] [Accepted: 09/01/2021] [Indexed: 11/18/2022]
Abstract
Since 2013, the process of pricing of innovative drugs by the French National Health Insurance has considered both cost-effectiveness and budget impact. CAR-T cell therapies were first subject to economic evaluation from 2019 in France. We aim to describe the process and results of the economic evaluation of tisagenlecleucel and axicabtagene ciloleucel as well as the challenges these evaluations raised. Evaluations submitted by the firms were reviewed by HAS and submitted to the Committee of Economic Evaluation and Public Health (CEESP). The CEESP issued opinions related to: (1) the methodological quality of economic evidence and, (2) the cost-effectiveness and budget impact of the drugs. The CEESP invalidated the estimated incremental cost-utility ratios (ICUR) of tisagenlecleucel due to the insufficient clinical evidence and methodological quality to extrapolate the long-term progression of the disease after treatment and compare tisagenlecleucel with alternatives. The CEESP concluded that tisagenlecleucel was not proven cost-effective. The estimated ICUR of axicabtagene ciloleucel at €114,509/QALY vs. chemotherapies was associated with an acceptable level of methodological quality despite being based on a weak indirect comparison and limited data on quality of life. The CEESP considered axicabtagene ciloleucel ICUR to be "very high" and questioned the societal/community willingness-to-pay of the claimed price. The primary source of uncertainty surrounding the ICUR estimates of both drugs was the lack of hindsight on effectiveness. The economic evaluation of CAR-T cell therapies highlights the risk of inefficient resource allocation driven by limited clinical data. It calls for payment schemes accounting for this risk and effective collection of post-marketing data.
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Affiliation(s)
- Véronique Raimond
- Haute Autorité de santé, Départment of Economic and Public Health Evaluation, 5, avenue du Stade de France, 93210 Saint-Denis, France.
| | - Emmanuelle Kaltenbach
- Haute Autorité de santé, Départment of Economic and Public Health Evaluation, 5, avenue du Stade de France, 93210 Saint-Denis, France
| | - Christophe Adam
- University of Bordeaux, Department of General Practice, 146, rue Léo Saignat, 33000 Bordeaux, France; Haute Autorité de santé, Committee for Economic and Public Health Evaluation, 5, avenue du Stade de France, 93210 Saint-Denis, France
| | - Sébastien Lazzarotto
- Aix-Marseille University, Health Service Research and Quality of Life Center-EA 3279, CEReSS, 27, boulevard Jean Moulin, 13005 Marseille, France; Haute Autorité de santé, Committee for Economic and Public Health Evaluation, 5, avenue du Stade de France, 93210 Saint-Denis, France
| | - Catherine Le Galès
- Université de Paris, Cermes 3, CNRS UMR 8211, EHESS Inserm U 988, 7, rue Guy Môquet, BP 8, 94801 Villejuif cedex, France; Haute Autorité de santé, Committee for Economic and Public Health Evaluation, 5, avenue du Stade de France, 93210 Saint-Denis, France
| | - Lionel Perrier
- Université Centre Léon-érard, GATE L-SE UMR 5824, 69008 Lyon, France; Haute Autorité de santé, Committee for Economic and Public Health Evaluation, 5, avenue du Stade de France, 93210 Saint-Denis, France
| | - Jérôme Wittwer
- Université de Bordeaux, Bordeaux Population Health, Inserm U1219, 146, rue Léo Saignat, 33000 Bordeaux, France; Haute Autorité de santé, Committee for Economic and Public Health Evaluation, 5, avenue du Stade de France, 93210 Saint-Denis, France
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12
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Moukoumbi Lipenguet G, Ngoungou EB, Ibinga E, Engohang-Ndong J, Wittwer J. Evaluation of direct costs associated with the management of clinical stage of malaria in children under five years old in Gabon. Malar J 2021; 20:334. [PMID: 34330288 PMCID: PMC8325277 DOI: 10.1186/s12936-021-03862-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 07/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria is one of the leading causes of morbidity and mortality in African countries. It is one of the leading causes of hospital visits and hospitalization in pediatric wards for children under 5 years old. Interestingly however, the economic burden of this disease remains unknown in these endemic countries including Gabon. The purpose of this study is to assess the direct hospital cost for the management of malaria in children under 5 years old at the Libreville University Hospital Centre (CHUL, Centre Hospitalier Universitaire de Libreville) in Gabon. METHODS This research work is a retrospective study using a comprehensive review of medical records of patients seen at the CHUL over a two-year period extending from January 2018 through December 2019. The study focused on children under 5 years old, admitted for malaria in the paediatric ward of the CHUL. The analysis targeted specifically direct hospital costs, which excluded salary and wages of health care workers. The monetary currency used in this study was the CFA francs, as that currency is the one used in Central Africa (as reference, 1 Euro = 656 CFA francs). RESULTS For the set timeframe, 778 patient records matched the study criteria. Thus, out of 778 admitted patients, 58.4% were male while 41.5% were female. Overall, the average age was 13.2 months (± 13.8 months). The total cost incurred by the hospital for the management of these 778 malaria patients was 94,922,925 CFA francs (144,699.58 €), for an average expense per patient topping at 122,008 CFA francs (185.99 €). The highest expenditure items were hospitalizations (44,200,000 CFA francs, 67,378.1 €), followed by drugs (26,394,425 CFA francs, 40,235.4 €) and biomedical examinations (14,036,000 CFA francs, 21,396.34 €). CONCLUSION The financial burden for managing malaria in the paediatric ward seems to be very high, not only for the hospital, but also for families in spite of the government medical insurance coverage in some cases. These findings bring new insights as to the urgency to develop policies that foster preventive initiatives over curative approaches in the management of malaria in children in endemic countries.
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Affiliation(s)
- Gaëtan Moukoumbi Lipenguet
- University of Bordeaux, Population Health of Bordeaux, Inserm U1219, EMOS team. ISPED, 146 rue Léo-Saignat, 33076, Bordeaux cedex, France. .,Department of Epidemiology-Biostatistics and Medical Informatics (DEBIM), Faculty of Medicine, University of Health Sciences, BP: 4009, Libreville, Gabon. .,University of Health Sciences, Research Unit in Epidemiology of Chronic Diseases and Environmental Health (UREMCSE), BP: 11587, Libreville, Gabon.
| | - Edgard Brice Ngoungou
- Department of Epidemiology-Biostatistics and Medical Informatics (DEBIM), Faculty of Medicine, University of Health Sciences, BP: 4009, Libreville, Gabon.,University of Health Sciences, Research Unit in Epidemiology of Chronic Diseases and Environmental Health (UREMCSE), BP: 11587, Libreville, Gabon.,UMR 1094 Inserm partner IRD-Tropical Neuroepidemiology (NET), Faculty of Medicine of the University of Limoges, 87 025, Limoges, France
| | - Euloge Ibinga
- Department of Epidemiology-Biostatistics and Medical Informatics (DEBIM), Faculty of Medicine, University of Health Sciences, BP: 4009, Libreville, Gabon.,University of Health Sciences, Research Unit in Epidemiology of Chronic Diseases and Environmental Health (UREMCSE), BP: 11587, Libreville, Gabon
| | - Jean Engohang-Ndong
- Department of Epidemiology-Biostatistics and Medical Informatics (DEBIM), Faculty of Medicine, University of Health Sciences, BP: 4009, Libreville, Gabon.,University of Health Sciences, Research Unit in Epidemiology of Chronic Diseases and Environmental Health (UREMCSE), BP: 11587, Libreville, Gabon.,Department of Biological Sciences, Kent State University at Tuscarawas, 330 University Dr. NE, New Philadelphia, OH, 44663, USA
| | - Jérôme Wittwer
- University of Bordeaux, Population Health of Bordeaux, Inserm U1219, EMOS team. ISPED, 146 rue Léo-Saignat, 33076, Bordeaux cedex, France
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13
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Abstract
BACKGROUND For financial reasons, dental prosthetics is one of the major unmet dental healthcare needs [Financial-SUN (F-SUN)]. Private fees for dental prosthetics result in significant out-of-pocket payments for users. This study analyzes the impact of geo-variations in protheses fees on dental F-SUN. METHODS Using a nationwide French declarative survey and French National Health Insurance administrative data, we empirically tested the impact of prosthetic fees on dental F-SUN, taking into account several other enabling factors. Our empirical strategy was built on the homogeneous quality of the dental prosthesis selected and used to compute our price index. RESULTS Unmet dental care needs due to financial issues concern not only the poorest but also people with middle incomes. The major finding is the positive association between dental fees and difficulty in gaining access to dental care when other enabling factors are taken into account (median fee in the highest quintile: OR = 1.35; P value = 0.024; 95% CI 1.04-1.76). People with dental F-SUN are those who have to make a greater financial effort due to a low/middle income or a lack of complementary health insurance. For identical financial reasons, the tendency to give up on healthcare increases as health deteriorates. CONCLUSIONS The results underscore the need for fee regulation regarding dental prosthetics. This is in line with the current French government dental care reform.
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Affiliation(s)
- Anne-Charlotte Bas
- Department of Public Health, Faculty of Dentistry, Paris University, Paris, France.,GHPS, Dentistry Unit, Assistance Publique des Hôpitaux de Paris, Paris, France.,INSERM, Centre de Recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, University of Paris-Sud, UVSQ, Hôpital Paul Brousse, Villejuif, France
| | | | - Sylvie Azogui-Levy
- Department of Public Health, Faculty of Dentistry, Paris University, Paris, France.,GHPS, Dentistry Unit, Assistance Publique des Hôpitaux de Paris, Paris, France.,LEPS EA 3412, Bobigny, France
| | - Jérôme Wittwer
- Inserm U1219, Bordeaux Population Health, University of Bordeaux, Bordeaux, France
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14
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Francis-Oliviero F, Cambon L, Wittwer J, Marmot M, Alla F. Theoretical and practical challenges of proportionate universalism: a review. Rev Panam Salud Publica 2020; 44:e110. [PMID: 33088291 PMCID: PMC7556407 DOI: 10.26633/rpsp.2020.110] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/23/2020] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it.The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues. METHODS We searched for all articles published until 6th of February 2020, mentioning "Proportionate Universalism" or its synonyms "Targeted universalism" OR "Progressive Universalism" as a topic in all Web of Science databases. RESULTS This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs. CONCLUSION This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.
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Affiliation(s)
| | - Linda Cambon
- University of BordeauxBordeauxFranceUniversity of Bordeaux, Bordeaux, France
| | - Jérôme Wittwer
- University of BordeauxBordeauxFranceUniversity of Bordeaux, Bordeaux, France
| | - Michael Marmot
- Institute of Health Equity at the University College LondonLondonUnited KingdomInstitute of Health Equity at the University College London, London, United Kingdom
| | - François Alla
- University of BordeauxBordeauxFranceUniversity of Bordeaux, Bordeaux, France
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15
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Broussy S, Rouanet F, Lesaine E, Domecq S, Kret M, Maugeais M, Aly F, Dehail P, Bénard A, Wittwer J, Salamon R, Sibon I, Saillour-Glenisson F. Post-stroke pathway analysis and link with one year sequelae in a French cohort of stroke patients: the PAPASePA protocol study. BMC Health Serv Res 2019; 19:770. [PMID: 31665006 PMCID: PMC6820977 DOI: 10.1186/s12913-019-4522-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 09/10/2019] [Indexed: 11/10/2022] Open
Abstract
Background Stroke is a health problem with serious consequences, both in terms of mortality, and after-effects affecting patient quality of life. Stroke requires both urgent and chronic management involving the entire health care system. Although large variability in the management of stroke patients have been noticed, knowledge of the diversity and the scalability of post-stroke pathways, whether it is the care pathway or the life pathway, is currently not sufficient. Moreover the link between post-stroke pathways and patients sequelae have not been yet clearly defined. All this information would be useful to better target the needs to improve stroke patient management. The purposes are to identify the post-stroke life pathways components associated with sequelae (activity limitations – main purpose, cognitive disorders, anxio-depressive disorders, fatigue, participation restrictions) at 3 months and 1 year post-stroke, to define a typology of life pathways of patients during the post-stroke year and to analyze the social and geographical inequalities in the management of stroke. Methods Design: a prospective multicenter comparative cohort study with a follow up to 1 year after the acute episode. Participant centers: 13 hospitals in the Aquitaine region (France). Study population: patients diagnosed with a confirmed ischemic or hemorrhagic stroke included in the Aquitaine Observatory of Stroke (ObA2) cohort and voluntary to participate. Data sources are existing databases (ObA2 database and the French National Health Data System - SNDS) to collect information about care pathways, patient characteristics and stroke characteristics and Ad hoc surveys to collect information about life pathways and post-stroke sequelae. The endpoints of the study are post-stroke activity limitations evaluated by the modified Rankin score, other post-stroke sequelae (Cognitive disorders, anxio-depressive disorders, fatigue, restriction of participation) assessed by standardized and validated scales and Clusters of patients responding to pathways with common or similar characteristics.; Discussion By integrating a longitudinal dimension and relying on a large cohort, the project will make it possible to identify the sources of disturbances and the factors favorable to the outcome of the life pathways, important for the planning of the offer and the management of the public policies concerning stroke pathways. Trial registration ClinicalTrials.gov ID: NCT03865173, March 6th, 2019.
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Affiliation(s)
- S Broussy
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France. .,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France.
| | - F Rouanet
- Pôle des Neurosciences Cliniques (I.S., F.R.) CHU Bordeaux, Bordeaux, France
| | - E Lesaine
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France.,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France
| | - S Domecq
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France
| | - M Kret
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, F-33000, Bordeaux, France
| | - M Maugeais
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France
| | - F Aly
- Physical and Rehabilitation Medicine Unit, EA4136, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - P Dehail
- Physical and Rehabilitation Medicine Unit, EA4136, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - A Bénard
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France.,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France.,CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, F-33000, Bordeaux, France
| | - J Wittwer
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France.,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France
| | - R Salamon
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France.,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France
| | - I Sibon
- Pôle des Neurosciences Cliniques (I.S., F.R.) CHU Bordeaux, Bordeaux, France.,Neurology, Stroke Unit, INCIA CNRS UMR 5287, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - F Saillour-Glenisson
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France.,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France.,CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, F-33000, Bordeaux, France
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16
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Pimouguet C, Sitta R, Wittwer J, Hayes N, Petit-Monéger A, Dartigues JF, Helmer C. Maintenance of occupational therapy (OT) for dementia: protocol of a multi-center, randomized controlled and pragmatic trial. BMC Geriatr 2019; 19:35. [PMID: 30727947 PMCID: PMC6366025 DOI: 10.1186/s12877-019-1046-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 01/24/2019] [Indexed: 11/23/2022] Open
Abstract
Background There is a growing interest in developing tailored non-pharmacological strategies to face patients’ needs in dementia. Occupational therapy (OT) may contribute to promote self-empowerment of both patients and caregivers. France has implemented nationwide OT over a short-term period of 3/4 months. The main objective of the MathéoAlz study is to measure the impact of maintaining OT over 4 supplementary months on patients’ neuropsychiatric symptoms. Methods/design The MatheoAlz trial (Maintenance of Occupational Therapy in Alzheimer’s disease) is a multi-center, pragmatic randomized controlled trial testing maintenance of OT over 4 supplementary months compared to routine OT delivered as recommended. This paper describes the study protocol. MatheoAlz plans to enroll 240 dyads, i.e. dementia patients and caregivers, whose main inclusion criteria are: prescription for routine OT, patients with mild or moderate dementia, living at home, receiving support from an informal caregiver. The study will compare a control group of patients benefiting from 12 to 15 initial sessions of OT over 3/4 months and an intervention group of patients benefiting from these initial sessions plus 8 extra home sessions over 4 supplementary months. The main outcome is the patient’s neuropsychiatric symptoms assessed by the Neuropsychiatric Inventory at 8 months. Several clinical outcomes and economic consequences are measured at 4, 8 and 12 months. Discussion This is the first trial designed to assess the specific impact of the maintaining OT on the patients’ neuropsychiatric symptoms burden. The results will inform policymakers on strategies to implement in the near future. Trial registration This trial was registered at ClinicalTrials.gov on February 16, 2018, identifier: NCT03435705.
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Affiliation(s)
- Clément Pimouguet
- Bordeaux Population Health Research Center, University Bordeaux, Inserm, ISPED, 146 rue Léo Saignat, CS61292, F-33076 BORDEAUX Cedex, UMR 1219, F-33000, Bordeaux, France.
| | - Rémi Sitta
- Methodology Research Unit, Bordeaux University Hospital, Bordeaux, France
| | - Jérôme Wittwer
- Bordeaux Population Health Research Center, University Bordeaux, Inserm, ISPED, 146 rue Léo Saignat, CS61292, F-33076 BORDEAUX Cedex, UMR 1219, F-33000, Bordeaux, France
| | - Nathalie Hayes
- Direction de la recherche clinique et de l'innovation, evaluation et accompagnement de l'innovation, Pole de sante publique, Service d'Information Medicale, CHU de Bordeaux, 33000, Bordeaux, France
| | - Aurélie Petit-Monéger
- Bordeaux Population Health Research Center, University Bordeaux, Inserm, ISPED, 146 rue Léo Saignat, CS61292, F-33076 BORDEAUX Cedex, UMR 1219, F-33000, Bordeaux, France.,CHU de Bordeaux, place Amelie Raba-Léon, 33000, Bordeaux, France
| | - Jean-François Dartigues
- Bordeaux Population Health Research Center, University Bordeaux, Inserm, ISPED, 146 rue Léo Saignat, CS61292, F-33076 BORDEAUX Cedex, UMR 1219, F-33000, Bordeaux, France.,Memory Consultation, CMRR, Bordeaux University Hospital, F-33076, Bordeaux, France
| | - Catherine Helmer
- Bordeaux Population Health Research Center, University Bordeaux, Inserm, ISPED, 146 rue Léo Saignat, CS61292, F-33076 BORDEAUX Cedex, UMR 1219, F-33000, Bordeaux, France.,Clinical Investigation Center - Clinical Epidemiology 1401, INSERM, Bordeaux, France
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17
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Fourneyron E, Wittwer J, Rachid Salmi L. [Health information technology: current use and challenges for primary healthcare services]. Med Sci (Paris) 2018; 34:581-586. [PMID: 30067214 DOI: 10.1051/medsci/20183406000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Health information technology is developing rapidly, due to a profusion of actors and support from public policies. It generates new uses and functions, for both patients and professional users, thereby suggesting a "digital revolution" is coming. Nevertheless, e-Health's development meets with a particularly complex healthcare system, especially when it comes to primary care services. This situation creates four types of challenges. Firstly, an organizational challenge, meaning e-Health implementation needs to take into account the organization in which it intends to integrate. Secondly, a social and territorial concern, as the burden of inequalities is one of healthcare system's major issues. The third challenge is about economics, as we need to search for new methods for globally apprehending e-Health's business model and long-term sustainability. Lastly, the fourth challenge relates to new technical and legal issues.
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Affiliation(s)
| | - Jérôme Wittwer
- Université de Bordeaux, Bordeaux Population Health, Inserm U1219, 146, rue Léo Saignat, 33000 Bordeaux, France
| | - Louis Rachid Salmi
- Université de Bordeaux, Institut de santé publique, d'épidémiologie et de développement (ISPED), CHU de Bordeaux, 33000 Bordeaux, France
| | -
- Évaluation de la mise en œuvre et des résultats du programme « Territoire de soins numérique » dans les cinq territoires pilotes. Institut de santé publique, d'épidémiologie et de développement (ISPED), 146, rue Léo Saignat, 33000 Bordeaux 1, France
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18
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Pimouguet C, Le Goff M, Wittwer J, Dartigues JF, Helmer C. Benefits of Occupational Therapy in Dementia Patients: Findings from a Real-World Observational Study. J Alzheimers Dis 2018; 56:509-517. [PMID: 27983551 DOI: 10.3233/jad-160820] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a growing interest in developing non-pharmacological approaches in dementia. Clinical efficacy of occupational therapy (OT) under routine care conditions has not been investigated yet. OBJECTIVE To analyze the short-term effects of OT in patients with dementia; and to identify factors related to greater benefit. METHODS Patients referred to OT were evaluated before starting a 3-month intervention and at 3 and 6 months later. Measures included: Mini-Mental State Examination (MMSE), Disability Assessment in Dementia (DAD), Neuropsychiatric Inventory (NPI) Questionnaire, patients' quality of life (EQ 5D-VAS), caregivers' burden (Zarit scale), and amount of informal care. Linear mixed models were used to analyze trajectories of outcomes. Logistic regressions with stepwise descending selection were used to study factors associated with benefits. RESULTS 421 dementia patients benefited from OT (mean MMSE = 17.3). Patients remained cognitively stable over time. Functional performances also remained stable at 3 months and significantly decreased at 6 months (crude reduction of 2.8 points, p < 0.01). Behavioral troubles were significantly reduced over the intervention period and remained stable after (p < 0.01). Patients' quality of life increased over the 3-month intervention (p = 0.16) and significantly decreased thereafter. Caregivers' burden and informal care significantly decreased over the 3-month intervention and remained stable thereafter. Patients who benefited from OT with regard to function were less educated and had higher cognitive level. CONCLUSION OT may be an effective intervention to maintain cognition and functionality and to reduce psychiatric symptoms in dementia patients. Mild stages of dementia could gain more benefits from OT with regard to functional decline.
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Affiliation(s)
- Clément Pimouguet
- INSERM, ISPED, Centre INSERM U1219-Epidemiologie-Biostatistique, Bordeaux, France.,University Bordeaux, Bordeaux, France
| | - Mélanie Le Goff
- INSERM, ISPED, Centre INSERM U1219-Epidemiologie-Biostatistique, Bordeaux, France.,University Bordeaux, Bordeaux, France
| | - Jérôme Wittwer
- INSERM, ISPED, Centre INSERM U1219-Epidemiologie-Biostatistique, Bordeaux, France.,University Bordeaux, Bordeaux, France
| | - Jean-François Dartigues
- INSERM, ISPED, Centre INSERM U1219-Epidemiologie-Biostatistique, Bordeaux, France.,University Bordeaux, Bordeaux, France.,Service de Neurologie, Department of Clinical Neurosciences, CHU Pellegrin, Bordeaux, France
| | - Catherine Helmer
- INSERM, ISPED, Centre INSERM U1219-Epidemiologie-Biostatistique, Bordeaux, France.,University Bordeaux, Bordeaux, France.,INSERM, Clinical Investigation Center - Clinical Epidemiology 1401, Bordeaux, France
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Guthmuller S, Wittwer J. The Impact of the Eligibility Threshold of a French Means-Tested Health Insurance Programme on Doctor Visits: A Regression Discontinuity Analysis. Health Econ 2017; 26:e17-e34. [PMID: 28321959 PMCID: PMC5811792 DOI: 10.1002/hec.3464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 10/08/2016] [Accepted: 11/15/2016] [Indexed: 06/01/2023]
Abstract
This paper assesses the impact of eligibility for a free means-tested complementary health insurance plan, called Couverture Maladie Universelle Complémentaire (CMUC), on doctor visits. We use information on the selection rule to qualify for the plan to identify the effect of eligibility and adopt a regression discontinuity approach. Our sample consists of low-income individuals enrolled in the Health Insurance Fund and recipients of social benefits from the Family Allowance Fund of an urban area in Northern France. Our findings do not show significant impacts of the CMUC threshold on the number of doctor visits within the full sample. Among the subsample of adults under 30 years old, however, eligible individuals are more likely to see a specialist and have, on average, significantly more specialist visits than non-eligible individuals. This specific impact of the CMUC cut-off point among young adults may be explained by the fact that young adults are less likely to be covered by a complementary health insurance plan when they are not recipients of the CMUC plan. © 2017 The Authors. Health Economics Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Sophie Guthmuller
- PSL, Université Paris DauphineLEDa‐LEGOSParisFrance
- European CommissionJoint Research CentreIspra (VA)Italy
| | - Jérôme Wittwer
- PSL, Université Paris DauphineLEDa‐LEGOSParisFrance
- Université de BordeauxInserm U1219 Bordeaux Population HealthBordeauxFrance
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Both C, Schmitz A, Buehler PK, Wittwer J, Weiss M, Schmidt AR. Comparison of a paediatric emergency ruler with a digital algorithm for weight and age estimation. Acta Anaesthesiol Scand 2017; 61:1122-1132. [PMID: 28791696 DOI: 10.1111/aas.12949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 07/03/2017] [Accepted: 07/07/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Emergency tapes like the "Paediatric-Emergency-Ruler" (PaedER) provide drug dosing and recommend medical airway equipment based on estimated patient bodyweight and age. Previous studies have revealed unsatisfactory accuracy in bodyweight estimation, due to the tapes' length-based weight categories. Therefore, we developed a digital algorithm allowing continuous length-based estimation of weight and age. The aim of this study was to compare the new algorithm with the PaedER regarding accuracy in estimating bodyweight and recommendation of medical airway equipment. METHODS Patients with a body length suitable for the PaedER were included in this single centre, prospective clinical observation trial after obtaining informed written parental consent. Bodyweight estimations by the algorithm and PaedER within ± 10% and ± 20% of the actual bodyweight were compared. Furthermore, medical airway equipment suggested by the PaedER and algorithm were compared with the equipment actually used for anaesthesia. Wilcoxon- and McNemar-Tests were used for statistical analysis. Results are median (interquartiles), P < 0.05 was considered significant. RESULTS In total, 489 patients aged 2.0 years (0.4-5.9), with a body length of 89.0 cm (63.5-114.5), weighing 12.8 kg (6.3-19.6), were included. The algorithm's precision of bodyweight estimation within ± 10%/± 20% was significantly higher at 64.0%/91.6% than the PaedER at 55.4%/81.8% (P < 0.001). Compared to PaedER the algorithm showed a higher incidence of correctly recommended medical airway equipment based on its accuracy for age and bodyweight estimation. CONCLUSION The new digital algorithm is an alternative to conventional emergency tapes, showing improved accuracy regarding length-based estimation of bodyweight and recommendation of medical airway equipment.
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Affiliation(s)
- Ch. Both
- Department of Anaesthesia and Children's Research Centre; University Children's Hospital; Zurich Switzerland
| | - A. Schmitz
- Department of Anaesthesia and Children's Research Centre; University Children's Hospital; Zurich Switzerland
| | - P. K. Buehler
- Department of Anaesthesia and Children's Research Centre; University Children's Hospital; Zurich Switzerland
| | - J. Wittwer
- Department of Anaesthesia and Children's Research Centre; University Children's Hospital; Zurich Switzerland
| | - M. Weiss
- Department of Anaesthesia and Children's Research Centre; University Children's Hospital; Zurich Switzerland
| | - A. R. Schmidt
- Department of Anaesthesia and Children's Research Centre; University Children's Hospital; Zurich Switzerland
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Dumontet M, Buchmueller T, Dourgnon P, Jusot F, Wittwer J. Gatekeeping and the utilization of physician services in France: Evidence on the Médecin traitant reform. Health Policy 2017; 121:675-682. [PMID: 28495205 DOI: 10.1016/j.healthpol.2017.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 03/13/2017] [Accepted: 04/23/2017] [Indexed: 10/19/2022]
Abstract
In 2005, France implemented a gatekeeping reform designed to improve care coordination and to reduce utilization of specialists' services. Under this policy, patients designate a médecin traitant, typically a general practitioner, who will be their first point of contact during an episode of care and who will provide referrals to specialists. A key element of the policy is that patients who self-refer to a specialist face higher cost sharing than if they received a referral from their médecin traitant. We consider the effect of this policy on the utilization of physician services. Our analysis of administrative claims data spanning the years 2000-2008 indicates that visits to specialists, which were increasing in the years prior to the implementation of the reform, fell after the policy was in place. Additional evidence from the administrative claims as well as survey data suggest that this decline arose from a reduction in self-referrals, which is consistent with the objectives of the policy. Visits fell significantly both for specialties targeted by the policy and specialties for which self-referrals are still allowed for certain treatments. This apparent spillover effect may suggest that, at least initially, patients did not understand the subtleties of the policy.
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Affiliation(s)
- Magali Dumontet
- Institut de Recherche et Documentation en Economie de la santé, Paris, France; LIRAES (EA 4470) & Endowed Chair AGEINOMIX, Univ. Paris Descartes, SPC, Paris
| | - Thomas Buchmueller
- Université de Bordeaux, Inserm U1219, France; University of Michigan, Ann Arbor, MI, USA
| | - Paul Dourgnon
- Institut de Recherche et Documentation en Economie de la santé, Paris, France
| | - Florence Jusot
- Institut de Recherche et Documentation en Economie de la santé, Paris, France; Université Paris Dauphine, PSL, LEDa-LEGOS, France
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Montagni I, Langlois E, Wittwer J, Tzourio C. Co-creating and Evaluating a Web-app Mapping Real-World Health Care Services for Students: The servi-Share Protocol. JMIR Res Protoc 2017; 6:e24. [PMID: 28209561 PMCID: PMC5334513 DOI: 10.2196/resprot.6801] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/09/2017] [Accepted: 01/11/2017] [Indexed: 11/13/2022] Open
Abstract
Background University students aged 18-30 years are a population group reporting low access to health care services, with high rates of avoidance and delay of medical care. This group also reports not having appropriate information about available health care services. However, university students are at risk for several health problems, and regular medical consultations are recommended in this period of life. New digital devices are popular among the young, and Web-apps can be used to facilitate easy access to information regarding health care services. A small number of electronic health (eHealth) tools have been developed with the purpose of displaying real-world health care services, and little is known about how such eHealth tools can improve access to care. Objective This paper describes the processes of co-creating and evaluating the beta version of a Web-app aimed at mapping and describing free or low-cost real-world health care services available in the Bordeaux area of France, which is specifically targeted to university students. Methods The co-creation process involves: (1) exploring the needs of students to know and access real-world health care services; (2) identifying the real-world health care services of interest for students; and (3) deciding on a user interface, and developing the beta version of the Web-app. Finally, the evaluation process involves: (1) testing the beta version of the Web-app with the target audience (university students aged 18-30 years); (2) collecting their feedback via a satisfaction survey; and (3) planning a long-term evaluation. Results The co-creation process of the beta version of the Web-app was completed in August 2016 and is described in this paper. The evaluation process started on September 7, 2016. The project was completed in December 2016 and implementation of the Web-app is ongoing. Conclusions Web-apps are an innovative way to increase the health literacy of young people in terms of delivery of and access to health care. The creation of Web-apps benefits from the involvement of stakeholders (eg, students and health care providers) to correctly identify the real-world health care services to be displayed.
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Affiliation(s)
- Ilaria Montagni
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team HEALTHY, UMR 1219, F-33000 Bordeaux, France
| | - Emmanuel Langlois
- Univ. Bordeaux, Centre Emile Durkheim, Science politique et sociologie comparative, UMR 5116, F-33000 Bordeaux, France
| | - Jérôme Wittwer
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team EMOS, UMR 1219, F-33000 Bordeaux, France
| | - Christophe Tzourio
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team HEALTHY, UMR 1219, F-33000 Bordeaux, France
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Cohen JM, Daviaud I, Delavier JC, Pla O, Samarco A, Wittwer J. Impact des cures thermales sur les dépenses de soins en ambulatoire des patients arthrosiques, France. Rev Epidemiol Sante Publique 2016. [DOI: 10.1016/j.respe.2016.06.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Gibson E, Mohajeri M, Wittwer J, Rogers P, Goralczyk R. Serotonin transporter genotype predicts changes in tryptophan-sensitive moods in women. Appetite 2016. [DOI: 10.1016/j.appet.2016.02.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
This article is focused on children providing and financing long-term care for their elderly parent. The aim of this work is to highlight the interactions that may take place among siblings when deciding whether or not to become a caregiver. We look at families with two children using data from the Survey of Health, Ageing and Retirement in Europe; our sample contains 314 dependent elderly and their 628 adult children. In order to identify the interactions between siblings, we have specified a two-person discrete game model. To estimate this model, without invoking the 'coherency' condition, we have added an endogenous selection rule to solve the incompleteness problem arising from multiplicity or absence of equilibrium. Our empirical results suggest that the three classical effects identified by Manski could potentially explain the observed correlation between the siblings' caregiving behaviour. Correlated effects alone appear to be weak. Contextual interactions and endogenous interactions reveal cross-effects. The asymmetric character of the endogenous interactions is our most striking result. The younger child's involvement appears to increase the net benefit of caregiving for the elder one, whereas the elder child's involvement decreases the net benefit of caregiving for the younger child.
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Affiliation(s)
- Roméo Fontaine
- LEDa-LEGOS, Université Paris-Dauphine, Paris Cedex 16, France.
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Fontaine R, Gramain A, Wittwer J. Les configurations d'aide familiales mobilisées autour des personnes âgées dépendantes en Europe. ACTA ACUST UNITED AC 2007. [DOI: 10.3406/estat.2007.7090] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Goldach R, Wittwer J. [Acquired agammaglobulinaemia with predominantly intestinal symptoms (author's transl)]. Dtsch Med Wochenschr 1977; 102:1585-7. [PMID: 72639 DOI: 10.1055/s-0028-1105542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In a 45-year-old female patient primary acquired agammaglobulinaemia was diagnosed. Intestinal symptoms predominated. The disease was characterized by a B-cell defect. Substitution with gamma-globulin (Beriglobin) practically cured the symptoms. The pathogenesis of the disease remains unexplained.
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Wittwer J, Hector V, Schulz KD. [Influence of the ovarian cycle on protein synthesis of various rat organs]. Arch Gynakol 1975; 219:568-70. [PMID: 1243488 DOI: 10.1007/bf00669248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Hector V, Wittwer J, Schulz KD. [In-vivo effect of prolactin-inhibiting substances on the amino-acid incorporation rate into hormone-depending mammary neoplasms of the rat]. Arch Gynakol 1975; 219:172-4. [PMID: 1243275 DOI: 10.1007/bf00669025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Wittwer J. [Narrative organization of 3 formally analogous short stories]. Rev Laryngol Otol Rhinol (Bord) 1973; 94:281-92. [PMID: 4788109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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