A conceptual framework to develop a patient-reported experience questionnaire on the cystic fibrosis journey in France: the ExPaParM collaborative study

BACKGROUND

The objective of the study was to elaborate a conceptual framework related to the domains of patient experience along the cystic fibrosis (CF) journey from the patients and parents of children with CF to inform the design of a patient-reported experience questionnaire.

METHOD

A collaborative research group including patients and parents with clinicians and academic researchers was set up. They identified the situations along the CF care pathway from diagnosis to paediatric care, transition to adult care and adult follow-up, transfer to transplant centres and follow-up after transplantation. Participants were recruited by CF centres in metropolitan France and overseas departments. Semi-structured interviews were conducted, transcribed verbatim and subjected to an inductive analysis conducted in duos of researchers/co-researchers using NVivo®. The conceptual framework was discussed with the research group and presented to the CF centres during two video conferences. The protocol obtained a favourable opinion from the Ethics Evaluation Committee of INSERM (IRB00003888-no. 20-700).

RESULTS

The analysis led to a conceptual framework composed of domains of the CF journey, each divided into several items. 1. CF care: Management of care by the CF centre team; in-hospital care; quality of care in the community; therapeutic education and self-management support; at-home care; new therapies and research; procreation; 2. Transplant care: management of transplant and CF care; coordination with other specialties; education and self-management support; at-home care; procreation; new therapies and research; 3. Turning points along the journey: diagnosis of CF, transition to adult care, transfer to transplantation; 4. Social life with CF: housing, employment and education, social relations, social welfare and family finances. The number of patients included and the diversity of situations made it possible to achieve a sufficient richness and saturation of codes by domain to develop patient experience questionnaires.

CONCLUSION

This conceptual framework, resulting from the participants' experience, will inform the design of a patient-reported experience tool, whose construct will be tested during the next phase of the ExPaParM project to assess its fidelity, intelligibility, and ability to report patient experience of the CF journey.

Collaborative research protocol to define patient-reported experience measures of the cystic fibrosis care pathway in France: the ExPaParM study

Introduction

In France, the cystic fibrosis (CF) care pathway is coordinated by multidisciplinary teams from specialised CF centres or transplant centres. It includes the care provided at home or out of hospital, risk prevention in daily life and adjustments to social life, which together contribute to the person’s quality of life. Patient experience is used to describe and evaluate the care and life of patients living with the disease.

Objectives

Our collaborative research aims to identify the most significant areas and criteria that characterise the CF pathway. It will lead to the development of a questionnaire to collect patients' experience, which can be administered to all patients or parents of children registered and followed in the centres. The article describes the protocol developed in partnership with patients and parents of children living with the disease.

Method

A multidisciplinary research group brings together researchers, patients, parents of children with CF and health care professionals. The patient partnership is involved in the 4 phases of the protocol: (1) setting up the study, recruiting patient and parent co-researchers, training them in qualitative research methods, defining the situations and profiles of patients in the study population, elaborating the protocol; (2) selecting the study sites, recruiting participants, carrying out semi-structured interviews, analysing verbatims using the grounded theory approach; (3) co-elaborating Patient-Reported Experience Measures (PREM) questionnaires adapted to the 4 types of participants: parents, adolescents, non-transplanted adults and transplanted adults; (4) validating the construct with participants and professionals from the study centres.

Results

The protocol obtained a favourable opinion from the Ethics Evaluation Committee of INSERM (IRB00003888—no. 20-700). Training was provided to the 5 patients and 2 parent co-researchers to enable them to participate effectively in the research. Eleven centres participated in the recruitment of participants in mainland France and Reunion Island. Eighty hours of interviews were conducted.

Discussion

The PREM questionnaires to be elaborated will have to undergo psychometric validation before being used by the actors of the CF network to assess the impact on the care pathways of quality approaches or new therapies available in cystic fibrosis.

Trial Registration Registry: IRB00003888 – no. 20-700. Issue date: 06/09/2020.

Valuing experiential knowledge in health promotion: a new method to build up knowledge in France

Issue

Effectiveness analyses of health promotion (HP) interventions (HPI) abound nowadays in France, but few research details how HPI work, nor explains how practitioners can translate conclusive evidence from the literature into action. Furthermore, large amounts of experiential knowledge remain untapped and undervalued. To close these gaps, a national multidisciplinary committee, comprising public officials, academics and practitioners, has worked since 2016 at designing a new method to build up knowledge in HP.

CEKHP

The method aims at Capitalizing, collecting and circulating Experiential Knowledge in HP (CEKHP).

Committee members first investigated methods used in other countries to synthesize and share practical evidence, then drafted and experimented CEKHP in 11 different settings to test its relevance and applicability.

Results

Key components of CEKHP are: 1/CEKHP consists in in-depth semi-structured interviews and offers a guideline template adjustable for various contexts and multiple public health issues (behaviors, environments, etc.); 2/a trained outsider, mastering 7 core competencies, must conduct CEKHP; 3/CEKHP includes a framework for reporting key mechanisms that influence HPI outcomes. Detailed mechanisms include: context, partnerships, key steps, barriers and levers, ethics, theoretical foundations (intervention models, evidence-based literature, etc.), transferability. A guidebook and a toolkit are published in 2020. CEKHP successfully disseminates within the French HP community. It is currently used as the main data collection tool in a research project investigating health promoting sports clubs (PROCeSS) and in a practice-focused project documenting tobacco prevention (DCAP).

Lessons

Practitioners benefit from access to knowledge on how HPI work. CEKHP offers new tools to value and disseminate experiential knowledge. Given that policymakers increasingly prioritize funding in France on documented HPI, providing such tools and training is crucial.

Key messages

CEKHP offers a new method in the French context that has proven fruitful in various settings, for various public health issues, and can be useful to practitioners and researchers alike. Building up experiential knowledge with and for practitioners can be effective at both documenting practices and helping them gain new skills and better understanding of their interventions.

How to make smoking prevention work for vulnerable populations: insights from French project DCAP

Issue

Smoking prevention interventions tend to reach with difficulty young people and disadvantaged groups in France. Yet, limited research provides practical evidence detailing tobacco prevention interventions (TPI) aimed at them. Documenting the practical experience of health promotion, social and education workers tackling this issue is therefore crucial. To that end, the French Society for Public Health designed and carries out a project to CAPitalize experiential Data on TPI: DCAP.

DCAP

Initiated in 2019, DCAP consists in capitalizing, i.e. collecting, documenting and circulating, experiential knowledge from practitioners who implement TPI at the local level for young people and vulnerable people. Goals include building up original knowledge from field actions, documenting how TPI unfold in various contexts and take into account health inequalities, and supporting professional practices. DCAP follows 3 main steps: 1/identifying promising TPI, 2/ documenting selected TPI and the key mechanisms impacting how TPI unfold (context, partnerships, barriers and levers, ethics), 3/ sharing knowledge built up on TPI, via an online portal.

Results

DCAP will document 40 interventions total. Preliminary results, based on TPI documented in 2019, highlight experiential knowledge built up to face 3 types of

Issues

1/building and sustaining partnerships for long-term TPI programs, between health professionals, schools and parents for example, 2/building support for TPI in difficult contexts: prisons, emergency housing, etc. 3/innovating and inventing collective TPI adjusted for disadvantaged groups. Insights also emerge on current trends. For example, programs for young people tend nowadays to favor global approaches to addiction prevention over smoking prevention alone.

Lessons

Most TPI remain confidential yet form a rich corpus of original and practical evidence other stakeholders can benefit from. Future research projects can also benefit from the data collected through DCAP.

Key messages

Documenting the practical experience health promotion, social and education workers hold is crucial to share knowledge and implement tobacco prevention interventions that work for vulnerable people. DCAP details key mechanisms in smoking prevention interventions aimed at vulnerable groups in France, including long-lasting partnerships building and innovative collective formats design.

Joining forces to build up knowledge in health promotion: lessons from a French coalition initiative

Issue

French public health authorities increasingly rationalize access to public funding, favoring evidence-based programs. Health Promotion (HP) interventions are especially urged to prove their efficiency in this context. To tackle this issue, HP practitioners hold experiential knowledge (EK) that proves useful to assess both the complexity and efficiency of HP interventions. United by this conviction in a multidisciplinary coalition, HP experts from various backgrounds came together five years ago to promote Experiential Knowledge in HP (EKHP) in France.

A national committee to promote EKHP

670 HP practitioners were surveyed in 2016. Results reported vast amounts of under-documented and often untapped field expertise in HP and numerous obstacles regarding access to scientific literature or systematic reviews. Consequently, the coalition launched a National Committee for EKHP, meeting 5 times a year since 2016. Members of 6 national HP organizations, of 4 regional HP institutes, national and local public health administrators, researchers, consultants and field workers participate. Steered by the French Society for Public Health and the National Federation for Health Education and Promotion, the committee devised a threefold action plan: 1/ advocate EKHP in all relevant institutional spaces, 2/ develop tools for EKHP, 3/ mobilize for EKHP at the local level.

Results

The committee designed a method for capitalizing, collecting and circulating EK and published in 2020 a guidebook and a toolkit. French Public Health authorities agreed to share EK nationwide on their online portal. Dissemination within the French HP community has started, through the committee members' networks, and will be amplified with a training program launched in 2021 at the National School of Public Health.

Lessons

Attention must be brought to HP practitioners’ experiential knowledge, both to recognize HP practitioners' expertise and to help improve the understanding of how HP interventions work.

Key messages

Experiential knowledge in HP remains undervalued and untapped in France. Dedicated practitioners, policymakers and researchers formed a multidisciplinary committee to promote and disseminate EKHP. A multilevel strategy combining advocacy and tool building can be effective at promoting experiential knowledge. A multidisciplinary coalition provided the necessary context-specific levers in France.

[Social inequalities in oral health and early childhood caries: How can they be effectively prevented? A scoping review of disease predictors]

BACKGROUND

Early childhood caries represent a major public health problem. In addition to their individual impact, the massive social inequalities in oral health that are at the roots and result from the disease have largely underestimated consequences for the child, his family and the community. In response to the question of "how and where to act?", this scoping review identifies the individual characteristics associated with the disease on which it would be possible to act, using appropriate prevention strategies.

METHODS

This scoping review is aimed at describing and analyzing available data in the literature on the different factors associated with early childhood caries.

RESULTS

The predictors of early childhood caries are represented by mediating (knowledge, attitudes and parents' oral health practices) and moderating (psychosocial parameters, parental health literacy and alcohol consumption) factors. Twenty-eight articles fulfilled the selection criteria, twenty of which studied mediators related to early childhood caries, and fourteen of which dealt with moderators. The lower the parents' level of knowledge and literacy in oral health, the higher a child's dmft index. Additional studies are needed to assess the role of psychosocial parameters.

CONCLUSION

Parents' knowledge and oral health literacy are the key predictors to be preferentially targeted in view of reducing social inequalities in health through actions undertaken on a local scale. The prevention of early childhood caries necessitates a combination of generic and targeted interventions.

Public Health, Ministry of Health and Economic Actors: the case of food and information of public

The experience of France in the implementation of a frontof- pack label, the Nutri-Score, clearly illustrates the constant tug-ofwar between public health experts and the industry and provides a framework for an efficient strategy that could be replicated at the EU level.

Dietary risk factors is in the top three leading causes of morbidity and mortality in Western Europe. Such high burden of diseases urges the implementation of strong and efficient public health strategies in order to curb the impact of poor diets. The public health community has long promoted strategies impacting both individual dietary behavior and the food environment, in a consistent global framework. However, the latter strategies imply to act upon the food and beverage manufacturers, to provide consumers with better information on the nutritional quality of the foods they produce and to ensure a shift in the nutritional composition of the food offer towards healthier foods.

Among the various public health nutrition strategies that are considered efficient in both modifying consumer behavior and enticing reformulations by the food industry, front-of-pack food labeling has been identified as a key policy component in a global program.

Mothers’ Oral Health Literacy and children’s oral health: study in the department of Pikine, Senegal

Background

Several studies have shown that social conditions in which children are raised and family psychosocial factors affect their oral health. Oral health literacy (OHL) has been shown to be associated with prevalence of dental caries, access to care and prevention of oral diseases. No studies have addressed this issue in Senegal.

Objective: To study the characteristics of the mothers’ OHL and its association with children’s dental health.

Methods

Cross- sectional study in the district of Pikine, a suburb of Dakar including 16 municipalities. Two-stage cluster sampling and a sample comprising 315 children from 3 to 9 years old and their mothers. Data on oral health status were collected from clinical examinations, sociodemographic and OHL (Sistani et al’ OHL-AQ) data were collected during face-to-face interview.

Results

More than half of the mothers (56.5%) had a low OHL, but 68.9% had an adequate score for the communication/interactive dimension. The level of OHL increased significantly with education level, household wealth and dynamism of the social support. Prevalence of dental caries was 64.8%, following a social gradient and significantly associated with the mothers’ OHL level (OR = 5.2) CI[2.2-14.1]. The oral health behaviour of families was significantly associated with the level of OHL and children’s dental health. A structural equation model showed the OHL was a mediating factor between social characteristics and oral health behaviours.

Conclusions

The OHL of mothers is an important variable to be included in the study of social inequalities in oral health. The communication/interactive dimension seems to be decisive in the African context of an oral culture and dynamic social support which makes it possible to provide better knowledge and preventive behaviour.

Key messages

High maternal OHL should be reinforced to lessen oral health inequalities among Senegalese children. The communication/interactive dimension seems to be decisive in the African context of an oral culture and dynamic social to enhance OHL.

How to build and share an experiential knowledge in public health?

Key messages

This work opens the way for an original reflection in public health to build a shareable experiential knowledge, and to valorize and strengthen field actors’ practical expertise. This work has pedagogical, political, scientific and informational impacts. It contributes to knowledge transfer and provides self-training, a practical vision of policies, and questions for research.

An Objective Method for Bed Capacity Planning in a Hospital Department

Objectives: To propose an objective approach in order to determine the number of beds required for a hospital department by considering how recruitment fluctuates over time. To compare this approach with classical bed capacity planning techniques.

Methods: Asimulated data-based evaluation of the impact that the variability in hospital department activity produces upon the performance of methods used for determining the number of beds required. The evaluation criteria included productive efficiency measured bythe bed occupancy rate, accessibility measured by the transfer rate of patients due to lack of available beds and a proxy of clinical effectiveness, by the proportion of days during which there is no possibility forunscheduled admission.

Results: When the variability of the number of daily patients increases, the Target Occupancy Rate favors productive efficiency at the expense of accessibility and proxy clinical effectiveness. On the contrary, when the variability of the department activity is marginal, the Target Activity Rate penalizes the proxy of clinical effectiveness, and the Target Occupancy Rate under-optimizes productive efficiency.

The method we propose led to a superior performance in terms of accessibility and proxy of clinical effectiveness at the expense of productive efficiency. Such a situation is suitable for intensive care units. In the case of other departments, a weighting procedure should be used to improve productive efficiency.

Conclusions: This approach could be considered as the first step of a family of methods for quantitative healthcare planning.

[Avoidable hospitalizations: the sole responsibility of primary care?]

BACKGROUND

Avoidable hospitalizations are used as a performance indicator of primary care in many countries. We investigate here the validity and usefulness of this measure both at a global scale and for the French healthcare system.

METHODS

A scoping study was performed to take a critical look at this concept. The different uses of avoidable hospitalizations as an indicator have already been reported in two recent systematic literature reviews.

RESULTS

Rates of avoidable hospitalizations seem to be far more correlated with the socioeconomic attributes of patients than with primary care supply. The few studies conducted in France confirm this international trend. Several weaknesses have been spotted in the building of this indicator: the choice of conditions that can be considered as sources of avoidable hospitalizations, their identification among hospitalization disease codes, the quality of hospital coding procedures, the ecological bias in the data collection of illustrative variables.

CONCLUSION

Guidelines for improvement of this indicator are provided. In particular, we discuss the possibility of its use at the scale of the whole healthcare system.

The Reconfiguration of the Relationship to Care for a Rare Disease: Neonatal Expended Screening in a Socio-material Perspective

Neonatal Screening (NBS) is a mass screening, secondary prevention policy aimed at detecting one or several often congenital disorders in all neonates in a given country. The French CF NBS programme is completely functional since the middle of 2003. Drawing its inspiration from the socio-material approach, this article advances a description and analysis of the interactions between the biomedical technologies used in neonatal cystic fibrosis screening and the resulting changes in clinical practice, the bioethical debate and finally in the interstice between voluntary individual consent to screening and the management of a population’s health. The analysis grid focuses on four dimensions: institutional, techno-scientific, regulatory and socio-professional. Backed up by a field survey conducted in the specialised healthcare centres, this study explores two major aspects of the repercussions of NBS: first, the genesis and institutionalisation of this public policy and the impact of a more flexible form of Evidence Based Medicine (EBM) and the sustained controversy on the neonatal screening programme uniting the community of cystic fibrosis paediatrics. This study suggests that institutional stability remains fragile and in this respect constitutes a paradoxical form of production with incompleteness and uncertainty as constituting factors.

Topical corticosteroid phobia in atopic dermatitis: a study of its nature, origins and frequency

BACKGROUND

Topical corticosteroids remain the mainstay of atopic dermatitis therapy. Many atopic dermatitis therapeutic failures appear to be attributable to poor adherence to treatment due to topical corticosteroid phobia.

OBJECTIVES

To assess the facets, origins and frequency of fear of topical corticosteroid use among patients with atopic dermatitis.

METHODS

A questionnaire comprising 69 items, generated from information gathered during interviews with 21 patients and 15 health professionals, was given to consecutive patients consulting at the outpatient dermatology departments of five regional university hospitals or with 53 dermatologists in private practice.

RESULTS

A total of 208 questionnaires were analysed (including 144 from parents and 87 from adult patients, 27 of whom were also parents); 80·7% of the respondents reported having fears about topical corticosteroids and 36% admitted nonadherence to treatment. A correlation was found between topical corticosteroid phobia and the need for reassurance, the belief that topical corticosteroids pass through the skin into the bloodstream, a prior adverse event, inconsistent information about the quantity of cream to apply, a desire to self-treat for the shortest time possible or poor treatment adherence. Topical corticosteroid phobia was not correlated with atopic dermatitis severity.

CONCLUSION

Topical corticosteroid phobia is a genuine and complex phenomenon, common among French patients with atopic dermatitis, that has an important impact on treatment compliance.

Who are the carriers of MRSA in the community? A prospective study in the Pays de la Loire region of France

The aim of this study was to determine the demographic characteristics of methicillin-resistant Staphylococcus aureus (MRSA) carriers in the community, to assess their risk factors and possible past hospitalization history and to describe the different resistance phenotypes of community isolates of S. aureus. Data were collected over the course of 16 months (from June 2005 to September 2006) in the Pays de la Loire region of France by MedQual, a network of private biological analysis laboratories. This work was based solely on the analysis of strains isolated in the community as opposed to isolates from private facilities such as nursing homes or hospitals. The antimicrobial susceptibility results for a total of 313 MRSA isolates were included in this study. The isolates were most frequently recovered from skin and soft tissue infections (41.2%), urine (38.3%) and genital samples (8.3%). We distinguished 36 patients without classical risk factors (WRF), such as demographic individual medical, healthcare exposure, carried MRSA, from the other 277 patients with at least one risk factor (RF). WRF MRSA patients were younger than RF patients and an infection was more often found among WRF patients. MRSA strains isolated from RF patients were resistant to ofloxacin in 81.1% of cases, whereas only 50% of the MRSA strains isolated from WRF patients were resistant (p <0.001). Nine resistance phenotypes were observed among the 313 MRSA strains. MRSA resistance profiles in the community have evolved in recent years. Therefore, it is necessary to study the resistance phenotypes of the circulating strains in order to adapt therapeutic care in the community.

Inégalités de santé et d'accès secondaire aux soins

The role of health care inequalities in social inequalities in health should be reconsidered since the quality of health care varies according to the social status. Some of the health care inequalities are constructed by not taking account of health inequalities in the development of programs or recommendations of medical practice and thus ending up with management procedures that do not reduce inequalities to a minimum but even contribute to increasing them. Other health care inequalities are due to omission, linked to the operating inertia of a health care system that does not recognize these inequalities and has no plan to catch them up. To reverse this situation it seems necessary to act at the three levels of the health care system: to change the clinical paradigm at the micro level, tackle the organizations issues at the meso level, and pursue the reform of the entire health care system at the macro level.

[An evaluation of a patient education programme for children with asthma at a French teaching hospital ("l'espace du souffle", Nantes) (2002-2003)]

A program of patient education was set up at the CHU of Nantes, for groups of children with asthma in 1997. The aim of this study is to realize a formative evaluation to corelate with some effects. This study was proposed to 99 families with asthmatic children. A written questionnaire, was administered to the parents and children, exploring their satisfaction with the programme, their general knowledge and know-how, biomedical parameters. The observation focused on skills and day-to-day life with the illness. The study was completed by 21 families. The majority of the children, aged 7 to 11 years old, had asthma that needed treatment. All of the parents and children were satisfied with their visit to "l'espace du souffle". They all declared having increased their general knowledge and know-how and biomedical parameters did better. They did, however, feel that they did not know enough about how to recognise precursory symptoms of an attack, about how to practise a sport or how to use "corticoids". They also could not control their personal fear during an attack. During the oral questionnaire a general feeling of stress and worry was clearly noticeable in the parents feeling, that did not appear in the written questionnaire. This patient education program appears to be beneficial. Furthermore, this evaluation highlights some subjects that pass unseen during current individual consultations.

[Main issues and contributions of the evaluation of health care networks]

Health care networks correspond to a form of horizontal and flexible organisation, which consists in dealing with complex problems of health and long-term care. Networks rest entirely on the mechanisms of coordination between the various actors of care, whose keystone is the medical information flow. The challenge of the health networks evaluation is to prove the added value of a network organization, instead of a conventional disease-centred health care. The evaluation of health care networks is legally required but not sustained by specialists. Evaluation must ensure the existence of a real management; measure the interest of health care professionals and the impact of the network on professional practices. Moreover, evaluation accompanies the development of the network and offers the advisability to the decision maker of obtaining a tool for control of management, i.e. an information tool and a decision-making help, with the aim of a continuous improvement of the quality of care. However the absence of formation of the medical coordinators to management, makes networks management problematic. Thus, health care networks cannot make the saving in a good administrative and management base. In the same way health care networks must obtain an information system adapted to their type of coordination, allowing the evaluation required by the financier.

[Local guidelines and quality of antibiotic treatment in urinary tract infections: a clinical audit in two departments of a university hospital]

AIM

To assess the effect of local guidelines implemented at the Nantes University Hospital regarding antibiotic therapy for urinary tract infections.

DESIGN

Before/after study of one medical ward and one urologic surgery ward. Quality was measured by two principal criteria: compliance with guidelines and medical justification in the specific clinical situation. Both criteria considered simultaneously the choice of drug, dose and duration of treatment. Deviations from the guidelines were described.

RESULTS

1086 UTI cases were identified over two 12-month periods, before and after the dissemination of guidelines (for prostatitis, pyelonephritis, indwelling catheter-associated UTIs, and other undefined UTIs). The guidelines were applicable in 313 (30%) cases. Overall, after implementation of the guidelines, the percentage of justified prescriptions did not change significantly (41.8% compared with 38.7%, p=0.299), but the percentage of correct (conforming) prescriptions fell (from 30.4% to 15.7%, p=0.0022). The percentages of correct and justified prescriptions differed in the medical (respectively 45.0% and 46.6%,) and surgical units (13.1% and 36.5%).

CONCLUSIONS

Issuing guidelines does not necessarily improve the quality of antibiotic therapy for UTIs in hospitals.

["Evaluating health workshops": the experience of health education committees in the Pays de la Loire region]

The five health promotion and education committees (CODES) from the Pays de la Loire region are carrying out health promotion projects involving socially disadvantaged people. These projects are referred to as ateliers santé (literally meaning "health workshops"). These interventions are conducted over a series of participatory sessions, which creates a more supportive structure to guide people with difficulties assisting them to better recognise and formulate their health needs, as they are normally part of a population group which is neither accustomed to expressing their health needs nor to being heard on this subject. At present little is known about these projects; therefore the Inter-regional and departmental health education committee from Nantes chose to carry out an evaluation of 7 of the 47 existing "workshops". Each one of the seven interventions required an average of 31 hours of preparation. Overall, there were 9 sessions organised with 8 to 9 participants, each lasting for the duration of 2.5 hours, held over a period of 32 weeks. At the end of each session, 85% of the participants claimed that there were satisfied. When questioned six months after the end of their "workshop", half of the 37 participants reported that their perceived health status was a little or much better after having taken part in the process. The evaluation demonstrates that a more clear definition of the operational objectives is necessary in order to promote increased input from the participants and to clarify the intentions of the project team towards a population group which needs a means by which it can enter into this critical debate. The process appears to be in accordance with the criteria and goals of health promotion: negotiation of the content, participation of members of the target audience throughout various stages of the project, and adjustment of the size and scale of the project being to involve a small total number of participants in order to favour effective follow up. Although evaluating the effectiveness and impact of such interventions is difficult and complicated by complex methodological questions, these "workshops" seem to have been greatly appreciated both by those who requested them and those who participated in them, with encouraging results having been witnessed in the lives of certain participants, which all serves as an incentive to pursue this kind of project.

Bonnes pratiques de prescription des antibiotiques pour la prise en charge des infections urinaires en milieu hospitalier : identification des écarts aux recommandations et actions correctrices

OBJECTIVE

We analyzed the adequacy of antibiotic therapy prescribed for urinary tract infections (UTI): prostatitis, pyelonephritis, indwelling catheter-associated UTIs, or other undefined UTIs.

DESIGN

The adequacy of prescriptions to local guidelines was assessed retrospectively in two wards (Internal Medicine and Surgical Urology) of the Nantes University Hospital. The principal criteria involved simultaneously: choice of the molecule, dose, and treatment duration. Non-observances of guidelines were major (non-adequacy of the molecule, prescription of a non-active molecule according to in vitro susceptibility tests, non-appropriate treatment abstention), or minor (non-justified treatment, non-justified bitherapy, no prescription of bitherapy when requested, no treatment adaptation when requested, too short or too long treatment length, dosage mistakes).

RESULTS

One thousand eighty-six infections were collected over a 24-month period. The overall rate of adequate prescriptions was 40.1% (46.6% in Internal Medicine and 36.5% in Surgical Urology). In Internal Medicine (226 non observance among 389 prescriptions), the ratio of major non-observance of guidelines was 9.8%. Among them, 44.7% were non-appropriate treatment abstentions. In Surgical Urology (539 non observance out of 695 prescriptions), non-observance related to treatment length were the most frequent. The ratio of major non-observance was 19.9%. Among them, non-adequacy of the molecule reached 60.7%. Non-justified treatment and non-appropriate bitherapies were frequent.

CONCLUSIONS

For both units, indwelling catheter-related UTIs and other UTIs accounted for more than 50% of the infections although not detailed in the local guidelines. Identifying and analyzing Non observance may lead to targeted correcting actions to improve prescription quality.

Vulnérabilité socialedes consultants d'odontologie d'un hôpital public

There are social inequalities in oral and dental health. It can be useful to identify people in socially vulnerable or marginalised situations because they require a particular kind of care. Through a survey of patients in a dentistry services in a public hospital, we sought to identify those people in a precarious socio-economic situation by the use of a tool designed and validated by multi-disciplinary experts. The tool includes five criteria, and is presented in the format of an index card which is filled in by the patient upon his arrival. This data collection was carried out in two distinctly separate period of time (winter and summer). 865 cards were collected, and the rate of collection of complete data was 73%. 94% of the cards allowed us to determine the socio-economic status of the patient, and 48% (n=382) of them were classified as having a socially vulnerable situation. Among them, 69% of them benefited from CMU or AME, and 59% of them do not have any supplementary health insurance. 47% of them admit to having difficulties in paying for their medications or covering the cost of their medical consultations, and 48% perceive a social service aide. The prevalence of social vulnerability of the dental centre's patients is estimated at 32%. This data collection tool has made it possible to measure the significance and the nature of the social vulnerability of the patients who receive care and services from this public hospital's dentistry unit. Its capacity to identify patients whose care needs are often not met remains to be seen, as well as the capacity of the hospital to make up for these lost opportunities thus remains to be highlighted.

A simple method to optimize hospital beds capacity

OBJECTIVE

The number of acute hospital beds is determined by health authorities using methods based on ratios and/or target bed occupancy rates. These methods fail to consider the variability in hospitalization demands over time. On the other hand, the implementation of sophisticated models requires the decision concerning the number of beds to be made by an expert. Our aim is to develop a new method that is as simple to use as the ratio method while minimizing the roundabout approaches of these methods.

METHOD

A score was constructed with three parameters: number of transfers due to lack of space, number of days with no possibility for S unscheduled admissions and number of days with at least a threshold of U unoccupied beds. The optimal number of beds is the number for which both the mean and the standard deviation of the score reach their minimum. We applied this method to two internal medicine departments and one urological surgery department and we compared the solutions proposed by this method with those put forward by the ratio method.

RESULTS

The solutions proposed by this method were intermediate to those calculated by the local and national length of Stays ratio methods. Simulating an unusual increase in admission requests had no consequence on the bed number selected, indicating that the method was robust.

CONCLUSION

Our tool represents a real alternative to the ratio methods. A software has been developed and is now available for use.

Facteurs de qualité de la prise en charge des sujets âgés opérés d’une fracture de l’extrémité supérieure du fémur

Hip fractures are one of the leading causes for admission of elderly subjects to healthcare facilities. Because of population aging, the incidence of hip fractures has increased considerably over the last years and will continue to increase in industrialized countries. Hip fracture in an elderly subject may be life threatening and has a significant functional and social impact not only because of the fracture itself, but also because of the risk of complications related to the patient's health status and the long hospital stay. The purpose of this work was to identify in the published literature professional practices, excepting the surgical procedure, associated with better early and long-term outcome in elderly patients with hip fracture. Questions raised concerning the patient's hospital stay include factors related to the preoperative phase (time to surgery, usefulness of traction), the operation itself (antibiotic prophylaxis, anesthesia technique), and the postoperative phase (prevention of venous thrombosis, malnutrition, episodes of confusion, duration of indwelling bladder catheter, correction of anemia, geriatric care during the stay in the orthopedic ward, early and intense rehabilitation, prevention of recurrence). Among these factors, several appear to be associated with better outcome, including long-term outcome--surgery as early as possible in light of the patient's general status, antibiotic prophylaxis in accordance with standard recommendations (SFAR), prevention of venous thrombosis with low-molecular-weight heparin initiated at admission and associated with elastic contention. Oral nutritional support is probably beneficial and should be proposed for all patients. Particular attention must be given to prevention of confusion in order to reduce the rate of institutionalization. The rythm of rehabilitation exercises should be at least five sessions per week. Finally, there are several methods, which are effective in preventing recurrence, taking into account osteoporosis, risk of falls. Preventive measures should be instituted for all patients undergoing surgery for hip fracture.