[Embolization of intracranial aneurysms: reimbursement and perspectives]

PURPOSE

To determine the costs related to the embolization of intracranial aneurysms compared to "rates per activity" (T2A) reimbursements.

MATERIALS AND METHODS

The hospital admissions of patients with intracranial aneurysms treated with embolization and classified under diagnosis-related group (DRG) 01K02Z in 2007 were included. The costs related to the single-use devices, neurointerventional suite and hospital stay were calculated by analytical accounting. Revenues were calculated based on DRG-based medical information system (PMSI) and medical data using the diagnosis-related groups and reimbursements from 2007 (V10 of DRG) and 2009 (V11).

RESULTS

Fifty-seven patients were included. The total cost was 932.278 euro and hospital revenues were 655.648 euro in 2007 and would have been 825.211 euro in 2009. The financial loss was on average 4.853 euro per admission in 2007 and 1.878 euro in 2009, and even more in two cases of ruptured aneurysm.

CONCLUSION

In 2001, embolization of intracranial aneurysms, the treatment of choice for this pathology, results in a financial loss for the hospital, larger for ruptured aneurysms compared to non-ruptured aneurysms. The updated DRG, while improving the situation, remains insufficient.

Cost analysis in total hip arthroplasty: experience of a teaching medical center located in Paris

BACKGROUND

Since the beginning of 2008, the implementation of a 100% activity-based payment system, has made efficiency one of the prime concern for the French health-care providing institutions. We therefore assessed the real cost of a scheduled total hip replacement (THR) ina teaching hospital and compared findings with French national data (and with the Government Healthcare Insurance System allowance).

HYPOTHESIS

The study should suggest possible means to optimize organization of management and/or clinicians' practice.

MATERIAL AND METHODS

This is a retrospective full-cost economic study. Patients were included only if fulfilling the following criteria: admitted in 2006; classified in Diagnosis-Related Group (DRG) 08C23 V or 08C23W (respectively THR without and with associated comorbidity); treated in a single department; admitted from home; and having undergone a THR (coded as NEKA020 in the french CPT) that same year. Treatment-cost was established on the basis of data collected from two main sources: the Information Systems Medicalization Program (ISMP) data-base, and the finance department data, which were taken into account in line with the French National Costs Study (NCS) structure.

RESULTS

The methodology employed here follows the 2006 National Costs Scale structure. Treatment costs (excluding the cost of implantable medical devices or IMDs) were estimated at 8,104.72 EUR for DRG 08C23W and 7,529.19 EUR for DRG 08C23 V. These figures were higher than the rates authorized in 2006 (excluding IMDs), which were 7,677.92 EUR for 08C23W and 6,358.97 EUR for 08C23 V (taking the 7% geographic coefficient into account) and than the 2005 NCS figures (excluding IMDs) of respectively 7,536.13 EUR and 6,083.59 EUR.

DISCUSSION

Clinical units and departments need to be able to assess costs for the pathologies they treat, as health-care institutions have to balance their expenditure against their income, which largely comes from their hospital-care activity. The methodology put forward here, of cost comparison according to the NCS structure, enables the total cost to be known. Comparing results (expenditure line by expenditure line) against national data, selectively highlights the areas in which efficiency can be improved. The exactitude of the obtained results remains, however, limited by the rules currently in use at each individual hospital's accounting department.

LEVEL OF EVIDENCE

Level IV, retrospective economic and decision analysis study.

A national prevalence study of pressure ulcers in French hospital inpatients

OBJECTIVE

To ascertain pressure ulcer prevalence rate in French hospitals.

METHOD

In 2004, a cross-sectional study was conducted in all French hospitals, except university hospitals. The National Pressure Ulcer Advisory Panel (NPUAP) staging was used. Data were collected using two self-administered questionnaires.

RESULTS

A total of 37,307 inpatients in 1170 wards in 1149 hospitals were assessed, representing a response rate of 93.5%. Their mean age was 72.3 years and 62% were females. In all, 3314 patients had at least one pressure ulcer, giving a prevalence rate of 8.9%. A total of 4991 pressure ulcers were recorded; 64% of the patients had only one pressure ulcer. Fifty-five per cent of the patients had at least two concomitant diseases. When patients with only one ulcer were assessed, the most common locations were the heels (53%) and sacrum (29%). Heel pressure ulcers were more common in patients with obliterative arterial disease, and sacral pressure ulcers were more frequent in incontinent (urine, faecal and double incontinence) patients. Patients with multiple pressure ulcers had more severe lesions.

CONCLUSION

These results indicate that the prevalence of pressure ulcers in French hospital inpatients has remained stable since the last prevalence study undertaken 10 years before, when the rate was 8.9%. Such studies should be encouraged in all health-care settings as a means of improving the care provided.

Physical and functional cooperation between AP-1 and beta-catenin for the regulation of TCF-dependent genes

Stabilization of cytoplasmic beta-catenin is a hallmark of a variety of cancers. The stabilized beta-catenin is able to translocate to the nucleus, where it acts as a transcriptional activator of T-cell factor (TCF)-regulated genes. beta-Catenin may cross-talk with many signalling cascades to activate target genes. Whether beta-catenin cooperates with AP-1, another transcriptional complex activated during tumorigenesis is not fully clarified. We show that beta-catenin co-immunoprecipitates with c-Jun and c-Fos. GST pull-down experiments indicate a physical association of the armadillo repeat domain of beta-catenin with the DNA-binding domain of c-Jun and of the C-terminal domain of beta-catenin with the N-terminal domain of c-Fos. Promoter studies indicate that overexpression of AP-1 activates the transcription of two beta-catenin target genes, cyclin D1 and c-myc, by a mechanism independent of the AP-1 site, and fully dependent on the TCF-binding site. We further demonstrate that AP-1/beta-catenin synergism is involved during serum-induced cyclin D1 transcriptional activation. We identify a TCF-binding site on the cyclin D1 promoter which binds in vivo a complex induced by serum, containing beta-catenin, TCF4, c-Fos, c-Jun, JunB and JunD. This novel mechanism of interaction between two signalling cascades might contribute to the potentiation of malignancy.

The LIM-only protein FHL2 is a negative regulator of E4F1

The E1A-targeted transcription factor E4F1 is a key player in the control of mammalian embryonic and somatic cell proliferation and survival. Mouse embryos lacking E4F die at an early developmental stage, whereas enforced expression of E4F1 in various cell lines inhibits cell cycle progression. E4F1-antiproliferative effects have been shown to depend on its capacity to repress transcription and to interact with pRb and p53. Here we show that full-length E4F1 protein (p120(E4F1)) but not its E1A-activated and truncated form (p50(E4F1)), interacts directly in vitro and in vivo with the LIM-only protein FHL2, the product of the p53-responsive gene FHL2/DRAL (downregulated in rhabdomyosarcoma Lim protein). This E4F1-FHL2 association occurs in the nuclear compartment and inhibits the capacity of E4F1 to block cell proliferation. Consistent with this effect, ectopic expression of FHL2 inhibits E4F1 repressive effects on transcription and correlates with a reduction of nuclear E4F1-p53 complexes. Overall, these results suggest that FHL2/DRAL is an inhibitor of E4F1 activity. Finally, we show that endogenous E4F1-FHL2 complexes form in U2OS cells upon UV-light-induced nuclear accumulation of FHL2.