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Dans un contexte de vieillissement de la population, différents scenarii sont envisagés pour réformer l’organisation et le financement de la prise en charge des personnes âgées dépendantes. La place de la prévoyance individuelle dans le financement de la dépendance est à ce titre largement débattue. À l’heure actuelle, malgré des restes à charge potentiellement conséquents, peu d’individus disposent d’une couverture assurantielle. Cet article vise à enrichir la littérature existante en évaluant dans quelle mesure les préférences observées dans la population limitent cette couverture. Nous mobilisons pour cela l’enquête Patrimoine et préférences vis-à-vis du temps et du risque (Pater) de 2011. À la demande de la Fondation Médéric Alzheimer, la vague 2011 de l’enquête Pater a intégré un questionnaire complémentaire relatif à la perception du risque dépendance et aux comportements d’assurance (Pated). L’enquête Pater permet la construction de scores quantifiant quatre dimensions des préférences susceptibles d’influencer la perception du risque et la probabilité de souscrire une assurance parmi les individus percevant le risque : la préférence pour le présent, l’aversion au risque, l’altruisme familial et le goût présumé pour l’aide informelle. Les résultats des estimations montrent le rôle significatif de chacune de ces dimensions dans la demande d’assurance. Néanmoins, même au sein d’une population présentant les préférences les plus favorables à la souscription d’une assurance, les simulations montrent que le taux d’équipement ne dépasserait pas 20 %. Le recours accru à la prévoyance individuelle par le biais d’une généralisation des couvertures assurantielles privées apparaît donc difficilement envisageable à moins d’une forte évolution de l’offre d’assurance ou d’une régulation publique incitant ou contraignant la souscription d’une assurance., Fontaine Roméo, Plisson Manuel, Zerrar Nina. Dans quelle mesure les préférences individuelles contraignent‑elles le développement du marché de l’assurance dépendance ?. In: Economie et statistique, n°474, 2014. PIB par habitant en longue période - Assurance dépendance - Durée de la retraite et espérance de vie - Mesure de la concentration spatiale. pp. 35-68.

Rapport d’étude de la Fondation Médéric Alzheimer

Une revue de la littérature, Question d’Economie de la Santé, n°188, IRDES.

Real-world evidence (RWE) provides external validity, supplementing and enhancing the randomized controlled trial data with valuable information on patient behaviors and outcomes, turning efficacy and safety results into real-world effectiveness and risks, but the use of RWE is associated with challenges. The objectives of this communication were to (1) summarize all guidance on how to conduct an RWE meta-analysis (MA) and how to develop an RWE cost-effectiveness model, (2) to describe our experience, challenges faced and solutions identified, (3) to provide recommendations on how to conduct such analyses. No formal guidelines on how to conduct an RWE MA or to develop an RWE cost-effectiveness model were identified. Using the context of non-vitamin K antagonist oral anticoagulants in stroke prevention in atrial fibrillation, we conducted an RWE MA, after having identified sources of uncertainty. We then implemented the results in an RWE cost-effectiveness model, defined as a model where all inputs come from RWE, including all parameters related to treatment effect. Based on challenges faced, our first recommendation relates to the necessity of conducting sensitivity analyses, either based on clinical or methodological considerations. Our second recommendation is the need for extensive collaboration with a wide range of experts, during the development of the analyses protocols, the implementation of the analyses and the interpretation of the results. RWE may address a number of gaps related to the treatment effect, and RWE economic evaluations for the treatment effect can provide extremely valuable insights into real-world economic value of interventions. As the increased recognition of the value of RWE could influence health technology assessment decision, and current practices, this communication supports the urgent need of more formal guidelines.

Equal Access to the COVID-19 vaccine for all remains a major public health issue. The current study compared the prevalence of vaccination reluctance in general and COVID-19 vaccine hesitancy and social and health factors associated with intentions to receive the vaccine. A random socio-epidemiological population-based survey was conducted in France in November 2020, in which 85,855 adults participants were included in this study. We used logistic regressions to study being "not at all in favor" to vaccination in general, and being "certainly not" willing to get vaccinated against Covid-19. Our analysis highlighted a gendered reluctance toward vaccination in general but even more so regarding vaccination against COVID-19 (OR = 1.88 (95% CI: 1.79–1.97)). We also found that people at the bottom of the social hierarchy, in terms of level of education, financial resources, were more likely to refuse the COVID-19 vaccine (from OR = 1.22 (95% CI:1.10–1.35) for respondents without diploma to OR = 0.52 (95% CI:0.47–0.57) for High school +5 or more years level). People from the French overseas departments, immigrants and descendants of immigrants, were all more reluctant to the Covid-19 vaccine (first-generation Africa/Asia immigrants OR = 1.16 (95% CI:1.04–1.30)) versus OR = 2.19 (95% CI:1.96–2.43) for the majority population). Finally, our analysis showed that those who reported not trusting the government were more likely to be Covid-19 vaccine-reluctant (OR = 3.29 (95% CI: 3.13–3.45)). Specific campaigns should be thought beforehand to reach women and people at the bottom of the social hierarchy to avoid furthering social inequalities in terms of morbidity and mortality.

Using the differentiated increase in retirement age across cohorts introduced by the 2010 French pension reform, we estimate the health-consumption effects of a 4-month increase in retirement age. We focus on individuals who were close to retirement age but not retired yet by the time the reform was passed. Using administrative data on individual sick-leave claims and nonhospital health-care expenses, we show that the probability of having at least one sickness absence increases for all treated groups, while the duration of sick leaves remains unchanged.Delaying retirement does not increase the probability of seeing a GP, except for men in the younger cohorts. In contrast, it raises the probability of having a visit with a specialist physician for all individuals, except men in the older cohorts. Delaying retirement also increases the probability of seeing a physiotherapist among women from the older cohorts. Overall, itincreases health expense claims, in particular in the lower part of the expenditure distribution.

En France, plus de 10 % des enfants âgés de moins de 5 ans pourraient présenter une ou plusieurs anomalies de la vision. Or l’on sait qu’un déficit précoce de la fonction visuelle peut interférer avec le développement de l’enfant et retentir sur l’ensemble de ses compétences, qu’elles soient motrices, cognitives ou affectives, et avoir ainsi des répercussions sur ses performances scolaires puis sur son insertion sociale et professionnelle.Les déficits les plus fréquents (hypermétropie, myopie, astigmatisme et strabisme), souvent dénuésd’impact immédiat notable sur le comportement ou la vie quotidienne du nourrisson ou du jeune enfant, sont parfois difficiles à déceler. S’ils ne sont pas diagnostiqués et traitésprécocement, ils peuvent être à l’origine d’une baisse irréversible de l’acuité visuelle, que l’allongement de la vie contribuera encore à majorer. Il est donc pertinent de s’interroger sur le bénéfice médical et économique d’un dépistage précoce et systématique des anomalies de la vision chez le jeune enfant et le nourrisson.La Mutuelle générale de l’Éducation nationale a souhaité accéder à un bilan des connaissances sur les modalitésdedépistage et de prise en charge précoces des différents types de déficits visuels rencontrés chez l’enfant.Pour répondre à cette demande, l’Inserm a, dans le cadre de la procédure d’expertise collective, réuni un groupe d’experts médecins et chercheurs dont les compétences ont couvert l’ensemble des aspects du problème : épidémiologie, ophtalmologie pédiatrique, neurosciences, psychologie cognitive, génétique, ingénierie optique, économie...Le groupe d’experts a structuré son analyse de la littérature internationale autour des questions suivantes :• Comment se développent les structures et les fonctions visuelles chez l’homme ? Quelles en sont les étapes-clés? À partir de quel âge peut-on détecter des anomalies ?• Que sait-on des interactions entre un déficit des fonctions visuelles et le développement de l’enfant, en particulier l’apprentissage de la lecture ?• Quelles sont les anomalies visuelles rencontrées chez le nourrisson et le jeune enfant, et leur étiologie ? Comment en faire le diagnostic ? Quelles sont les techniques diagnostiques validées ?• Quels sont les modes de prise en charge (optique, chirurgicale, médicamenteuse) des différents troubles recensés?• Quelles sont les prévalences des différentes anomalies de la vision chez le nourrisson et l’enfant, et leur impact en santé publique ?• Comment identifier des populations à risque ? Quels sont les facteurs génétiques impliqués dans les déficits visuels ? • Quels sont les programmes de dépistage général ou spécifique mis en place chez les enfants d’âge préscolaire dans différents pays ? Quelle est l’efficacité de ces programmes ? Quelles sont les données sur les évaluations économiques des stratégies de dépistage et de traitement précoces ?Une interrogation ciblée des bases bibliographiques Medline, Embase, Pascal et Psycinfo a permis de sélectionner plus de 1 400 articles. Au cours de 10 séances de travail organisées entre décembre 2000 et septembre 2001, les experts ont, chacun dans leur champ de compétences, présenté un bilan critique des publications qui leur ont été proposées pour analyse. Les toutes dernières réunions ont été consacrées à l’élaboration d’une synthèse commune et à la proposition de recommandations d’action et de recherche.Des auditions ont été programmées et font l’objet de communications. Elles ont permis au groupe d’experts de prendre connaissance des résultats d’études pilotes de dépistage précoce dans certaines régions françaises, et de recueillir l’expérience de professionnels spécialisés dans la prise en charge des enfants malvoyants.

We investigate the gender gap in hypertension misreporting using the French Constances cohort. We show that false negative reporting of hypertension is more frequent among men than among women, even after conditioning on a series of individual characteristics. As a second step, we investigate the causes of the gender gap in hypertension misreporting. We show that women go to the doctor more often than men do and that they have better knowledge of their family medical history. Once these differences are taken into account, the gender gap in false negative reporting of hypertension is reversed. This suggests that information acquisition and healthcare utilisation are crucial ingredients in fighting undiagnosed male hypertension.

Using a simple theoretical decision model and an original database, we were able to elicit thedistribution of the utility value of having a child with Down syndrome for a large sample of Frenchpregnant women (n = 28, 341) between 2003 and 2007. We found that, on a scale where the value ofa fetal death is 0 and the value of a healthy child is 1, the mean value for a child with Down syndromeis about −0.6. Assuming that the policymaker used the same decision model as the women, we inferfrom the French amniocentesis reimbursement regulation an implicit social value for a child withDown syndrome of −2.5. We conclude from our study that the policymaker is more likely to preventthe birth of children with Down syndrome than French women themselves.

We evaluate the impact of a French vaccination campaign against Hepatitis B (HB) in 1994. Usinga regression discontinuity design, we show that this campaign created an exogenous shock on vaccinationbehavior, increasing the vaccination rate for children aged 11 and above. We also show that this vaccinationscheme led to a decline in the knowledge about HB transmission modes, as well as public confusion aboutthe target population. But our most important result is a drop in measles, mumps, and rubella (MMR)vaccination rate and an increase in the belief that measles is a benign disease. We interpret these results asa salience effect: the focus on HB vaccination may lead to a decrease in the beliefs that other vaccines are asimportant. We find that the decrease in MMR vaccination is mostly due to high-educated parents who aremore likely to substitute MMR with HB for their children, and could have been influenced by their familydoctor. The effect on MMR vaccination was relatively unexpected and may imply a negative externality.Measles is an extremely contagious disease. If the vaccination rate falls, the disease will spread further,raising the question of the net effect of the HB vaccination campaign on the well-being of the population.Overall, it shows the necessity - but also the difficulty- to evaluate the effects of a public policy as a whole,taking into account all potential side effects but also unexpected adverse effects.

International audience; The Isotrace CNRS workgroup in collaboration with National Research Council of Canada has characterized a number of trace element mass fractions and isotope ratios currently not certified in AQUA-1 natural drinking water reference material (NRC Canada). This survey further expands the use of this material as a tool for environmental quality control, method validation, and method development tool for the international community. Simultaneously, the SLRS-6 river water was analyzed as quality control and also in order to compare both water characteristics, which were sampled in the same area but having undergone different treatment. Mass fractions for B, Cs, Li, Ga, Ge, Hf, Nb, P, Rb, Rh, Re, S, Sc, Se, Si, Sn, Th, Ti, Tl, W, Y, Zr, REEs, and six isotopic ratios are proposed for Sr and Pb. Measurements were mostly performed using ICP-MS with various calibration approaches. The results are reported as consensus or indicative values depending on the number of available datasets, with their associated uncertainties.

International audience; In 2009, a system of pay-for-performance (P4P) was offered to physicians in France via the Contrat d’Amélioration des Pratiques Individuelles (CAPI). This study assesses the causal impact of CAPI on their behaviour in terms of care provision. Based on a panel of general practitioners in private practice observed before (2005 and 2008) and after (2011) its introduction, we use an instrumental variables approach, applied to a model in first-differences in order to correct the endogeneity biases linked to the fact that signing up to CAPI is a choice. We show that, unlike other practitioners, those who have signed up to CAPI have not reduced their number of consultations per patient or the amount of prescriptions per patient. They have also increased, to a greater extent than others, the proportion of their patients who they treat as the primary care doctor(i.e. the médecin traitant). Moreover, CAPI has enabled them to increase their fees per patient with, as a consequence, a higher treatment cost for the Social Security system.

AIM: Edoxaban, a nonvitamin K antagonist oral anticoagulant, is an oral factor Xa inhibitor approved for the prevention of stroke and systemic embolism in adult patients with atrial fibrillation and for the treatment and secondary prevention in adult patients with venous thromboembolism (VTE). This study details the design of the Edoxaban Treatment in routiNe clinical prActice for patients with Atrial Fibrillation in Europe (ETNA-AF-Europe) study - a postauthorization observational study, which is part of the postapproval plan for edoxaban agreed with the European Medicines Agency. METHODS: The ETNA-AF-Europe study (Clinicaltrials.gov: NCT02944019) is a multicenter, prospective, observational study that enrolled 13 980 patients with atrial fibrillation treated with edoxaban from 852 sites across 10 European countries (Austria, Belgium, Germany, Ireland, Italy, the Netherlands, Portugal, Spain, Switzerland, and the United Kingdom). Patients treated with edoxaban were prospectively enrolled and will be followed up for 4 years with yearly follow-up visits. ASSESSMENTS: The primary objective of the ETNA-AF-Europe study is to assess the real-world safety of edoxaban by evaluating bleeding events, including intracranial hemorrhage; drug-related adverse events, such as hepatic events; and cardiovascular and all-cause mortality. In addition, efficacy will be assessed by recording major adverse cardiovascular events including stroke, systemic embolic events, transient ischemic attacks, and also VTE episodes, acute coronary syndromes, and hospitalizations related to cardiovascular condition. Event rates will be compared with event rates reported in the PREvention oF thromboembolic events-European Registry in Atrial Fibrillation in atrial fibrillation (PREFER in AF) and PREFER in AF Prolongation registries, and in the Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation - Thrombolysis in Myocardial Infarction 48 study datasets.

Introduction In the KEYNOTE-024 trial, pembrolizumab demonstrated significant improvements in progression-free survival (PFS) and overall survival (OS) versus Standard-of-Care (SoC) platinum-based doublets for first-line treatment of PD-L1 -positive (≥50%) metastatic Non-Small-Cell Lung Cancer (NSCLC) patients with no EGFR mutations or ALK translocations. This study aims to assess the cost-effectiveness of pembrolizumab versus SoC platinum-based chemotherapy from the French healthcare system perspective. Methods A three-state partitioned-survival model was adapted to project outcomes and costs of squamous and non-squamous NSCLC patients respectively, over a 10-year time horizon. Clinical and utility data were collected from the trial. A network meta-analysis was performed to consider platinum-based triplets also used for non-squamous NSCLC. Direct medical costs were considered based on ressources identified from the trial and literature. Costs and outcomes were discounted at 4% per year. Incremental cost-effectiveness ratios (ICERs) were calculated as cost per Life Year (LY) and cost per Quality-Adjusted Life Year (QALY). Sensitivity and scenario analyses were performed to assess the robustness of results. Results For squamous NSCLC, pembrolizumab was projected to increase life expectancy of patients by 0.93 LY (11 months), and 0.74 QALY (9 months) for an incremental cost of €62,032 compared with platinum-based doublets. The ICER of pembrolizumab versus platinum-based doublets was €66,825/LY and €84,097/QALY. For non-squamous NSCLC, pembrolizumab was projected to increase life expectancy of patients by 0.85–1.32 LYs (10.2–15.8 months) and 0.64–1.02 QALYs (7.7–12.2 months) for an incremental cost varying from €-14,947-+47,064 depending on the specific comparator. The ICER of pembrolizumab versus platinum-based chemotherapy with paclitaxel plus bevacizumab was €62,846/LY and €78,729/QALY; regimens including pemetrexed were dominated. Results were most sensitive to extrapolations of survival outcomes and assumptions for continued effectiveness and treatment duration of pembrolizumab. Conclusions Pembrolizumab appears cost-effective versus SoC chemotherapy for first-line treatment of PD-L1-positive (50%) metastatic NSCLC patients in France, assuming willingness-to-pay under 100,000€/QALY (OECD threshold in the discussion section).

International audience; This paper investigates the impact of delaying retirement on mortality among the French population. We take advantage of the 1993 pension reform in the private sector to identify the causal effect of an increase in claiming age on mortality. We use administrative data which provide detailed information on career characteristics, dates of birth and death. Our results, precisely estimated, show that an exogenous increase of one year in the claiming age has no significant impact on the probability to die, measured between age 61 and 79, even when we allow for nonlinear effects of treatment intensity. To test the power of our sample to detect statistically significant effects for rare events like death, we compute minimum detectable effects (MDEs). Our MDE estimates suggest that, if an impact of later retirement on mortality would be detectable, it would remain very small in magnitude.

Background Diseases consequence on individual work as much as consequences of being absent from work are matters of interest for decision makers. Methods We analyzed lengths of absenteeism and related indirect costs for patients with a paid activity in the year following the diagnosis of early stage breast cancer, in the prospective OPTISOINS01 cohort. Both human capital and friction costs approach were considered for the valuation of lost working days (LWD). For the analysis, the friction period was estimated from recent French data. The statistical analysis included simple and multiple linear regression to search for the determinants of absenteeism and indirect costs. Results 93 % of the patients had at least one period of sick leave, with on average 2 period and 186 days of sick leave. 24 % of the patients had a part-time resumption after their sick leave periods, during 114 days on average (i.e. 41 LWD). Estimated indirect costs were 22,722.00 € and 7,724.00 € per patient, respectively for the human capital and the friction cost approach. In the multiple linear regression model, factors associated with absenteeism were: the invasive nature of the tumor (p = .043), a mastectomy (p = .038), a surgery revision (p = .002), a chemotherapy (p = .027), being a manager (p = .025) or a craftsman (p = .005). Conclusion Breast cancer lead to important lengths of absenteeism in the year following the diagnosis, but almost all patients were able to return to work. Using the friction cost or the human capital approach in the analysis led to an important gap in the results, highlighting the importance of considering both for such studies.

Patients undergoing percutaneous coronary intervention (PCI) have an increased risk of both ischemic events and bleeding complications resulting from antithrombotic therapy. These events are particularly common in patients with a concomitant indication for oral anticoagulation, such as those with atrial fibrillation, and are associated with a substantial healthcare resource burden. Advances in procedural aspects of PCI have led to marked improvements in outcomes and a consequent reduction in the costs resulting from PCI-associated complications. Furthermore, recent randomized clinical trials have investigated the optimal antithrombotic strategy in the specific case of patients with atrial fibrillation undergoing PCI, leading to a shift toward the tailoring of antithrombotic therapy according to the patient's individual stroke and bleeding risks. Here we review these recent advances, with a particular focus on the improvements in antithrombotic strategies offered by the non-vitamin K antagonist oral anticoagulants.

We investigate the causal effect of retirement on health through literature. We explore the potential mechanisms which explain three effects: the switch from employment to retirement, later retirement, and earlier retirement. The empirical strategies used to identify the causal effects are mainly based on the observation of changes in health status at the legal age for retirement entitlement or on reforms that have led to changes in retirement incentives. Literature renders possible to make several observations on the average effect estimation. Retirement leads to better self-reported health, less depression, a decrease in healthcare consumption, a decline in cognition and an ambiguous effect on physical health. Later retirement has no effect on mortality, decreases healthcare consumption, and has a negative or non-significant impact on self-reported health. Studies on the impact of earlier retirement are scarce due to few natural experiments exploiting such a variation. Lastly, some studies find evidence of heterogeneous effects by gender and occupational status. As there are relatively few studies on this aspect, the question should be seriously explored in future research.

International audience; We investigate the impact of cognitive load on occupational injuries using survey data. Cognitive load is defined in the literature as a tax on bandwidth which reduces the amount of cognitive resources available for engaging in logical reasoning. We proxy cognitive load with the number of nonprofessional tasks that individuals perform every day, conditional on the time they spend on them. The underlying assumption is that when individuals perform a large number of those tasks, this requires mental organization which keeps part of their working memory busy. We show that cognitive load increases the risk of occupational injury for both males and females. The effect is stronger for individualsin high-risk occupations and, among those, for low-educated workers.

National audience; Présentation publique de l’enquête européenne SHARE (Survey on Health, Ageing and Retirement in Europe) : une enquête longitudinale, multidisciplinaire et internationale concernant plus de 80 000 européens âgés de 50 ans et plus. L’enquête est réalisée tous les deux ans depuis 2004 et se déroule désormais dans vingt-sept pays européens. Les données recueillies grâce à SHARE portent sur l'état de santé des répondants et de leurs proches ainsi que sur leur situation sociale (famille, entraide, réseaux sociaux) et économique (emploi, retraite, patrimoine). Les données de SHARE sont gratuites et mises à disposition des chercheurs qui en formulent la demande

At the ocean surface, satellite observations have shown evidence of a large spectrum of waves at low latitudes. However, very little is known about the existence and properties of the deep variability. Most of the subsurface observations rely on localized measurements, which do not allow for a global estimation of this variability. In this study, we use velocity estimates, provided by Argo float drifts at 1,000 m, to analyze the spatial and temporal distribution of the deep eddy kinetic energy (EKE) and its spectral signature with an unprecedented time and space coverage. In the tropical Pacific, high EKE is found along the equator, at the western boundary and poleward of 7 degrees N. EKE meridional distribution is also found to vary at the scale of the meridionally alternating mean zonal jets: it is higher inside eastward currents. We develop an original statistical scale analysis to determine the temporal and spatial scale dependence of this deep EKE footprint. We show the presence of periodic features whose characteristics are compatible with theoretical equatorial waves dispersion relations. Annual and semiannual Rossby waves are observed at the equator, as well as similar to 30-day Yanai waves, consistent with surface tropical instability waves. The location and intensification of these waves match the downward energy propagation predicted by ray tracing linear theory. Short-scale variability (with similar to 70-day periods and 500-km wavelength) has also been detected poleward of 7 degrees N. The generation mechanisms of this variability are discussed, as well as its potential importance for the mean circulation. Plain Language Summary Energy in the deep ocean is important as it is a potential driver of the deep circulation, which has important climate feedbacks. Because of its singular dynamics, the equatorial ocean is a preferential region of transfer of energy from the surface to the interior of the ocean. Very little is known, however, about the energy content in the deep equatorial oceans. In this study, we use the large number of floats, called Argo floats, drifting at 1,000-m depth in the ocean to describe the deep kinetic energy in equatorial regions. We show that various energetic waves are present at 1,000m in the tropical Pacific, and we discuss their potential generation mechanisms as well as their implications for the circulation. These new observations may help to validate some theories or numerical simulations of the deep equatorial and tropical circulation.

This paper investigates the causal effect of the amount of formal care used on the informal care received by formal care users. We use an original instrument for formal care volume based on local disparities (NUTS 3 level, 96 units) in the price of formal care. Using the French CARE survey, we use a two-part model to assess the effect of formal care on the extensive and the intensive margin of informal care. An increase in the amount of formal care is found to be associated with a small decrease in the probability of using informal care. Heterogeneity tests show that this negative effect is mainly driven by help for daily activities provided by women. At the intensive margin, informal care is not significantly affected by the amount of formal care. Reforms increasing subsidies for formal care can thus be suspected to have a limited effect on informal care arrangements.

While the health of young adults is a recognised public health issue in France, less atten-tion is paid to their use of healthcare. This article examines the existence of unequal opportunities in the use of healthcare for young adults using data from the National Survey on the Resources of Young Adults (Enquête nationale sur les ressources des jeunes - 2014). Using the framework of the philosophy of responsibility, a distinction is made between “unfair” inequalities linked to circums-tances beyond the control of young people – or unequal opportunity, and “fair” inequalities linked to characteristics for which they are responsible. Linear probability models are used to estimate the associations between the probabilities of non-use (non-utilisation and foregone health care) and parental characteristics (complementary health insurance, main activity, income, marital and vital status) on the one hand and those of the young person (education, main activity, whether living in the parental home or not, financial resources, complementary health insurance) on the other, reflecting the existence of unfair and fair inequalities respectively. Variance decomposition makes it possible to quantify these inequalities and suggests that unfair inequalities outweigh fair inequalities.; Alors que la santé des jeunes adultes est un enjeu reconnu de santé publique en France, moins d’attention est accordée à leur recours aux soins. Cet article s’interroge sur l’existence d’iné‑galité des chances dans le recours aux soins des jeunes adultes à partir des données de l’Enquête nationale sur les ressources des jeunes (2014). En mobilisant le cadre de la philosophie de la responsabilité, une distinction est faite entre des inégalités « injustes » liées à des circonstances en dehors du contrôle des jeunes et des inégalités « justes » liées à des caractéristiques relevant de leur responsabilité. Des modèles de probabilité linéaire sont mobilisés pour estimer les associations entre les probabilités de non‑recours (non‑utilisation et renoncement aux soins) et les caractéristiques parentales (assurance complémentaire santé, activité principale, revenu, situation familiale et statut vital) d’une part et celles du jeune (éducation, activité principale, cohabitation, ressources financières, assurance complémentaire santé) d’autre part, traduisant respectivement l’existence d’inégalités injustes et d’inégalités justes. La décomposition de la variance permet de quantifier ces inégalités et suggère que les inégalités injustes sont plus importantes que les inégalités justes.

En France, l'entame d'une sortie du confinement depuis le 11 mai s'est accompagnée de préconisations visant à réduire les contacts pour les populations dites « vulnérables », c'est-à-dire à risque accru de formes graves de Covid-19 en raison de leur âge ou de leurs pathologies. Ainsi, le décret du 5 mai 2020 définit la « vulnérabilité » au sens de l'article 20 de la Loi du 25 avril 2020, c'est-à-dire comme pouvant donner droit au dispositif d'activité partielle. Selon nos estimations, en excluant les critères liés à l'âge, la France métropolitaine compte 12,6 millions de personnes vulnérables soit 24 % de la population. Même si la prévalence des pathologies à risque est liée à l'âge, elle reste importante aux âges actifs et même si un nombre important de personnes vulnérables sont hors de l'emploi, en raison de leur âge, mais aussi de la sélection par la santé dans l'emploi, ce sont 4,8 millions de personnes vulnérables qui occupent un emploi, soit 17,5 % des personnes en emploi. Si la pratique du télétravail est théoriquement possible pour certains ces travailleurs, 3,5 millions d'actifs occupés répondraient aux critères de vulnérabilité sans possibilité de travailler à distance dont 2,8 millions de salariés. Ceux-ci sont concentrés parmi les artisans et les commerçants, les ouvriers et dans une moindre mesure les employés. De même, les salariés des secteurs de l'agriculture, du commerce, de la construction, ou encore de l'industrie agroalimentaire sont plus impactés du fait à la fois d'une prévalence plus forte de la vulnérabilité et d'autre part d'une propension à télétravailler plus faible que les cadres ou les professions intermédiaires. Selon nos estimations, sous l'hypothèse que l'ensemble des salariés éligibles à l'activité partielle pour vulnérabilité y recourt, et sous l'hypothèse que ces derniers ne sont pas déjà en activité partielle pour cause de baisse de l'activité de leur entreprise, l'indemnisation des 2,8 millions de salariés concernés coûterait 2,8 milliards d'euros par mois à l'État et l'Unedic et 400 millions d'euros aux entreprises. Si la question du recours aux dispositifs de protection, que nous discutons en détail, est centrale pour appréhender les conséquences économiques de la protection des salariés vulnérables, notre évaluation permet d'estimer l'impact économique de mesures de reconfinement ciblées qui pourraient être mises en place en cas de rebond épidémique et qui se traduiraient par un retrait systématique des personnes vulnérables en emploi ne pouvant pas télétravailler. Ces mesures ciblées permettraient d'atténuer le choc économique d'un reconfinement.

Planning for old age needs involves ‘high stakes’ decisions such as the choice of a retirement plan, generic saving and investment decisions alongside the take up of insurance for long-term care . We argue that these individual decisions are formed upon limited information and, result from beliefs about future needs that are often not well understood. This paper provides an overview of a number of behavioral ‘regularities’ that illustrate areas where traditional economic approaches should include behavioral economic explanations to better understand and describe decisions for old age. These include the role of framing and reference points, the effects of misperception and behavioral learning, as well as the role of several biases such as optimism, present bias and overconfidence. We contend that choice architectures that incorporate such regularities can help making old age decisions.

We use quasi-random variation in graduation years during the onset of a very deep national recession to study the relationship between early labor market conditions and young females' family formation outcomes. A policy-pilot affecting the length of upper-secondary education in Swedish vocational schools allows us to compare females who graduated into the onset of the Swedish financial crisis of the 1990s to those graduating during the final phase of the preceding economic boom while netting out the main effect of the policy. We find that graduating straight into the recession had negative labor market consequences during the first few years but we find no evidence of permanent labor market scars. In contrast, graduating into the crisis had lasting effects on family formation outcomes of low-grade students in particular. Those who graduated into the recession because of the policy-pilot formed their first stable partnerships earlier and had their first children earlier. Their partners had lower grades, which we show to be a strong predictor of divorce, and worse labor market performance. Divorces were more prevalent and the ensuing increase in single motherhood was long-lasting. These negative effects on marital stability generated persistent increases in the use of welfare benefits despite the short-lived impact on labor market outcomes. The results suggest that young women respond to early labor market prospects by changing the quality threshold for entering into family formation, a process which affects the frequency of welfare-dependent single mothers during more than a decade thereafter.

Objective The objective was to assess the real-world cost-effectiveness of rivaroxaban, versus vitamin K antagonists (VKAs), for stroke prevention in patients with atrial fibrillation (AF) from a French national health insurance perspective. Methods A Markov model was developed with a lifetime horizon and cycle length of 3 months. All inputs were drawn from real-world evidence (RWE) studies: data on baseline patient characteristics at model entry were obtained from a French RWE study, clinical event rates as well as persistence rates for the VKA treatment arm were estimated from a variety of RWE studies, and a meta-analysis provided comparative effectiveness for rivaroxaban compared to VKA. Model outcomes included costs (drug costs, clinical event costs, and VKA monitoring costs), quality-adjusted life-years (QALY) and life-years (LY) gained, incremental cost per QALY, and incremental cost per LY. Sensitivity analyses were performed to test the robustness of the model and to better understand the results drivers. Results In the base-case analysis, the incremental total cost was €714 and the total incremental QALYs and LYs were 0.12 and 0.16, respectively. The resulting incremental cost/QALY and incremental cost/LY were €6,006 and €4,586, respectively. The results were more sensitive to the inclusion of treatment-specific utility decrements and clinical event rates. Conclusions Although there is no official willingness-to-pay threshold in France, these results suggest that rivaroxaban is likely to be cost-effective compared to VKA in French patients with AF from a national insurance perspective.

We examine the targeting effects of stricter screening in the Dutch Disability Insurance (DI) program induced by a major nationwide reform. The drastic 2003 “Gatekeeper Protocol” raised DI application costs and revealed more information about individual true ability to work. Discontinuity-in-Time regressions on administrative datashow substantial declines in DI application rates (a 40% decrease in one year), with the largest decline occurringin difficult-todiagnose impairments and less severe health disorders. This resulted in a more deserving pool of applicants. At the same time, those who stopped applying had worse health, worked less, and were more likelyto be on UI and social assistance than workers who did not apply in the old system. There are no additional targeting gains at the point of the award decision, implying that changes in average health conditions ofawardees were fully driven by self-screening and work resumption in the DI waiting period., We examine the targeting effects of stricter screening in the Dutch Disability Insurance (DI) program induced by a major nationwide reform. The drastic 2003 “Gatekeeper Protocol” raised DI application costs and revealed more information about individual true ability to work. Discontinuity-in-Time regressions on administrative data show substantial declines in DI application rates (a 40% decrease in one year), with the largest decline occurring in difficult-to-diagnose impairments and less severe health disorders. This resulted in a more deserving pool of applicants. At the same time, those who stopped applying had worse health, worked less, and were more likely to be on UI and social assistance than workers who did not apply in the old system. There are no additional targeting gains at the point of the award decision, implying that changes in average health conditions of awardees were fully driven by self-screening and work resumption in the DI waiting period.

This chapter provides an overview of the findings from studies investigating the effect of retirement on cognitive functioning. Most studies suggest an average negative effect of retirement on cognitive functioning. It also shows that the effect tends to differ according to the type of occupation.

This chapter opens with a thorough review of the literature on the health effects of social capital in a large collection of countries, especially in developing countries such as Indonesia. The study includes many innovations and new findings. For example, it finds that inequalities in health opportunities account for 10 per cent of inequalities in health.

Background Projections estimate an increase of 50% of the incidence of lung cancer by 2030. Early-stage non-small cell lung cancer represented 19% of NSCLC cases diagnosed in the US between 2005 and 2011. There is rising evidence in favour of lung cancer screening, which will reduce the occurrence of later-stage lung cancers while raising the incidence of early-stage NSCLC. Current guidelines state that for early-stage NSCLC, surgical resection should be performed, and stereotactic body radiotherapy (SBRT) is an option for patients who are non-medically operable. In this study, we compared the cost-effectiveness of SBRT with lobectomy in medically operable patients. Methods We developed a Markov model based on the survival results of two randomized studies comparing SBRT and video assisted thoracoscopic surgery (VATS) lobectomy in early-stage NSCLC, to describe survival and treatment related complications of patients treated for early-stage NSCLC. This analysis was conducted from the French payer perspective on a lifetime perspective. Utility values, recurrence risks, and costs were adapted from the literature. Deterministic (DSA) and probabilistic (PSA) sensitivity analyses were performed to assess the influence of the assumptions made. Results The Markov model developed was consistent with survival data reported in the pool analysis of the randomized studies. SBRT and lobectomy total costs were 9,234.15€ and 10,726.98€, respectively, and the quality-adjusted life expectancies were 16.35 and 15.80 QALYs, respectively. The DSA, run on every assumption made, revealed that the incremental cost-effectiveness ratio was mainly sensitive to the decrement of utility caused by treatment related complications and initial cost of both surgery and SBRT. The PSA showed that SBRT had the highest probability of cost-effectiveness compared to lobectomy. Conclusions This is the first medico-economic study evaluating SBRT and lobectomy in stage I NSCLC based on randomized studies, and our analyses suggest that SBRT is dominant over lobectomy in operable early-stage NSCLC treatment. Deterministic and probabilistic sensitivity analyses confirmed that this result was robust and that it was not modified by the assumptions made in the Markov model building.

We investigate the impact of local social pressure against dismissals on the choice of employment contracts made by firms using French linked employer-employee data. Taking into account the potential endogeneity of plant location, we show that establishments located closer to headquarters have higher shares of fixed-term contracts in hiring than those located further away whenever firms' headquarters are located in self-centered communities. We also show that this relationship is driven by firms that are highly visible in the community of the headquarters and whose CEOs not only work but also live there. In contrast, when firms' headquarters belong to communities that are not self-centered, the impact of distance to headquarters on the share of fixed-term contracts turns out to be positive. We show that these findings can only be explained by local social pressure. When the local community at the firm's headquarters is self-centered, CEOs are under pressure to avoid dismissing workers close to headquarters. By adding to the adjustment costs associated with open-ended contracts, this creates an incentive for CEOs to rely more on fixed-term contracts, in an attempt to escape social pressure.

BACKGROUND The physical, social and mental burden of psoriasis is well known, but its occupational impact has been less investigated. OBJECTIVE To assess the impact of psoriasis on the working life of patients compared with the general population. METHODS A national survey compared people with and without psoriasis using online questionnaires. In addition to the demographic, medical and professional characteristics, data on recent absenteeism and presenteeism were captured using the validated WPAI-PSO questionnaire. RESULTS The patient sample comprised 714 with psoriasis (PsO), including 81 treated with systemic therapies (PsoST), and 84 with associated psoriatic arthritis (PsO + PsA). The control sample comprised 604 active subjects representative of the French population. Compared to controls, the impact of the disease on working life was no greater in PsO patients. Conversely, unemployment within the past 5 years and mean number of sick leaves within the previous year were more frequent in PsO + PsA. In patients with active psoriasis skin lesions, all aspects of the WPAI questionnaire were negatively impacted in PsoST and PsO + PsA patients, but not in PsO patients: Levels of absenteeism were 3.3% in controls, 5.6% in PsO (NS), 8.3% in PsoST (P

Objective: The aim of this study was to investigate the impact of methodological choices in a meta-analysis of real-world evidence (RWE) comparing three non-vitamin-K antagonist oral anticoagulants...

Most developed nations provide generous coverage of care services, using either a tax financed healthcare system or social health insurance. Such systems pursue efficiency and equity in care provision. Efficiency means that expenditures are minimized for a given level of care services. Equity means that individuals with equal needs have equal access to the benefit package. In order to limit expenditures, social health insurance systems explicitly limit their benefit package. Moreover, most such systems have introduced cost sharing so that beneficiaries bear some cost when using care services. These limits on coverage create room for private insurance that complements or supplements social health insurance. Everywhere, social health insurance coexists along with voluntarily purchased supplementary private insurance. While the latter generally covers a small portion of health expenditures, it can interfere with the functioning of social health insurance. Supplementary health insurance can be detrimental to efficiency through several mechanisms. It limits competition in managed competition settings. It favors excessive care consumption through coverage of cost sharing and of services that are complementary to those included in social insurance benefits. It can also hinder achievement of the equity goals inherent to social insurance. Supplementary insurance creates inequality in access to services included in the social benefits package. Individuals with high incomes are more likely to buy supplementary insurance, and the additional care consumption resulting from better coverage creates additional costs that are borne by social health insurance. In addition, there are other anti-redistributive mechanisms from high to low risks. Social health insurance should be designed, not as an isolated institution, but with an awareness of the existence—and the possible expansion—of supplementary health insurance.

In France, the horizontal equity principle is a founding principle of the social security. It is stated by the maxim “From each according to his ability to pay, to each according to his need”. However, the French health insurance system lets copay-ments for all health expense, in order to contain health expenditures and give incentives to patients. However, such copayments are financial barriers to health care access and sources of inequalities in use of health services. In order to improve equity in the financial access to health services, policies have been implemented in the last decades. This paper proposes an overview of the findings of these policies and provides new results on inequalities in access to health care in France. Most policies packages consis, in setting free access to certain types of care or to reduce health insurance premiums. Free care and free insurance have been demonstrated to be effective in reducing health care use inequalities, although such actions can diminish perceived quality of the service and lead to discrimination when physician fees are caped. By contrast, the literature has also shown the ineffectiveness of health insurance premium subsidy. More recent reforms of the health system, not assessed yet, are aiming at containing prices types of care which are poorly covered by the public health insurance. Despite those policies, we demonstrate that, controlling for need, inequalities in health care use subsist, particularly on specialist, dental, optical and preventive care. This suggests that the reduction in the financial barriers to health care access is a necessary condition but far from being sufficient for achieving equity in health., En France, le principe d’équité horizontale dans l’accès aux soins est au cœur du pacte de 1945, selon la maxime « De chacun selon ses moyens, à chacun selon ses besoins ». Pour autant, le système d’assurance maladie laisse depuis sa création une part du coût des soins à la charge des patients, afin notamment de les responsabiliser. Toutefois, ces instruments constituent des barrières financières à l’accès aux soins, qui sont autant de sources d’inégalités sociales de recours aux soins. Afin d’améliorer l’équité dans l’accès financier aux soins, diverses politiques ont été mises en œuvre au cours des dernières décennies. Cet article propose d’en tirer les leçons et de dresser le bilan des connaissances sur les inégalités de recours aux soins en France. L’essentiel des dispositifs ont consisté à introduire la gratuité de certains soins ou à réduire le coût de la complémentaire santé pour les ménages les plus modestes. Les évaluations disponibles démontrent l’efficacité de la gratuité, que celle-ci s’applique aux soins ou à l’assurance, même si elle peut conduire à une moindre qualité perçue ou à des discriminations lorqu’elle est assortie de tarifs plafonnés. La littérature converge également sur l’inefficacité des subventions à l’assurance. Les réformes les plus récentes, non encore évaluées, visent quant à elles à modérer les prix des soins mal couverts par l’assurance maladie. En dépit de ces dispositifs, il subsiste des inégalités de recours aux soins, à besoins de soins donnés, particulièrement importantes pour les soins de spécialistes, les soins dentaires et d’optique et les soins préventifs. La réduction des barrières financières est donc une condition nécessaire mais non suffisante pour atteindre l’équité en santé.

Introduction: Numerous real-world studies have compared non-vitamin K antagonist oral anticoagulants (NOACs) with vitamin K antagonists (VKAs) in patients with non-valvular atrial fibrillation (NVAF). A meta-analysis was performed to synthesize the available evidence. \ud \ud Methods: Systematic searches were performed through 12/2016 to identify non-randomized NVAF studies comparing NOACs with VKAs, and reporting effectiveness, safety, or persistence. \ud \ud Results: Of 562 citations identified, 49, 79, and 18 compared rivaroxaban, dabigatran, and apixaban, respectively, with VKAs and were included. Compared with VKAs, rivaroxaban was associated with a reduced risk of ischemic stroke (IS) (hazard ratio [HR] = 0.83, 95% confidence interval [CI] = 0.75-0.93), intracranial haemorrhage (ICH) (HR = 0.69, 95% CI = 0.52-0.90), and non-persistence (HR = 0.62, 95% CI = 0.60-0.65). Dabigatran was associated with a significantly lower risk of IS (HR = 0.80, 95% CI = 0.65-0.98) and ICH (HR = 0.45, 95% CI = 0.36-0.58), but not for non-persistence (HR = 0.91, 95% CI = 0.53-1.55), compared with VKAs. Apixaban was associated with a lower risk of ICH than VKAs (HR = 0.41, 95% CI = 0.28-0.60), but was not different to VKAs in terms of IS (HR = 1.01, 95% CI = 0.87-1.17) or non-persistence (HR = 1.08, 95% CI = 0.81-1.45). \ud \ud Conclusion: NOACs appear to be at least as effective and safe as VKAs for stroke prevention in patients with NVAF.

Over the past 10 years, merger activities in the private for-profit nursing home industry have been increasing in Europe. In this paper, we investigate chain affiliation’s influence on the performance of lucrative nursing homes. We measure performance using a cost frontier estimated by stochastic analysis on a sample of 370 French for-profit nursing homes. We find that cost efficiency decreases with the number of facilities in a chain. We also identify different external actor types in nursing homes’ institutional environment and test their influence. We show that nursing home chains’ cost efficiency improves when local governments and shareholders exert pressure. Our results are robust to alternative model specifications and another definition of costs. Overall, our findings inform researchers, as well as standards setters, of the relevance of chain affiliation and of the role of institutional pressures regarding cost containment at the nursing home level.

Background French clinical recommendations suggest prescribing long-acting injectable (LAI) antipsychotics to patients with a maintenance treatment indication in schizophrenia. Despite this, and due to their relatively high acquisition and administration costs, LAIs are still underused in clinical practice in France, thus highlighting the need for pharmacoeconomic evaluations. Objective Our objective was to estimate the cost effectiveness of paliperidone LAI (or paliperidone palmitate), a once-monthly second-generation LAI antipsychotic, compared with the most common antipsychotic medications for the maintenance treatment of schizophrenia in France. Methods A Markov model was developed to simulate the progression of a cohort of schizophrenic patients through four health states (stable treated, stable non-treated, relapse and death) and to consider up to three lines of treatment to account for changes in treatment management. Paliperidone LAI was compared with risperidone LAI, aripiprazole LAI, olanzapine LAI, haloperidol LAI (or haloperidol decanoate) and oral olanzapine. Costs, quality-adjusted life-years (QALYs) and number of relapses were assessed over 5 years based on 3-month cycles with a discount rate of 4 % and from a French health insurance perspective. Patients were considered to be stabilised after a schizophrenic episode and would enter the model at an initiation phase, followed by a prevention of relapse phase if successful. Data (e.g. relapse or discontinuation rates) for the initiation phase came from randomised clinical trials, whereas relapse rates in the prevention phase were derived from hospitalisation risks based on real-life French data to capture adherence effects. Safety and utility data were derived from international publications. Additionally, costs were retrieved from French health insurance databases and publications. Finally, expert opinion was used for validation purposes or in case of gaps in data. The robustness of results was assessed through deterministic and probabilistic sensitivity analyses. Results All LAI antipsychotics were found to have similar costs over 5 years: approximatively €55,000, except for paliperidone LAI which had a discounted cost of €50,880. Oral olanzapine was less costly than LAIs (i.e. €50,379 after 5 years) but was associated with fewer QALYs gained and relapses avoided. Paliperidone LAI dominated aripiprazole LAI, olanzapine LAI and haloperidol LAI in terms of costs per QALY, and it was associated with slightly fewer QALYs when compared with risperidone LAI (i.e. 3.763 vs 3.764). This resulted in a high incremental cost-effectiveness ratio (ICER) (i.e. €4,770,018 per QALY gained) for risperidone LAI compared with paliperidone LAI. Paliperidone LAI was more costly than olanzapine oral but associated with more QALYs (i.e. ICER of €2411 per QALY gained for paliperidone LAI compared with oral olanzapine). Paliperidone LAI had a probability of being the optimal strategy in more than 50 % of cases for a willingness-to-pay threshold of €8000 per QALY gained. Conclusion This analysis, to the best of our knowledge, is the first of its kind to assess the cost effectiveness of antipsychotics based on French observational data. Paliperidone LAI appeared to be a cost-effective option in the treatment of schizophrenia from the French health insurance perspective.

Trichodesmium is the major nitrogen-fixing species in the western tropical South Pacific (WTSP) region, a hot spot of diazotrophy. Due to the paucity of in situ observations, remote-sensing methods for detecting Trichodesmium presence on a large scale have been investigated to assess the regional-to-global impact of this organism on primary production and carbon cycling. A number of algorithms have been developed to identify Trichodesmium surface blooms from space, but determining with confidence their accuracy has been difficult, chiefly because of the scarcity of sea-truth information at the time of satellite overpass. Here, we use a series of new cruises as well as airborne surveys over the WTSP to evaluate their ability to detect Trichodesmium surface blooms in the satellite imagery. The evaluation, performed on MODIS data at 250 m and 1 km resolution acquired over the region, shows limitations due to spatial resolution, clouds, and atmospheric correction. A new satellite-based algorithm is designed to alleviate some of these limitations, by exploiting optimally spectral features in the atmospherically corrected reflectance at 531, 645, 678, 748, and 869 nm. This algorithm outperforms former ones near clouds, limiting false positive detection and allowing regional-scale automation. Compared with observations, 80 % of the detected mats are within a 2 km range, demonstrating the good statistical skill of the new algorithm. Application to MODIS imagery acquired during the February-March 2015 OUTPACE campaign reveals the presence of surface blooms northwest and east of New Caledonia and near 20∘ S–172∘ W in qualitative agreement with measured nitrogen fixation rates. Improving Trichodesmium detection requires measuring ocean color at higher spectral and spatial ( m) resolution than MODIS, taking into account environment properties (e.g., wind, sea surface temperature), fluorescence, and spatial structure of filaments, and a better understanding of Trichodesmium dynamics, including aggregation processes to generate surface mats. Such sub-mesoscale aggregation processes for Trichodesmium are yet to be understood.

Background Venous thromboembolism (VTE, including deep vein thrombosis [DVT] and pulmonary embolism [PE]) has an annual incidence rate of 104–183 per 100,000 person-years. After a VTE episode, the two-year recurrence rate is about 17%. Consequently, effective and safe anticoagulation is paramount. Edoxaban is a direct oral anticoagulant (DOAC) approved VTE treatment. Current safety and efficacy data are derived from clinical trials, and information about treatment durations beyond 12 months are not available. Methods ETNA-VTE-Europe is an 18-month prospective, single-arm, non-interventional, multinational post-authorisation safety study. Approximately 310 sites across eight European countries (Austria, Belgium, Germany, Ireland, Italy, the Netherlands, Switzerland and the United Kingdom) will participate in the study, with the intention to represent the regional distributions of centres, healthcare settings and specialties. An estimated cohort of 2700 patients will be recruited, the only enrolment criteria being acute symptomatic VTE, no participation in an interventional study, and treating physician decision to prescribe edoxaban independently from the registry. Data from patient medical records and/or telephone interviews will be collected at baseline, 1, 3, 6, 12 and 18 months. The primary objective is to evaluate the 18-month rate of symptomatic VTE recurrence in patients with VTE treated with edoxaban outside a clinical trial. The co-primary objective is to evaluate the real-world rates of bleeding and adverse drug reactions. Secondary outcomes include rates of other patient-relevant safety events, adherence to and discontinuation of edoxaban. Furthermore, 12-month ETNA-VTE-Europe data will be considered in the context of those for patients receiving different anticoagulants in the PREFER in VTE registry and Hokusai-VTE clinical trial. Conclusions ETNA-VTE-Europe will allow the safety and effectiveness of edoxaban to be evaluated over an extended period in acute symptomatic VTE patients encountered in routine clinical practice. Findings will be informative for European practitioners prescribing edoxaban as part of real-world VTE treatment/prevention. Trial registration ClinicalTrials.gov Identifier: NCT02943993.

Background: To enhance usage of health technology assessment (HTA) in decision-making, it is important to prioritise important barriers and facilitators to the uptake of HTA. This study aims to quantify and compare the relative importance of barriers and facilitators regarding the use of HTA in several European countries.Methods: A survey containing two best-worst scaling (BWS) object case studies (i.e. barriers and facilitators) were conducted among 136 policy makers and HTA researchers from the Netherlands, Germany, France, and United Kingdom. Hierarchical Bayes analysis generated the mean relative importance score (RIS) for each factor and subgroup analyses assessed differences between countries.Results: Six barriers (RIS5) and five facilitators (RIS6) were deemed highly important. Eleven barriers and ten facilitators differed in their importance between countries. Policy characteristics, research & researcher characteristics, and organisation & resources were particularly important to facilitate uptake of HTA, such as an explicit framework for decision-making and research of sufficient quality.Conclusion: The most paramount barriers and facilitators to HTA usage were quantified. For all countries it is crucial to create an explicit framework for the decision-making context to include HTA evidence. Country differences in the quality of research emphasize the need for enhanced international collaboration in HTA.

Do remittances sent by migrants have an impact on their family’s consumption of health care in their country? By easing the budgetary constraint, these transfers should improve access to health care, particularly in systems with low public expenditure on health. However, transfers can be suspected of being endogenous, as the need for care may prompt migrants to send more money. This article examines the issue in the case of Tajikistan, where both high direct health expenditure and high migration dependence are observed. It is based on data from the Tajikistan Living Standards Survey (2007). The results show that transfers have a positive impact which is however heterogeneous according to the level of care consumption.; Les remises de fonds envoyées par les migrants ont-elles un impact sur la consommation de soins de leur famille au pays ? En assouplissant la contrainte budgétaire, ces transferts devraient améliorer l’accès aux soins, en particulier dans les systèmes avec de faibles dépenses publiques de santé. Cependant, on peut soupçonner les transferts d’être endogènes, les besoins de soins pouvant inciter les migrants à envoyer davantage d’argent. Cet article étudie la question dans le cas du Tadjikistan, où l’on observe à la fois des dépenses directes de santé élevées et une forte dépendance aux migrations. Il s’appuie sur les données du Tajikistan Living Standards Survey (2007). Les résultats montrent que les transferts ont un impact positif mais hétérogène selon le niveau de la consommation de soins.

The ANI reform mandates all private sector employers to offer sponsored Complementary Health Insurance (CHI) to all of their employees beginning on January 1st, 2016. This research simulates the likely effects of this mandate on the welfare of the population considering the Expected utility theory framework. The results show that the ANI reform may induce an increase in social welfare only if wages and CHI’s premiums remain the same. Assuming that premiums of individual CHI contracts increase because of the new risks segmentation, the reform may hardly impact the social welfare. The gain in welfare that benefit private sector employees is therefore offset by the loss of welfare that suffer the individuals insured by an individual CHI contract or who chose to be uninsured before the reform. Considering in addition that employers will include their subsidy amount into wages, the reform may greatly reduce the social welfare.; Depuis le 1er janvier 2016, les employeurs du secteur privé ont obligation de proposer et de financer partiellement une complémentaire santé à tous leurs salariés. Dans ce travail, nous simulons les gains et les pertes de bien-être à attendre de cette réforme sur l’ensemble de la population en mobilisant la théorie de l’utilité espérée. Les résultats montrent que la réforme augmente le bien-être collectif si et seulement si les salaires et les primes des contrats restent inchangés. En considérant que les primes des contrats individuels augmentent du fait de l’accord national interprofessionnel (ANI), l’impact de la réforme est quasi nul sur le bien-être collectif. Le gain en bien-être des salariés qui bénéficient de la réforme est alors contrebalancé par la perte de bien-être subie par les personnes couvertes en individuel ou que la réforme oblige à s’assurer. En considérant en sus que les employeurs intègrent le montant de leur subvention aux salaires, l’ANI réduit fortement le bien-être collectif.

Background Innovative pricing agreements for medicines have been used in European markets for more than 20 years, and offer an opportunity for payers and pharmaceutical companies to align on value, optimise speed to patients, and share risk. Developing successful agreements requires alignment between key stakeholders, yet there is a lack of summative data on how current innovative agreements are used in the real-world (e.g. the level of realised access to medicines, and rebates and discounts, which are often non-transparent). Methods This research used a web-based survey of payer stakeholders to determine what kinds of innovative agreements are currently used, anticipated future usage, attitudes, and drivers of adoption. Participants included national and regional payers (or former payers) and hospital-level decision makers. Results Sixty-six payers completed the survey. Respondents expected that the use of innovative pricing agreements will remain the same or increase in the future. Overall, they felt there is a positive attitude towards new schemes, and that innovative agreements are likely to be used when they reduce total costs or reduce uncertainty. Conclusions Given payer expectations, pharmaceutical companies should continue to take a role in ensuring that they have sufficient capacity to support payers in the design and implementation of innovative pricing agreements.

International audience; We evaluate the introduction of various forms of antihypertensive treatments in France with a distribution-sensitive cost-benefit analysis. Compared to traditional cost-benefit analysis, we implement distributional weighting based on equivalent incomes, a new concept of individual well-being that does respect individual preferences but is not subjectively welfarist. Individual preferences are estimated on the basis of a contingent valuation question, introduced into a representative survey of the French population. Compared to traditional cost-effectiveness analysis in health technology assessment, we show that it is feasible to go beyond a narrow evaluation of health outcomes while still fully exploiting the sophistication of medical information. Sensitivity analysis illustrates the relevancy of this richer welfare framework, the importance of the distinction between an ex ante and an ex post approach, and the need to consider distributional effects in a broader institutional setting.

International audience; We evaluate the introduction of various forms of antihypertensive treatments in France with a distribution-sensitive cost-benefit analysis. Compared to traditional cost-benefit analysis, we implement distributional weighting based on equivalent incomes, a new concept of individual well-being that does respect individual preferences but is not subjectively welfarist. Individual preferences are estimated on the basis of a contingent valuation question, introduced into a representative survey of the French population. Compared to traditional cost-effectiveness analysis in health technology assessment, we show that it is feasible to go beyond a narrow evaluation of health outcomes while still fully exploiting the sophistication of medical information. Sensitivity analysis illustrates the relevancy of this richer welfare framework, the importance of the distinction between an ex ante and an ex post approach, and the need to consider distributional effects in a broader institutional setting.

Introduction: Multi-criteria decision analysis (MCDA) could potentially solve current methodological difficulties in the appraisal of orphan drugs.Areas covered: We provide an overview of the existing evidence regarding the use of MCDA in the appraisal of orphan drugs worldwide. Three databases (Pubmed, Embase, Web of Science) were searched for English, French and German literature published between January 2000 and April 2017. Full-text articles were supplemented with conference abstracts. A total of seven articles and six abstracts were identified.Expert commentary: The literature suggests that MCDA is increasingly being used in the context of appraising orphan drugs. It has shown itself to be a flexible approach with the potential to assist in decision-making regarding reimbursement for orphan drugs. However, further research regarding its application must be conducted.

How does the retirement age affect the physical and mental health of seniors? We identify this effect based on the 1993 reform of the French pension system, which was heterogeneously introduced among the population. The French government gradually increased the incentive to work using two tools: the contribution period required for entitlement to a full pension and the number of reference earning years taken to calculate pensions. This created heterogeneity of incentives to work among the population. We use a unique database on health and employment in France in 1999 and 2005, when the cohorts affected by the reform started to retire. Taking the reform as a tool to filter out the potential influence of health on employment choices, we show that retirement improves physical and social health. The more physically impacted are the low-educated individuals. Subsequently, a difference-indifferences approach among the working population, with the control group comprising public sector employees (not concerned by the 1993 reform), finds that the people more affected by the reform, and hence with a stronger incentive to work, were those posting less of an improvement and even a deterioration in their health between 1999 and 2005.

International audience; In this research, we investigate the long-term effects of job displacement on several dimensions of job quality and satisfaction, focusing only on individuals who lose their job because of plant closure. Using the German Socio-Economic Panel data from 1984 to 2012, we build a database containing 2,396 individuals who have lost their job because of plant closure. Our control group is created by finding workers who have similar characteristics to the displaced workers before their displacement. The matching method that we use is a coarsened exact matching on pre-treatment covariates and pre-treatment outcomes. We then compare the evolution of job quality in both groups to measure the causal impact of displacement. Our main findings indicate a large and long-lasting impact of displacement on employment probability. The effects of displacement on earnings and hourly wages last until three or four years. As for job security, displaced workers report to be more likely to lose their job again. Indicators of quality of the working environment (working full time, long hours, distance to work), are all affected by displacement in the long run except the probability of working full time. These results are robust when we focus on individuals who do not experience a significant period out of employment.