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Background: Regionalization of care for ST-segment elevation myocardial infarction (STEMI) has been advocated, although its effect on processes of care and clinical outcomes remains uncertain., Aim: To assess the impact of a regional system of care on provision of reperfusion therapy for STEMI patients relative to control hospitals., Methods: We analysed the original data from two nationwide prospective cohort studies conducted in 2000 and 2005, respectively. Overall, 160 hospitals participated in both studies, including seven hospitals involved in a regional system of care implemented in the Northern Alps in 2002 and 153 control hospitals located in other French areas., Results: A total of 102 and 2377 STEMI patients were enrolled in Northern Alps and control hospitals, respectively. Overall, patients enrolled in 2005 were more likely to receive any reperfusion therapy (60% vs 52%; P < 0.001), prehospital fibrinolysis (33% vs 15%; P < 0.001), and primary percutaneous coronary intervention (32% vs 26%; P < 0.001) than those enrolled in 2000. However, the regional system of care was associated with a larger absolute change in the use of prehospital fibrinolysis (45.0 vs 17.0; P = 0.02) and rescue or early routine coronary angiography or intervention after fibrinolysis (35.3 vs 15.2; P = 0.01). Patients enrolled in 2005 had lower adjusted hazard ratios for death (0.70, 95% confidence interval 0.57-0.87; P = 0.001), with no significant interaction between study groups., Conclusion: Regionalization of care for STEMI patients improves access to reperfusion therapy, although its impact on clinical outcomes deserves further study., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objectives: Diabetes mellitus is frequently associated with HIV infection but there's only limited evidence regarding the control and impact of this co-morbidity. This study aimed to estimate the prevalence of diabetes, compliance with treatment, perception and quality of life of HIV patients with diabetes., Methods: We conducted a cross-sectional study among patients treated for diabetes and registered in the DMI2 databasis in a French university hospital in January 2010. Clinical assessment and follow-up data were collected using chart review and self-administered questionnaires. Quality of life (MOS SF-12) and compliance with treatment (simplified medication adherence questionnaire) were assessed using validated scales., Results: The prevalence of treated diabetes mellitus was 3.9% (29/748, 95% confidence interval, 2.6% to 5.5%). Among these 29 HIV diabetic patients, 93% had a virologic control of HIV infection while only 22% had well-controlled diabetes. Ninety-six percent of patients were scared to die from HIV-which was rated as the main pathology-compared with 71% of patients for diabetes. The mean score for physical quality of life was 43.1 (13.2), which was lower than estimates for overall population. Non-compliance with treatment was reported for 35% of patients., Discussion: Although anti-retroviral treatments turned HIV infection into a chronic disease, patient perception was not altered. This study shows a better control of HIV infection than diabetes. We have to find out ways (e.g. patient education programs, annual multidisciplinary consultation...) to give the patient a global feel for his health thereby improving prognosis and quality of life., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background: Time until revascularization is an important prognostic factor for patients with ST-elevation myocardial infarction. The objective of this study was to investigate the factors associated with patients' delay in calling for emergency medical services (SAMU, "15" in France)., Methods: We analyzed the original data of a permanent prospective register of patients receiving care from mobile intensive care units staffed by emergency physicians and dispatched by SAMU in southern Isère (France), from October 1, 2002, through December 31, 2004., Results: Of the 380 patients analyzed, 71% were men and 15% had a history of coronary disease. The median age was 60 years for men and 72 for women. The median time from symptom onset to calling SAMU was 63 minutes (interquartile range, 27 to 144). In the univariate analyses, the time to the call was higher for women (90 v 58, p<0.01) and increased with age (p<0.01) and prior calls to a physician or nurse (115 v 45, p<0.001). In the multivariable analysis, factors independently associated with delay in calling SAMU included female gender, age of 55-64 years, prior calls to a physician or nurse, and onset of pain during the weekend or at night. The media call delay did not differ for patients with and without a history of coronary disease., Conclusion: The subpopulations of patients characterized by the factors associated with delayed calls should be the target of programs to stress the importance of calling SAMU quickly, regardless of the time of day; the effectiveness of these programs should be evaluated by randomized studies before they enter general use.

Objectives: The aim of this study was to assess the reliability and validity of tests assessing medical students' ability to read medical journal articles critically., Methods: All third-year students at our medical school (n=125) took three tests between December 2004 and June 2005 as part of a program to teach critical appraisal of medical literature. Each test required students to write a 250-word structured abstract and to answer a set of 6 to 8 appraisal questions. Interrater reliability was assessed with the intra-class correlation coefficient for the first test. Validity was assessed 1) by calculating the correlation coefficient between the mean scores on the three critical appraisal tests and 2) by calculating the correlation coefficient between these tests and eight other tests in other subjects that the students took over the same period., Results: Interrater reliability was satisfactory for the overall score (ICC=0.72) and for the score for the questions alone (ICC=0.73). It was only moderate, however, for the structured abstract test (ICC=0.53) and varied markedly from question to question (ICC range: 0.29-0.86). Intertest correlations were all statistically significant (p<0.001) and the mean score on the critical reading tests was significantly correlated with the mean score on the tests for other subjects that year (r=0.60; p<0.001)., Conclusion: The validity and reliability of the tests of critical reading of medical literature are satisfactory but can be improved by developing more explicit scoring templates.

Objective: The Grenoble clinical research centre carried out a prospective satisfaction survey of subjects taking part in clinical studies undertaken in its buildings., Materials and Methods: A questionnaire adapted from Grenoble teaching hospital's inpatient satisfaction survey was sent to 198 subjects. It comprised 24 items pooled in categories on which were calculated average scores. The participation rate of the survey was 82.6%. On the whole, 94.4% of the questioned subjects would accept to take part in a new study if we requested them, and 72.2% were satisfied or very satisfied with their stay; 24% had no opinion. The mean overall satisfaction score was 8.6 (95% confidence interval: 7.6-9.6) out of 10., Conclusion: This investigation shows that the assumption of responsibility of the subjects by specific personnel and in an adapted place, within the framework of clinical protocol of research, is associated with a high satisfaction of the subjects. However, we still have to improve the transmission of the clinical study results to the patients.

Objective: To assess the conformity of practitioners' practices in the management of community acquired pneumonia with the French Agence Nationale d'Accréditation et d'Evaluation en Santé (Anaes) guidelines., Methods: We retrospectively reviewed a random sample of 210 medical records which included a principal or associated diagnosis of pneumonia in a French university hospital., Results: A hundred and one medical records were assessable. Sixty-two patients were high risk (Pneumonia Severity Index class IV or V of the prediction rule of Fine et al.), and 10 patients were admitted into an intensive care unit. The overall in-hospital mortality was 14 patients [8-22]. The level of care was appropriate according to the guidelines in 40 cases ([30-50)]. Seven patients did not require hospitalisation, 31 patients required admission into a medical department, 56 patients into an intensive care unit and 7 patients were managed in non specified conditions. Eighteen patients ([11-27]) had appropriate microbiologic investigations. Forty-three patients (([33-53]) received antibiotics within 8 hours of arrival. Empirical antibiotic treatment (dosage and molecule) was appropriate in 38 patients ([28-48]). There was no significant relationship between compliance with the guidelines and in-hospital mortality., Conclusion: The rate of conformity of practitioners' practices with the Anaes guidelines for management of community-acquired pneumonia is low in our hospital. It could be improved by active implementation of these guidelines.

The aim of the study was to assess the impact of an individual patient order form which concerned the 21 most costly antibiotics in a university hospital. Antibiotics expenditures were monitored from 1995 to 1999 and were expressed in 1999 French Francs per 100 patient days (p.d.). The time series were analyzed by auto-regressive models. The trend of antibiotics expenditures which were concerned by the individual patient order form was a yearly increase of 50 FF/100 p.d. (p < 0.01). The individual patient order form had no significant impact on global antibiotics expenditures but there were some differences across departments: antibiotics costs decreased 1.293 FF/100 p.d. (p = 0.02) in intensive care departments. Monitoring antibiotics consumption should be continued in order to increase power of analysis and to assess the impact of the implementation of guidelines.

In Quebec, the evaluation of health care providers' practices is organized for each professional group. It is an official part of the health care regulation policy and is defined by legal texts. Evaluation of medical practices is controlled by physicians through their professional order and consultative medical councils in hospitals. The role of the Collège des Médecins du Québec is to warrant the quality of medical acts. The College watches over the quality of the physician's initial education using a process of agreement for all training departments and for the medical school curriculum. Young graduates must pass the College's examination before being licensed to practice. The College watches over improvements in professional practices via inspections of individual practices and hospitals and continuous education programs. There are three levels of physician supervision: screening for poor practices, inspection, and in-depth investigation. In hospitals, a consultative medical council is in charge of assuring quality medial practice. Mortality and morbidity conferences, claims analysis, audits with explicit evaluation criteria and indicator monitoring are the basic tools used for assessing the quality of medical practice. The Quebec experience demonstrating how a medical profession can organize a full system for evaluating medical practice can be a model for other countries.

Objectives: Acute acoustic trauma (AAT) refers to damage to sensitive cochlear structures caused by excessive exposure to impulse noise. The aim of this study was to 1) assess the incidence of ATT in French soldiers and 2) to clarify the circumstances under which AAT occurs., Patients and Methods: We carried out a prospective study of AAT events reported to medical officers in 1998., Results: The incidence of AAT was 156 per 100,000 person-years (150-161). It was higher in conscripts and in soldiers aged under 31 years. Fifty-seven percent were wearing hearing protectors when the accident took place., Conclusion: According to these results, specific preventive programs were planned and should be assessed by epidemiological surveillance of exposed populations.

Objectives: To assess the impact of patient satisfaction survey method on response rate, data quality and satisfaction., Patients and Methods: Four modes of data collection were assessed during a randomized trial that included 400 inpatients discharged from a teaching hospital., Results: The response rate was 58% within the mail survey group (72% with follow-up letter) versus 73% and 81% within the home and telephone interview group (p < 0.01). 69% of the mailed questionnaires contained no missing values versus 94% and 96% for home and telephone interview modes (p < 0.01). The global satisfaction scale score was greater within the mail survey groups (8.1/10 without follow-up letter and 7.9 with follow-up letter) than within the telephone interview group (7.8) and the face to face interview group (7.3), (p < 0.05)., Conclusion: Mail survey with follow-up letter constitutes an operational method despite lower data quality and overestimation of patients' satisfaction scores.