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Position du probleme : Estimer l’impact economique (cout pour l’hopital) des injections de toxine botulique dans la prise en charge des patients paralyses cerebraux marchants presentant une spasticite des membres inferieurs.Methodes : Enfants inclus dans l’observatoire Botuloscope, multicentrique, evaluant une serie consecutive d’enfants paralyses cerebraux âges entre 2 et 16 ans presentant une spasticite focale invalidante.L’etude de cout a ete realisee dans la perspective de l’hopital. Les couts directs hospitaliers (annee 2004) etaient ceux induits par l’utilisation de la toxine botulique a 12 mois en MCO et SSR.Resultats : Deux cent quarante enfants ont ete inclus, 486 seances d’injection de toxine ont ete realisees pendant l’annee de suivi. Le cout moyen de la seule seance d’injection (toxine + analgesie + consultation ou hospitalisation) a ete estime pour l’ensemble des enfants a 731 € par enfant, dont plus de la moitie pour la toxine et l’analgesie. Sur 12 mois, le cout hospitalier de la prise en charge des enfants a ete estime a un peu plus de 2 500 € par enfant.Conclusion : S’il existe depuis 2009 un Groupe Homogene de Malades (GHM) specifique pour l’injection de toxine en ambulatoire, valorise a 375,55 € en 2014, ce remboursement ne couvre pas le cout moyen d’une seance d’injection tel que nous avons pu le calculer. Le tarif du GHM ne tient en effet pas compte (1) du nombre de muscles injectes, (2) du nombre de membres traites (3) du niveau de dependance du patient, (4) des doses de toxine injectee, et (5) de la necessite d’une procedure antalgique lourde ou non.Conflit d’interet : aucun.

To describe coping strategies in children and adolescents with cerebral palsy (CP), relative to age.Patients were prospectively recruited from two paediatric rehabilitation centres in France. The Pediatric Pain Coping Inventory - French and Structured Pain Questionnaire were completed by an experienced professional for each child.One hundred and forty-two children with CP were included (80 males, 62 females; median age 12y; IQR=8-15y). They generally used fewer coping strategies than typically developing children ('Seeks social support and action': 12.47 vs 12.85, p=0.477; 'Cognitive self-instruction': 9.28 vs 10.90, p0.001; 'Distraction': 4.89 vs 7.00, p0.001; 'Problem solving': 4.43 vs 5.19, p0.001). In the CP group, 'Seeks social support and action' decreased with age (p=0.021) and 'Cognitive self-instruction' increased with age (p0.001). 'Problem solving' and 'Distraction' did not change with age. Coping strategies were influenced by Gross Motor Function Classification System level (p=0.022) and history of surgery (p=0.002).Children with CP generally used fewer coping strategies than typically developing children and tended to rely on social support. Use of active strategies increased with age; however, they appeared later than in typically developing children and were used to a lesser extent.Children with cerebral palsy (CP) use fewer pain-coping strategies than typically developing children. Children with CP tend to use social support to cope with pain. Children with CP learn more appropriate strategies from previous painful experiences. Active coping strategies appear later but remain underused in children with CP.ESTRATEGIAS DE AFRONTAMIENTO DEL DOLOR EN NIÑOS CON PARÁLISIS CEREBRAL: OBJETIVO: Describir estrategias de afrontamiento en niños y adolescentes con parálisis cerebral (PC), en relación con la edad. MÉTODO: Los pacientes fueron reclutados prospectivamente de dos centros de rehabilitación pediátrica en Francia. El Inventario de Afrontamiento del Dolor Pediátrico - Cuestionario de Dolor Francés y Estructurado fue completado por un profesional con experiencia para cada niño. RESULTADOS: Se incluyeron 142 niños con PC (80 varones, 62 mujeres; mediana de edad de 12 años; IQR = 8-15 años). En general, los niños con PC utilizaron menos estrategias de afrontamiento que los niños con desarrollo típico (“Busca apoyo social y acción”: 12,47 vs 12,85, p = 0,477; “Autoinstrucción cognitiva”: 9,28 vs 10,90, p0,001; “Distracción”: 4,89 vs 7,00, p0,001; “Resolución de problemas”: 4,43 vs 5,19, p0,001). En el grupo de PC, la búsqueda de apoyo y acción social disminuyó con la edad (p = 0,021) y la autoinstrucción cognitiva aumentó con la edad (p0,001). La “resolución de problemas” y la “distracción” no cambiaron con la edad. Las estrategias de afrontamiento se vieron influenciadas por el nivel del Sistema de Clasificación de la Función Motora Gruesa (p = 0,022) y los antecedentes quirúrgicos (p = 0,002). INTERPRETACIÓN: Los niños con PC generalmente usaron menos estrategias de afrontamiento que los niños con un desarrollo típico y tendían a confiar en el apoyo social. El uso de estrategias activas aumenta con la edad; sin embargo, aparecieron más tarde que en los niños con un desarrollo típico y se utilizaron en menor medida.ESTRATÉGIAS PARA LIDAR COM A DOR EM CRIANÇAS COM PARALISIA CEREBRAL: OBJETIVO: Descrever estratégias para lidar com a dor em crianças e adolescentes com paralisia cerebral (PC), com relação à sua idade. MÉTODO: Pacientes foram prospectivamente recrutados em dois centros de reabilitação pediátrica na França. O Inventário Pediátrico de Manejo da Dor - Francês e o Questionário Estruturado sobre dor foram completados para cada criança por um profissional com experiência. RESULTADOS: Cento e quarenta e duas crianças com PC foram incluídas (80 do sexo masculino, 62 do sexo feminino; idade mediana 12a; IIQ=8-15a). Elas geralmente usaram menos estratégias para lidar com a dor do que crianças com desenvolvimento típico (‘Procura suporte e ação social’: 12,47 vs 12,85, p=0=,477; ‘Auto-instrução cognitiva’: 9,28 vs 10,90, p0,001; ‘Distração: 4,89 vs 7,00, p0,001; ‘Resolução do problema’: 4,43 vs 5,19, p0,001). No grupo com PC, ‘Procura suporte e ação social’ diminuiu com a idade (p=0,021) e Auto-instrução cognitiva’ aumentou com a idade (p0,001). ‘Resolução de problemas’ e ‘Distração’ não mudaram com a idade. As estratégias de manejo da dor foram influenciadas pelo nível do Sistema de Classificação da Função Motora Grossa (p=0,022) e histórico de cirurgia (p=0,002). INTERPRETAÇÃO: Crianças com PC geralmente usam menos estratégias para lidar com a dor do que crianças com desenvolvimento típico, e tendem a depender de suporte social. O uso de estratégias efetivas aumentou com a idade; no entanto, elas aparecem mais tarde do que em crianças com desenvolvimento típico, e são utilizadas em menor escala.

Background Organ recovery costs should be assessed to allow efficient and sustainable integration of these costs into national healthcare budgets and policies. These costs are of considerable interest to health economists, hospitals, financial managers and policy makers in most developed countries. This study assessed organ recovery costs from 2007 to 2014 in the French healthcare system based on the national hospital discharge database and a national cost study. The secondary objective was to describe the variability in the population of deceased organ donors during this period. Methods All stays for organ recovery in French hospitals between January 2007 and December 2014 were quantified from discharge abstracts and valued using a national cost study. Five cost evaluations were conducted to explore all aspects of organ recovery activities. A sensitivity analysis was conducted to test the methodological choice. Trends regarding organ recovery practices were assessed by monitoring indicators. Results The analysis included 12 629 brain death donors, with 28 482 organs recovered. The mean cost of a hospital stay was €7469 (SD = €10, 894). The mean costs of separate kidney, liver, pancreas, intestine, heart, lung and heart-lung block recovery regardless of the organs recovered were €1432 (SD = €1342), €502 (SD = €782), €354 (SD = €475), €362 (SD = €1559), €542 (SD = €955), €977 (SD = €1196) and €737 (SD = €637), respectively. Despite a marginal increase in donors, the number of organs recovered increased primarily due to improved practices. Conclusion Although cost management is the main challenge for successful organ recovery, other aspects such as organization modalities should be considered to improve organ availability.

Objective Some patients (10 % – 32 %) with a positive guaiac fecal occult blood test (gFOBT) do not undergo the recommended colonoscopy. The aim of this study was to compare video capsule endoscopy (VCE) and computed tomography colonography (CTC) in terms of participation rate and detection outcomes when offered to patients with a positive gFOBT who did not undergo the recommended colonoscopy. Methods An invitation letter offering CTC or VCE was sent to selected patients after randomization. Acceptance of the proposed (or alternative) procedure and procedure results were recorded. Sample size was evaluated according to the hypothesis of a 13 % increase of participation with VCE. Results A total of 756 patients were targeted. Following the invitation letter, 5.0 % (19/378) of patients underwent the proposed VCE and 7.4 % (28/378) underwent CTC, ( P = 0.18). Following the letter, 9.8 % (37/378) of patients in the VCE group underwent a diagnostic procedure (19 VCE, 1 CTC, 17 colonoscopy) vs. 10.8 % in the CTC group (41/378: 28 CTC, 13 colonoscopy; P = 0.55). There were more potentially neoplastic lesions diagnosed in the VCE group than in the CTC group (12/20 [60.0 %] vs. 8/28 [28.6 %]; P = 0.04). Thus, 15/20 noninvasive procedures in the VCE group (19 VCE, 1 CTC; 75.0 %) vs. 10/28 in the CTC group (35.7 %; P = 0.01) resulted in a recommendation of further colonoscopy, but only 10/25 patients actually underwent this proposed colonoscopy. Conclusion Patients with a positive gFOBT result who do not undergo the recommended colonoscopy are difficult to recruit to the screening program and simply proposing an additional, less-invasive procedure, such as VCE or CTC, is not an effective strategy. ClinicalTrials.govNCT02558881TRIAL REGISTRATION: Randomized, controlled trial NCT02558881 at clinicaltrials.gov.

Background— Therapeutic management of asymptomatic patients with a Wolff–Parkinson–White (WPW) pattern is controversial. We compared the risk:benefit ratios between prophylactic radiofrequency ablation and no treatment in asymptomatic patients with WPW. Methods and Results— Decision analysis software was used to construct a risk–benefit decision tree. The target population consisted of 20- to 40-year-old asymptomatic patients with WPW without structural fatal heart disease or a family history of sudden cardiac death. Baseline estimates of sudden death and radiofrequency ablation complication rates were obtained from the literature, an empirical data survey, and expert opinion. The outcome measure was death within 10 years. Sensitivity analyses determined the variables that significantly impacted the decision to ablate or not. Threshold analyses evaluated the effects of key variables and the optimum policy. At baseline, the decision to ablate resulted in a reduction of mortality risk of 8.8 patients for 1000 patients compared with abstention. It is necessary to treat 112 asymptomatic patients with WPW to save one life over 10 years. Sensitivity analysis showed that 3 variables significantly impacted the decision to ablate: (1) complication of radiofrequency ablation, (2) success of radiofrequency ablation, and (3) sudden death in asymptomatic patients with WPW. Conclusions— This study provides a decision aid for treating asymptomatic patients with the WPW ECG pattern. Using the model and the population we tested, prophylactic catheter ablation is not yet ready for widespread clinical use.

Background The costing method used can change the results of economic evaluations. Choosing the appropriate method to assess the cost of organ recovery is an issue of considerable interest to health economists, hospitals, financial managers and policy makers in most developed countries. Objectives The main objective of this study was to compare a mixed method, combining top-down microcosting and bottom-up microcosting versus full top-down microcosting to assess the cost of organ recovery in a French hospital group. The secondary objective was to describe the cost of kidney, liver and pancreas recovery from French databases using the mixed method. Methods The resources consumed for each donor were identified and valued using the proposed mixed method and compared to the full top-down microcosting approach. Data on kidney, liver and pancreas recovery were collected from a medico-administrative French database for the years 2010 and 2011. Related cost data were recovered from the hospital cost accounting system database for 2010 and 2011. Statistical significance was evaluated at P

International audience; BACKGROUND: In France, for patients aged 75 or older, it has been estimated that the hospital readmission rate within 30 days is 14 %, a quarter being avoidable. Some evidence suggests that interventions "bridging" the transition from hospital to home and involving a designated professional (usually nurses) are the most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a care transition program from hospital to home for elderly admitted to short-stay units. METHODS: This is a multicentre, stepped-wedge cluster randomised trial. The program will be implemented at three times of the transition: 1) during the patient's stay in hospital: development of a discharge plan, creation of a transitional care file, and notification of the primary care physician about inpatient care and hospital discharge by the transition nurse; 2) on the day of discharge: meeting between the transition nurse and the patient to review the follow-up recommendations; and 3) for 4 weeks after discharge: follow-up by the transition nurse. The primary outcome is the 30-day unscheduled hospital readmission or emergency visit rate after the index hospital discharge. The patients enrolled will be aged 75 or older, hospitalized in an acute care geriatric unit, and at risk of hospital readmission or an emergency visit after returning home. In all, 630 patients will be included over a 14-month period. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded. DISCUSSION: Our study makes it possible to evaluate the specific effect of a bridging intervention involving a designated professional intervening before, during, and after hospital discharge. The strengths of the study design are methodological and practical. It permits the estimation of the intervention effect using between- and within-cluster comparisons; the study of the fluctuations in unscheduled hospital readmission or emergency visit rates; the participation of all clusters in the intervention condition; the implementation of the intervention in each cluster successively. TRIAL REGISTRATION: This study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02421133 ). Registered 9 March 2015.

Objectives The aim of this study was to evaluate how advances in CF management in France between 2000 and 2003 impacted CF-related costs. Methods The analysis of direct medical costs was done in 2000 and 2003 from the perspective of the French national healthcare insurance system. The patients, 65 in 2000 and 64 in 2003, were followed-up in one pediatric and one adult CF reference center (CFRC). We quantified and valued CF-related home and hospital care costs. Results We found an average cost of €16474/patient/year in 2000, and €22725 in 2003 (based on the 2003 euro value). Hospital care increased from 15% of the total cost in 2000 to 22% in 2003. Medications accounted for 45% of the total cost for the two periods, with an average cost of €7229/patient/year in 2000 and €10336 in 2003. Home intravenous antibiotic therapy accounted for 20% of the total cost for the two periods. Conclusions We highlighted an increase in CF care costs between 2000 and 2003, which might be related to the changes in practice patterns that followed guidelines implementation, such as the use of new medications (dornase alpha and tobramycin) and more frequent follow-up in the CFRC.

Molecular evidence indicates that P. jirovecii may be nosocomially transmitted to severely immunosuppressed patients., Ten Pneumocystis jirovecii pneumonia (PCP) cases were diagnosed in renal transplant recipients (RTRs) during a 3-year period. Nosocomial transmission from HIV-positive patients with PCP was suspected because these patients shared the same hospital building, were not isolated, and were receiving suboptimal anti-PCP prophylaxis or none. P. jirovecii organisms were typed with the multitarget polymerase chain reaction–single-strand conformation polymorphism method. Among the 45 patients with PCP hospitalized during the 3-year period, 8 RTRs and 6 HIV-infected patients may have encountered at least 1 patient with active PCP within the 3 months before the diagnosis of their own PCP episode. In six instances (five RTRs, one HIV-infected patient), the patients harbored the same P. jirovecii molecular type as that found in the encountered PCP patients. The data suggest that part of the PCP cases observed in this building, particularly those observed in RTRs, were related to nosocomial interhuman transmission.

We thank Dr Robert R. Hamilton for his insightful comments and are very pleased that he brings his own experience into the difficult debate on the indication of ablation of the asymptomatic patients with Wolff–Parkinson–White. We feel that some elementary notions about decision analysis have to be restated. There are 2 main arguments for using decision analysis models and to find out how the decision process for a given patient can be improved: a randomized prospective study comparing abstention versus ablation will never be done, and the risk:benefit ratio of both strategies has never been quantified. Interpretation of the results of our study will be facilitated with the …

Background: This open controlled prospective study aimed at evaluating the medical and economical impact of first line chemotherapy for metastatic breast cancer (MBC). Patients and Methods: Two groups of HER +++ MBC patients were compared: 26 were treated by a combination of trastuzumab and paclitaxel in 4 “prescriber” centers (group A) and 19 patients were treated by any chemotherapy without addition of trastuzumab, in 6 control centers (group B). The cost of chemotherapy and related hospitalizations was taken into account during the first 8 cycles. Results: Forty-five patients, mean age 51 years have been included. The objective response rate was significantly higher in group A (42% vs. 6%, P = 0.036). The median overall survival was 17 months longer in the group A (29 vs. 12 months). The median progression free survival rate was 12.2 months longer in the group A (19 vs. 7 months). The 1-year survival rate was 85% in the group A and 47% in the group B. The mean overall care cost was 33.271 € per patient in group A versus 11.191 € per patient in group B. The additional cost per saved year of life expressed as the incremental cost-effectiveness ratio is 15.370 € 2002. Conclusion: The related additional cost seems affordable for an European health care system and justifies the recommendation for its use in the subpopulation overexpressing HER2.

Hip fractures are responsible for excessive mortality, decreasing the 5-year survival rate by about 20%. From an economic perspective, they represent a major source of expense, with direct costs in hospitalization, rehabilitation, and institutionalization. The incidence rate sharply increases after the age of 70, but it can be reduced in women aged 70-80 years by therapeutic interventions. Recent analyses suggest that the most efficient strategy is to implement such interventions in women at the age of 70 years. As several guidelines recommend bone mineral density (BMD) screening of postmenopausal women with clinical risk factors, our objective was to assess the cost-effectiveness of two screening strategies applied to elderly women aged 70 years and older.A cost-effectiveness analysis was performed using decision-tree analysis and a Markov model. Two alternative strategies, one measuring BMD of all women, and one measuring BMD only of those having at least one risk factor, were compared with the reference strategy "no screening". Cost-effectiveness ratios were measured as cost per year gained without hip fracture. Most probabilities were based on data observed in EPIDOS, SEMOF and OFELY cohorts.In this model, which is mostly based on observed data, the strategy "screen all" was more cost effective than "screen women at risk." For one woman screened at the age of 70 and followed for 10 years, the incremental (additional) cost-effectiveness ratio of these two strategies compared with the reference was 4,235 euros and 8,290 euros, respectively.The results of this model, under the assumptions described in the paper, suggest that in women aged 70-80 years, screening all women with dual-energy X-ray absorptiometry (DXA) would be more effective than no screening or screening only women with at least one risk factor. Cost-effectiveness studies based on decision-analysis trees maybe useful tools for helping decision makers, and further models based on different assumptions should be performed to improve the level of evidence on cost-effectiveness ratios of the usual screening strategies for osteoporosis.

The increasing costs of care make it important to identify those strategies of greatest value from both an effectiveness and cost perspective. Economic analysis is characterized by a simultaneous consideration of alternatives costs and outcomes, and can provide useful data for managerial decision making. In this paper, methods of economic evaluations in general and in cancer in particular is reviewed. In cancer treatment, preventive, curative or palliative strategies can be concerned. Economic evaluation have become increasingly important in oncology because of the proliferation of expensive new treatments. Furthermore, considering quality of life effects is particularly important in oncology, where many treatments obtain modest improvements in response or survival. Quality of life measurements are also reviewed.

In an era where health care expenditure control is a necessity, weighing a new treatment's cost against its added benefits is of crucial importance. These medico-economic analyses may be planned for the evaluation of new molecules in their daily use. Different methods may be used. The medico-economic evaluation of a drug can be performed with the use of clinical studies or modelization techniques. "Clinical studies" include the following methods: randomized trials, so-called "experimental", non-randomized studies, and observational studies. This classification follows a downward evolution of both the investigator's intervention power and the level of proof. Finally, modelization is becoming a commonly used tool. Randomized trials are the "gold standard" but the other, more pragmatic study types, providing a lesser degree of proof can complete the evaluation of a new molecule. One must find the best compromise between the study's objectives and the study type.