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International audience; Purpose To address the gap highlighted in the literature on the effect of professional interventions to facilitate continued employment, this study aims to evaluate the effect of workplace accommodations on the continued employment 5 years after a cancer diagnosis. Methods This study is based on VICAN5, a French survey conducted in 2015-2016 to examine the living conditions of cancer survivors 5 years after diagnosis. Two subsamples, one with and one without workplace accommodations, were matched using a propensity score to control for the individual, professional, and medical characteristics potentially associated with receipt of workplace accommodations. Results The study sample was composed of 1514 cancer survivors aged 18-54 and employed as salaried at diagnosis. Among them, 61.2% received workplace accommodations within 5 years after diagnosis: 35.5% received a modified workstation, 41.5% received a modified schedule, and 49.2% received reduced hours. After matching, receipt of workplace accommodations appeared to improve the continued employment rate 5 years after cancer diagnosis from 77.8% to 95.0%. Conclusions Receipt of workplace accommodations strongly increases the continued employment of cancer survivors 5 years after diagnosis. More research is needed to better understand the differences in receipt of workplace accommodations along with the related selection effect.

Background. Many cancer survivors experience late effects of cancer treatment and therefore struggle to return to work. Norway provides rehabilitation programs to increase labor force participation for cancer survivors after treatment. However, the extent to which such programs affect labor force participation has not been appropriately assessed. This study aims to investigate i) labor force participation, sick leave and disability rates among cancer survivors up to 10 years after being diagnosed with cancer and identify comorbidities contributing to long-term sick leave or disability pensioning; ii) how type of cancer, treatment modalities, employment sectors and financial- and sociodemographic factors may influence labor force participation; iii) how participation in rehabilitation programs among cancer survivor affect the longterm labor force participation, the number of rehospitalizations and incidence of comorbidities. Design and methods. Information from four medical, welfare and occupational registries in Norway will be linked to information from 163,279 cancer cases (15.68 years old) registered in the Norwegian Cancer Registry from 2004 to 2016. The registries provide detailed information on disease characteristics, comorbidities, medical and surgical treatments, occupation, national insurance benefits and demographics over a 10-year period following a diagnosis of cancer. Expected impact of the study for Public Health. The study will provide important information on how treatment, rehabilitation and sociodemographic factors influence labor force participation among cancer survivors. Greater understanding of work-related risk factors and the influence of rehabilitation on work-participation may encourage informed decisions among cancer patients, healthcare and work professionals and service planners. Significance for public healthThis study could potentially determine the influence of cancer treatment, rehabilitation and sociodemographic factors on labour force participation and use of social benefits and health care resources. Data from five nationwide medical, welfare and occupational registries from the whole cancer population in Norway over a ten-year period following diagnosis will be analyzed. In addition, the study will expand the knowledge on risk factors for rehospitalization, sick leave and disability, and provide important health-related, financial and sociodemographic information of patients referred to rehabilitation. The study has the potential to provide solid evidence to guide treatment options and develop social benefit programs for a large and vulnerable patient population.

Background Compared with the number of studies performed in the United States, few studies have been conducted on the link between health insurance and healthcare consumption in Europe, likely because most European countries have compulsory national health insurance (NHI) or a national health service (NHS). Recently, a major French private insurer, offering voluntary complementary coverage in addition to the compulsory NHI, replaced its single standard package with a range of offers from basic coverage (BC) to extended coverage (EC), providing a quasi-natural experiment to test theoretical assumptions about consumption patterns. Methods Reimbursement claim data from 85,541 insurees were analysed from 2009 to 2018. Insurees who opted for EC were matched to those still covered by BC with similar characteristics. Difference-in-differences (DiD) models were used to compare both the monetary value and physical quantities of healthcare consumption before and after the change in coverage. Results As expected, the DiD models revealed a strongly significant, though transitory (mainly during the first year), increase after the change in coverage for EC insurees, particularly for costly care such as dental prostheses and spectacles. Surprisingly, consumption seemed to precede the change in coverage, suggesting that one possible determinant of opting for more coverage may be previous unplanned expenses. Conclusion Both catching-up behaviour and moral hazard are likely to play a role in the observed increase in healthcare consumption.

Background Musculoskeletal disorders (MSD) can cause short-term disorders and permanent disabilities which may all result in serious limitations in activities of daily living. According to the WHO, MSD are the second largest cause of disability worldwide. In France, preventing MSD became a challenge for both the sickness fund and the complementary health insurers as the MSD prevalence increased by more than 50% since 2003, the MSD representing more than 80% of the occupational diseases leading to sick-leaves or financial compensations in 2015. Methods Data from the IRDES 2012 health and social welfare survey (ESPS, enquête santé et protection sociale) was matched with individual care consumptions from the French health insurance. The ESPS survey is a national representative survey including 23,047 CATI/CAPI interviewed individuals (participation rate: 66%). Respondents self-assessed their health status, including MSD among other health troubles. Prediction of MSD risk was designed as a supervised binary classification problem, with the help of Random Forest (RF) and Gradient Boosting Machine (GBM) methods. Results Variable importance scores based on the squared error criterion over all trees were computed for the continuous and categorical variables supposed to be associated with MSD: the consumption of medicines, physiotherapists’ and GPs’ services, medical imaging, biomedical analyses, dental care, and sociodemographic features (occupation, age and income). Slightly better results were obtained with GBM compared to RF (overall test accuracy rate: 70% for both methods). Conclusions Machine learning methods with merged survey and registry data may help health insurers to better identify the individual MSD risk and prevent the occurrence and the disabling consequences of MSD with the help of individualized prevention strategies. This research is financially supported by Malakoff Mederic Humanis, life & health French insurance for employees and individuals. Key messages The use of machine learning methods may be of interest to improve the ability to predict the MSD risk and help to identify insured people whom individualized prevention strategies can be offered to. Matching survey and health insurance liquidation data improves the ability to identify people at improved risk of MSD and gives the opportunity to provide them resources to prevent and to cope with.

Background Each year, almost 400,000 new individuals are diagnosed with cancer in France and nearly half of them are in the working age. The disease was found to have a negative impact on professional life, especially for the most vulnerable cancer survivors. Literature reviews have pointed out the lack of studies focusing on the evaluation of interventions. In France, workstation layouts are recommended by the French law, but not mandatory to facilitate return to work. The aim of this study was to explore the effect of having a workstation layout after a cancer diagnosis on maintenance in employment five years after diagnosis. Methods We used the French VICAN survey carried out in 2015/2016 on living conditions five years after a cancer diagnosis. Using propensity score matching, we matched two subsamples (with and without workstation layout) to investigate the effect of workstation layout taking into account the characteristics associated with the access to these arrangements. Results Among the 1,514 individuals aged between 18 and 54 at diagnosis and employed in a salaried job at this time, three in five (61.2%) had a workstation layout within the five years following the diagnosis: 35.5% had a position type layout, 41.5% had a schedule layout, and 49.2% had a working time layout. Among those who had a workstation layout, 89.7% were still in employment five years after diagnosis against only 77.8% of those who did not so (p.value Conclusions Having a workstation layout after a cancer diagnosis strongly increases maintenance in employment of five years cancer survivors. More research is needed to better understand the differences in access to these arrangements and the related selection effect. Key messages Workstation layout increases maintenance in employment of survivors five years after a cancer diagnosis. Therefore, it should be used more systematically to facilitate work with a chronic disease. Having a workstation layout may constitute a disadvantageous selection bias for more vulnerable workers. It can also lead to discrimination feelings.

Delegating tasks to paramedics is a fairly recent development in France. So far it has essentially been developed in hospitals and is incipient in general practice. This paper focuses on the willingness of general practitioner to do so. A 2012 survey of 2,000 GPs might help anticipate GPs’ willingness to delegate. This paper tests whether a more favourable funding system might help increase GP willingness. We implement a quasi-experimental design wherein GPs are randomly selected to form three groups of equal size, each of them being exposed to a different funding scheme when declaring their willingness to delegate tasks to nurses: Fully Funded (FF) by the social security administration, self-funded by GPs’ revenues (Self-Funded, SF) and half-funded by both the social security administration and GPs (Half-Funded, HF). GPs’ likelihood to favour task delegation is estimated with a probit model that especially considers a GP’s attitude towards risk (aversion or tolerance) among a set of covariates, such as age, gender, rural/urban area, GP density and funding scheme. This article shows that, first, GPs are more likely to favour delegation, when they share a lower proportion of the cost. Second, the effect of risk aversion on the likelihood of favouring delegation is not altered by the funding scheme.

International audience; Purpose To describe: (i) patterns of self-employment and social welfare provisions for self-employed and salaried workers in several European countries; (ii) work-related outcomes after cancer in self-employed people and to compare these with the work-related outcomes of salaried survivors within each sample; and (iii) work-related outcomes for self-employed cancer survivors across countries. Methods Data from 11 samples from seven European countries were included. All samples had cross-sectional survey data on work outcomes in self-employed and salaried cancer survivors who were working at time of diagnosis (n = 22–261 self-employed/101–1871 salaried). The samples included different cancers and assessed different outcomes at different times post-diagnosis. Results Fewer self-employed cancer survivors took time off work due to cancer compared to salaried survivors. More self-employed than salaried survivors worked post-diagnosis in almost all countries. Among those working at the time of survey, self-employed survivors had made a larger reduction in working hours compared to pre-diagnosis, but they still worked more hours per week post-diagnosis than salaried survivors. The self-employed had received less financial compensation when absent from work post-cancer, and more self-employed, than salaried, survivors reported a negative financial change due to the cancer. There were differences between self-employed and salaried survivors in physical job demands, work ability and quality-of-life but the direction and magnitude of the differences differed across countries. Conclusion Despite sample differences, self-employed survivors more often continued working during treatment and had, in general, worse financial outcomes than salaried cancer survivors. Other work-related outcomes differed in different directions across countries.

International audience

International audience

Introduction Studies on cancer survivors’ (CS) return to work (RTW) after cancer have mostly focused on salaried workers. RTW among self-employed CS has almost not been focused although there are big differences in these two groups’ working conditions and social welfare provisions. The aim of this study is therefore to bring together data from multiple European countries to: describe RTW–related outcomes after cancer in self–employed people; compare these outcomes for the self–employed with those for salaried workers; and describe RTW–related outcomes after cancer for self–employed people across countries. Methods Eleven cross-sectional studies from seven countries were included. All studies had survey data on work-outcomes in self-employed and salaried CS who were employed at time of diagnosis (n=22–261 self-employed/101–1627 salaried). The studies included different cancers and assessed different outcomes at different times post-diagnosis. Results Fewer self-employed CS took time off work due to cancer compared to salaried survivors. More self-employed than salaried worked post-diagnosis in almost all countries. Among those working at the time of survey, self-employed survivors had made a larger reduction in working hours compared to pre-diagnosis, but they still worked more hours per week post-diagnosis than salaried survivors. The self-employed had received less financial compensation when absent from work post-cancer, and more self-employed, than salaried, survivors reported a negative financial change due to the cancer. There were differences between self-employed and salaried survivors in physical job demands, work ability and quality-of-life but the direction and magnitude of the differences differed across countries. Discussion Self-employed and salaried CS differ when it comes to RTW-related outcomes, but the patterns vary between countries. Support should be provides to self-employed survivors to help them balance their health needs with those of their business.

International audience; People with disabilities use various preventive health services less frequently than others, notably because of a lower socioeconomic status (SES). We examined variations of seasonal influenza vaccine uptake according to type/severity of disability and SES. We analyzed (in 2016) data from the 2008 French national cross-sectional survey on health and disability (n=12,396 adults living in the community and belonging to target groups for seasonal influenza vaccination). We defined seasonal influenza vaccine uptake during the 2007–2008 season by the self-reporting of a flu shot between September 2007 and March 2008. We built scores of mobility, cognitive, and sensory limitations, and an SES score based on education, occupation, and income. We performed bivariate analyses and then multiple log-binomial regressions. The prevalence of vaccine uptake was 23% in the 18–64 group and 63% in the ≥65 group. In bivariate analyses, it was higher among people in both age groups who had mobility and/or cognitive limitations and in the ≥65 group among those with sensory limitations. In the multiple regression analyses, only the presence of major mobility limitations in the18–64 group remained significant. The probability of vaccine uptake was higher in the highest SES category than in the lowest. Among at-risk groups, people with disabilities were more frequently vaccinated than others, mainly because of their higher levels of morbidity and healthcare use. Socioeconomic inequalities in access to vaccination persist in France. Future research is needed to monitor the trend in vaccine uptake in institutions.

ACL-2; International audience; This paper analyses how French general practitioners? (GPs) labour supply would respond to changes in their fee per consultation, seeking to determine whether there is a backward-bending curve.?Because French GPs? fees only evolve very slowly and are generally fixed by the National Health Insurance Fund, fee variability is not sufficient to observe changes in labour supply.?Therefore, we designed a contingent valuation survey randomly presenting GPs with three hypothetical fee increases.?Empirical evidence from 1,400 GPs supports the hypothesis of a negative slope in their labour supply curve.?This suggests that increasing fees is not an effective policy to increase the supply of medical services. JEL Codes: C21, I12, J22, J4.

The aim of this study is to investigate whether salaried and self-employed workers differ regarding factors relevant for return to work after being diagnosed with cancer. The possible mediators of an effect of self-employment on work ability were also investigated. A total of 1115 cancer survivors (1027 salaried and 88 self-employed) of common invasive cancer types who were in work at the time of diagnosis completed a mailed questionnaire 15–39 months after diagnosis. Twenty-four percent of self-employed cancer survivors reported that they had not returned to work at the time of the survey, and 18 % of those who were salaried had not. While 9 % of the self-employed had received disability or early retirement pension, only 5 % had received such a pension among salaried employees. Compared with the salaried workers, the self-employed people reported significantly more often reduced work hours (P

International audience

The aim of this study was to investigate whether the labor market mobility of a population of cancer survivors 2 years after diagnosis differed compared to the French general population by focusing on the differences between self-employed workers and salaried staff. Coarsened exact matching was implemented to reduce the sampling bias introduced by the comparison of individuals from two different surveys. Then, labor market mobility was analyzed by estimating transition probability matrices from 2010 to 2012 under the framework of a continuous-time Markov technique and by estimating a two-step model. Salaried employees and self-employed workers from the general population were more likely to remain employed 2 years after 2010 compared to salaried employees and self-employed workers who survived cancer. There was no major difference between salaried and self-employed workers surviving cancer in terms of job retention. French workers surviving cancer face the same difficulties that were observed in the National Cancer Survey of 2004: unemployment and inactivity caused by the diagnosis of cancer. Among cancer survivors, self-employed workers do not seem to be particularly more affected by inactivity than salaried staff. However, unemployment insurance is not compulsory for them, contrary to salaried staff. In this regard, self-employed workers might be a more vulnerable group.

Le vieillissement de la population est communément présenté comme un facteur majeur de l’augmentation des dépenses de santé. La concomitance des deux phénomènes ne vaut toutefois pas causalité. En effet, les habitudes de consommation de soins de plus en plus coûteux et la médicalisation croissante de la santé chez toutes les générations, y compris les plus âgées, semblent avoir un impact plus important dans la hausse des dépenses de soins et de biens médicaux. Pour autant, aux côtés des frais médicaux, l’avancée dans l’âge révèle des besoins croissants en aide humaine destinée à compenser la perte d’autonomie, éventuellement complétée par des dispositifs techniques. Cette aide humaine est en grande partie assumée par l’entourage proche, sur lequel elle fait peser des coûts dont l’évaluation économique dépasse largement ceux tirés des comptes officiels de la dépendance.

This study sought to identify the effect of drug reimbursability--a decision made in France by the National Authority for Health--on physicians' prescribing practices for a diet drug such as rimonabant, approved for obese or overweight patients with type-2 diabetes. A cross-sectional survey of French general practitioners (GPs) presented a case-vignette about a patient for whom this drug is indicated in two alternative versions, differing only in its reimbursability, to two separate randomized subsamples of GPs in early 2007, before any decision was made about reimbursement. The results indicate that (i) more than 20% of GPs in private practice would be willing to prescribe a non-reimbursed diet drug for patients with obesity complicated by type 2 diabetes; (ii) the number of GPs willing to prescribe it would increase by 47.6% if the drug were reimbursed, and (iii) such a drug would be adopted at a higher rate by GPs who have regular contacts with pharmaceutical sales representatives. In France, unlike most other countries, drug reimbursement status is a signal of quality. However, our results suggest that a significant proportion of GPs would spontaneously adopt anti-obesity drugs even if they were not reimbursed. Decisions about reimbursement of pharmaceutical products should be made taking into account that reimbursement is likely to intensify prescription.

Une personne sur quatre, âgee de 60 ans ou plus, et vivant a domicile, recoit une aide humaine pour la realisation des activites de la vie quotidienne. Dans 75% des cas, cette aide provient, en tout ou partie, de l’entourage. Outre l’etat de sante et la severite de la perte d’autonomie, elle depend de l’insertion sociofamiliale et du statut socioeconomique. Elle representerait 63,5 % des 9,6 milliards d’euro a consacrer a l’aide aux personnes âgees en domicile ordinaire.

Les evolutions demographiques et sociales liees au vieillissement de la population posent la question de l’organisation de l’aide et des soins de longue duree a apporter aux personnes âgees. Ce travail utilise les donnees de l’enquete nationale Handicaps-Incapacites-Dependance (HID), menee en menages ordinaires en 1999. Il porte sur un echantillon de personnes âgees de 60 ans et plus, ayant declare avoir besoin d’aide pour les activites quotidiennes (se laver, s’habiller, preparer les repas, faire les tâches menageres, etc.). L’article cherche a identifier les facteurs medicaux, socioeconomiques et environnementaux (reseau de proches potentiellement disponible) associes au type d’aide recue. Quatre situations sont possibles. Les personnes peuvent ne recevoir aucune aide (une personne âgee dependante sur trois). L’aide recue peut etre informelle, c’est-a-dire apportee exclusivement par l’entourage (55 % des personnes âgees dependantes recevant une aide), formelle, fournie exclusivement par des professionnels (25 %) ou mixte, lorsqu’elle provient des deux sources d’aide (20 %). Le statut socio-economique est discriminant vis-a-vis du type d’aide recue, ce qui revele une serie de problemes informationnels, cognitifs et financiers pour acceder aux services d’aide formelle. Les couts et les difficultes d’acces a l’aide professionnelle peuvent avoir des repercussions sur la facon dont sont soignees les personnes âgees.

Resume Dans les enquetes sur la sante en population generale, lorsque l’etat de sante des personnes interrogees est trop degrade pour que l’information soit recueillie directement aupres d’elles, il est frequent de les aider ou de les remplacer par un repondant proxy, ce qui fait naitre un risque d’endogeneite du statut du repondant a l’etat de sante du sujet interroge. Cet article propose une modelisation permettant de tenir compte de la double endogeneite potentielle du recours a un proxy dans l’estimation de deux equations probit de la declaration, par des personnes âgees vivant en domicile ordinaire, de besoins d’aide d’une part et de besoins d’aide non satisfaits ou insuffisamment satisfaits d’autre part. A la difference des resultats publies en la matiere, il apparait que les repondants proxy n’ajoutent aucune subjectivite dans l’evaluation des besoins des personnes âgees vivant en domicile ordinaire mais que leur subjectivite semble bien reelle lors de l’evaluation de la satisfaction de ces memes besoins.

A bivariate probit model with sample selection is used to estimate the conditional probability of reporting a need for personal assistance (NPA) with at least one activity of daily living among French community-dwelling elderly. 71.8% of men and 77.3% of women reported impairments and among those who reported impairments, 7.5% of men and 10.8% of women reported NPA. NPA is associated not only with age (i.e., the oldest individuals, for women only) and health status (such as a specific type of impairment), but also with socioeconomic (living with intermediate income; living with someone, partner or other) and environmental factors (having and using assistive technologies).

Resume Nous proposons d’evaluer l’impact du cancer sur l’activite professionnelle en estimant des matrices de transition « comparees » entre les differents etats d’occupation professionnelle. L’argument de depart est que tout individu tire au hasard dans la population generale fait l’experience dans sa vie professionnelle de mouvements entre differentes situations, que ce soit vers l’emploi, vers le chomage, la retraite ou l’inactivite, et cette dynamique est gouvernee par des probabilites a priori de transition entre ces differents etats. Il faut alors mesurer l’impact du cancer en partant de cette dynamique « prealable » et en estimant une deviation des probabilites de transition. Pour ce faire, nous fusionnons deux echantillons : l’enquete Emploi de l’INSEE et notre echantillon de survivants au cancer. Cette strategie nous permet d’etablir une separation claire entre, d’un cote, l’impact professionnel du cancer et, d’un autre cote, celui lie aux particularites sur le marche de l’emploi de certaines sous-populations etudiees ici (les ouvriers partent a la retraite plus precocement, par exemple). La methode est proposee sur l’echantillon dans son ensemble, puis en stratifiant suivant des criteres sociodemographiques (categories socioprofessionnelles, sexe, âge) ou epidemiologiques (gravite de la maladie). Nous pouvons alors distinguer les causes a l’origine des differences systematiques observees entre les PCS dans leur propension a retourner a l’emploi, qu’elles soient d’ordre epidemiologique (type de cancer ou qualite du pronostic de vie), ou qu’elles soient liees a la nature de leur emploi (penibilite). De fait, l’ecart de taux de retour a l’emploi entre PCS, avec un retour plus faible pour les professions manuelles, peut etre explique en partie par le pronostic de guerison — significativement plus mauvais pour ces PCS manuelles. Mais il existe une deuxieme source d’ecart qui ne depend d’aucune difference epidemiologique : sur une perte d’employabilite de 11 points entre PCS non manuelles et PCS manuelles, 9,6 points (90 %) sont a imputer au type meme de l’emploi occupe. Ce dernier chiffre est une mesure nette du handicap relatif des travailleurs manuels a retourner a l’emploi apres avoir ete atteint d’un cancer.

Background This paper is aimed at investigating the extents to which illness modifies labour supply and employment conditions of people with chronic diseases (defined as severe diseases giving rise to 100% coverage of health expenditures by the Sickness Fund). Methods It is based on the data of 35 073 individuals interviewed in the 2002–2003 French Decennial Health Survey, reporting their health, health care consumption and socioeconomic characteristics, and collected by the French National Institute of Statistics and Economic Studies. Models have been estimated with logistic strategies. Results Participation in labour market appears, all other things being equal, to be less important for people with chronic diseases. Chronic diseases are more deleterious for blue collar than for white collars workers. The probability to have a part-time job is raised by 60% for people with chronic diseases (100% for men, 50% for women). Suffering from chronic diseases raises the probability to have a desired part-time job rather than a full-time job by 80% (170% for men, 60% for women) and the probability to have an undesired part-time job rather than a full-time job by 50% (30% for men, 50% for women). For the elderly (50–65 years), chronic diseases multiply by three the probability to be out-of-work (and not retired), by two the probability to be retired and by 1.5 the probability to be unemployed compared to being employed. Conclusion The consequences of chronic diseases on the workplace are not negligible, creating new social inequalities that the French social protection system does not seem to be able to completely cover.

International audience; BACKGROUND: General practitioners (GPs) play a key role in identifying and managing patients with suicidal tendencies. Few studies, however, examine both GP and patient characteristics and GP practices associated with suicide assessment. This article aims to evaluate 1) GPs' success in early identification of suicidal ideation (SI) in patients starting antidepressant or anxiolytic treatment, and 2) patient- and GP-related factors associated with this success. METHODS: Survey of 144 GPs practising in southeastern France and of consecutive adults consulting them during June-October 2004 and prescribed antidepressant or anxiolytic treatment. Data were collected from GPs (consultation-questionnaires focusing on their prescription, diagnosis and detection of SI) and patients (self-administered questionnaires including the Hospital Anxiety and Depression scale and social and demographic characteristics). We used multilevel logistic regression to analyse factors associated with SI detection. RESULTS: GPs completed consultation-questionnaires for 713 patients, 405 of whom completed self-administered questionnaires. Eighty-nine patients (22%) reported SI; in 43 cases (48%) SI had not been detected by the GP. GPs detected SI more frequently when they had completed continuing medical education about depression, when patients had higher depressive symptom scores, and when consultations were relatively long. LIMITATIONS: Study limited to patients receiving initial prescriptions for antidepressants or anxiolytics. CONCLUSIONS: The percentage of undetected SI in this study population was high. Additional training of GPs increases the chances of detecting SI. Medical training and continuing medical education should include better instruction about SI risk factors and diagnosis, including non-major depressions, and stress that screening requires sufficient consultation time.

Summary Objectives Physicians frequently fail to detect mental health disorders in patients consulting them. This study tests the hypothesis that patients repeatedly prescribed analgesics or antiinflammatory drugs or X-ray examinations for unexplained somatic symptoms are at higher risk of antidepressant treatment, independent of physical comorbidity. Methods This case-control study is based on health reimbursement data for self-employed artisans and shopkeepers. Cases were subjects who first began antidepressant treatment between January and March 2003. Controls, matched for age, sex, and urban or rural residence, had not been reimbursed for any psychotropic drug in the 18 months before and 6 months after this quarter. Reimbursement data for analgesic and antiinflammatory drugs, and X-rays, temporary disability payments and their reasons, chronic diseases, and hospitalizations over the 18-month period before inclusion were compared for cases and controls with simple and multiple logistic regressions. Results The study included 988 cases (36.5% of whom were reimbursed only once for an antidepressant) and 1976 controls. The multiple logistic regressions adjusted for history of psychiatric morbidity and somatic comorbidity showed significant linear associations between starting antidepressant treatment and reimbursements for analgesic and anti-inflammatory drugs or X-rays. Discussion Severe somatic diseases can induce psychological distress. At the same time, mental disorders may be manifested as unexplained chronic pain, without the individual recognizing the link between them. Conclusion These results confirm the initial hypothesis and suggest signs that may alert physicians to possible undetected psychological distress or mental disorders.

ACL-1; International audience; In the mid 2000s, in an effort to increase competition among hospitals in France – and thereby reduce hospital care costs – policymakers implemented a prospective payment system and created incentives to promote use of for-profit hospitals. But such policies might incentivize ‘upcoding’ to higher-reimbursed procedures or overuse of preference-sensitive elective procedures, either of which would offset anticipated cost savings. To explore either possibility, we examined the relative use and costs of admissions for ten common preference-sensitive elective surgical procedures to French not-for profit and for-profit sector hospitals in 2009 and 2010. For each admission type, we compared sector-specific hospitalization characteristics and mean per-admission reimbursement and sector-specific relative rates of lower- and higher-reimbursed procedures. We found that, despite having substantially fewer beds, for-profit hospitals captured a large portion of market for these procedures; further, for-profit admissions were shorter and less expensive, even after adjustment for patient demographics, hospital characteristics, and patterns of admission to different reimbursement categories. While French for-profit hospitals appear to provide more efficient care, we found coding inconsistencies across for-profit and not-for-profit hospitals that may suggest supplier-induced demand and upcoding in for-profit hospitals. Future work should examine sector-specific changes in relative use and billing practices of for elective surgeries, the degree to which these elective surgeries are justified in either sector, and whether outcomes differ according to sector used.

Le vieillissement de la population confronte les pays qu’il concerne à certains défis, notamment au regard des soins de long-terme. Prendre en charge une personne âgée en perte d’autonomie génère en effet à la fois des coûts publics et privés qui se chiffrent en milliards d’euros chaque année. L’objectif de cette analyse est d’étudier les déterminants du consentement à payer (CAP) des aidants informels pour l’aide qu’ils apportent aux personnes âgées de 75 ans et plus vivant à domicile, en utilisant la méthode de l’évaluation contingente. Les données utilisées proviennent de l’enquête nationale Handicap-Santé Aidants informels (HSA) de 2008. On y trouve des questions sur le montant que les aidants seraient prêts à payer pour être déchargés d’une heure d’aide. Un modèle en deux étapes à la Heckman est construit afin d’analyser à la fois les facteurs associés aux montants déclarés de disposition à payer, et les raisons pour lesquelles certains aidants n’ont pas voulu donner de valeur (répondants protestataires). D’après les résultats, des caractéristiques telles que la distance entre lieux de vie de l’aidé et de l’aidant ou encore la dégradation de la santé mentale de ce dernier expriment le besoin de reconnaissance des aidants informels à travers les valeurs déclarées qui leur sont associées, ainsi que leur besoin de répit, dû au fardeau qu’ils supportent parfois depuis plusieurs années. Le contexte socioéconomique joue aussi un rôle important : plus le revenu de l’aidant et celui de la personne aidée sont élevés, plus le montant du CAP est élevé. Ces éléments peuvent être utiles aux politiques publiques en charge de développer des mesures visant tout à la fois à promouvoir l’aide informelle apportée aux personnes âgées et à soulager ceux qui l’apportent., Davin Bérangère, Paraponaris Alain, Protière Christel. Pas de prix mais un coût ? Évaluation contingente de l'aide informelle apportée aux personnes âgées en perte d'autonomie. In: Economie et statistique, n°475-476, 2015. La santé et les soins. pp. 51-69.

Social and economic motives for unmet needs of disabled elderly living in the community This paper is aimed at identifying with the help of a bivariate probit model with sample selection the key-factors associated to need for personal assistance and unmet or undermet needs for 21 activities of daily living reported by elderly in the community. It uses data from the 1999 home wave of the national survey on Handicaps, Disabilities, Dependence about 8,727 60 years of age and older. In the regressors set including demographic, social, medical and economic variables, a low socio-economic status particularly seems to matter doubly, by enhancing both the probability to declare a need for help and by strengthening the probability not to get a sufficient help to meet the needs., Résumé. L'objet de cet article est d'identifier, à l'aide d'un modèle pro- bit bivarié avec sélection d'échantillon, les déterminants des besoins non satisfaits et insuffisamment satisfaits exprimés par des personnes âgées vivant à domicile dans la réalisation de vingt-et-une activités de la vie quotidienne. Il utilise les données du premier passage à domicile de l'enquête nationale sur les Handicaps, les incapacités et la dépendance (HID) collectées en 1999 auprès de 8 727 personnes âgées de 60 ans et plus. Parmi les variables démographiques, sociales, médicales et économiques constituant l'ensemble des facteurs explicatifs envisageables, la précarité socio-économique des répondants semble jouer un rôle doublement important, en majorant en même temps la probabilité de la déclaration d'un besoin d'aide et la probabilité que les besoins d'aide exprimés ne reçoivent pas en contrepartie toute l'aide jugée suffisante par les répondants., Ayuda necesaria e insuficiencia de la ayuda humana para las personas de edad a domicilio El objeto del presente artículo es identificar, utilizando un modelo probit bivariado con selección de muestras, los déterminantes de las necesidades no satisfechas e insuficientemente satisfechas, expresadas por personas mayores viviendo en su domicilio, en lo que toca al desempeño de 21 actividades de la vida diaria. Se utilizan los datos de la primera visita hecha en el domicilio (en 1999) para la investigación nacional sobre desventajas, incapacidades y dependencia (HID), datos obtenidos de 8 727 personas con 60 años de edad o mas. Dentro de las variables demográficas, sociales, medicales y económicas que constituyen el conjunto de los factores explicativos que se pueden considerar, la precariedad socioeconómica de los participantes en particular parece desempeñar un papel doblemente importante, por el hecho de que aumenta a la vez la probabilidad de declaración de necesidad de ayuda y la probabilidad de que los requerimentos expresados no reciban toda la ayuda que los que han contestado consideran como suficiente., Davin Bérangère, Joutard Xavier, Moatti Jean-Paul, Paraponaris Alain, Verger Pierre. Besoins et insuffisance d'aide humaine aux personnes âgées à domicile : une approche à partir de l'enquête « Handicaps, incapacités, dépendance ». In: Sciences sociales et santé. Volume 24, n°3, 2006. Déterminants socio-économiques des inégalités de santé. pp. 59-93.

Position du probleme Les gains d’esperance de vie constates dans les pays occidentaux ont ete accompagnes d’une augmentation des maladies chroniques et incapacites dans la realisation d’activites de la vie quotidienne (AVQ) et d’activites instrumentales de la vie quotidienne (AIVQ). Bien que ces incapacites favorisent l’institutionnalisation, les personnes âgees continuent majoritairement de vivre a domicile en France. Ce travail vise a identifier les besoins d’aide de ces personnes et leur association avec certains facteurs demographiques et socio-economiques. Methodes Les besoins declares d’aide humaine dans les AVQ et AIVQ sont etudies a partir d’un echantillon representatif de 8 745 personnes de 60 ans ou plus vivant a domicile en 1999 tire de l’enquete transversale francaise Handicaps-Incapacites-Dependance. Les associations ont ete evaluees a l’aide d’odds-ratio (OR) bruts puis ajustes dans le cadre d’une adaptation du modele comportemental d’Andersen-Newman. Resultats Plus d’un million de personnes declarent avoir besoin d’aide pour la realisation d’au moins une AVQ (toilette, habillage, utilisation des toilettes, alimentation, transferts, sorties) et pres de 2,5 millions pour une ou plusieurs AIVQ (courses, repas, tâches menageres). La declaration d’un besoin d’aide pour au moins une AVQ est associee a l’âge (OR = 1,4 pour les 70-79 ans, 3,6 pour les 80 ans ou plus), au fait d’etre un homme âge de 80 ans ou plus (OR = 0,5), a l’absence de diplome (OR = 1,5), au fait de vivre en couple (OR = 1,7) ou avec une personne autre que le conjoint (OR = 2), a un revenu disponible inferieur a 540 euro mensuel ou compris entre 540 et 1 080 euro (OR = 1,3), a differents types de deficience : motrice (OR = 3), du langage (OR = 2,1), visuelle (OR = 1,7), intellectuelle (OR = 1,5) ou autre (OR = 1,2), a la disponibilite d’aides techniques d’equipement (OR = 3,5), au deplacement (OR = 3) ou autres (OR = 2,1). Le risque d’un besoin d’aide humaine se trouve particulierement majore (OR = 4) pour les personnes assistees dans leurs reponses comme pour celles remplacees (OR = 5,5). La declaration d’un besoin d’aide pour une AIVQ au moins est globalement associee aux memes facteurs. Conclusion Les resultats traduisent une realite des besoins d’aide humaine qui tient plus compte du contexte socio-environnemental qu’elle n’est strictement liee a des limitations fonctionnelles.

This study investigated attitudes toward buprenorphine maintenance treatment (BMT) among general practitioners (GPs) and their maintained patients' propensity to turn to several prescribers (doctor shopping), among a sample of 345 GPs prescribing BMT in South-Eastern France. Survey data were anonymously matched to administrative data that provided information about GPs' patients. A simultaneous equation model suggests that GPs' attitude influenced doctor shopping, not the reverse. Doctor shopping was lower among GPs who reported inducting BMT with 8 mg of buprenorphine per day or more, and was higher for GPs endorsing a stringent attitude toward patients. Thus doctor shopping should not be understood exclusively as a deviant behaviour. It is partially physician-driven, and further research is needed to assess whether it reflects patients' dissatisfaction toward inappropriate care supply and the difficulty to establish a good therapeutic relationship between an opiate-dependent patient and a general practitioner.

Resume Objectifs Etude de la collaboration entre medecins de ville et pharmaciens lors de la prescription de buprenorphine haut dosage (BHD) comme traitement de substitution de la dependance aux opiaces. Methodes Une enquete telephonique, realisee aupres d’un echantillon de medecins prescripteurs de BHD dans le departement des Bouches-du-Rhone realisee en octobre 2002, a permis le recueil d’informations sur les pratiques, connaissances et opinions en matiere de traitement de BHD, completees par des donnees de l’assurance maladie et de l’Insee. Une regression logistique a permisd’identifier les facteurs independamment associes a la collaboration avec un pharmacien. Resultats Trois cent quarante-cinq medecins ont participe a l’enquete et 54 % ont declare collaborer parfois avec un pharmacien pour la prise en charge de ses patients sous BHD. Les medecins dans ce cas se distinguaient par une prise en charge de leurs patients sous BHD plus continue et declaraient plus frequemment adapter les dosages en cours de traitement. La collaboration etait associee a la formation en toxicomanie, au contact avec un reseau, a une intervention precoce ainsi qu’a une opinion favorable a la prescription de BHD en medecine de ville. Conclusion La mise en œuvre de la collaboration medecin-pharmacien passe par le soutien global a la formation des medecins en toxicomanie et a l’activite des reseaux des soins. L’application plus coercitive des dispositifs de collaboration est susceptible de limiter la diffusion de la prescription parmi les medecins comme l’acces aux soins des patients.

We investigate the relationship between employability and obesity, particularly how obesity and overweight are associated with the percentage of working years spent unemployed and the ability to regain employment. Data for adults who responded to the 2003 Decennial Health Survey collected by the French National Institute of Statistics and Economic Studies revealed that the percentage of time spent unemployed during working years is significantly higher for each kg/m2 deviation from the mean body mass index (BMI) attained at age 20 and that the probability of regaining employment after a period of unemployment is much lower.

Resume Objectif Decrire les attitudes, les connaissances et les pratiques des medecins generalistes (MG) en Provence Alpes-Cote d’Azur (PACA) concernant la prise en charge des problemes de poids chez les enfants et les adultes. Methodes Enquete telephonique aupres d’un panel de 600 MG representatif des MG liberaux de la region PACA sur leurs attitudes et opinions a l’egard du surpoids et de l’obesite, leurs connaissances et formation dans la prise en charge de ces problemes ainsi que leurs pratiques (diagnostic, objectifs therapeutiques, conseils dietetiques et suivi). Resultats La plupart des MG (90,2 %) consideraient que l’obesite est une maladie dont la prise en charge s’inscrit sur le long terme (99,5 %) et 79 % pensaient que la prise en charge des problemes de poids etait de leur ressort. Cependant, 58 et 66 % se sentaient peu ou pas efficaces lors de la prise en charge, respectivement, de patients adultes et d’enfants. Environ 30 % des MG ont declare des attitudes negatives envers les personnes en surpoids ou obeses. Les pratiques des MG apparaissaient globalement proches des recommandations mais 60 % fixent a leurs patients obeses des objectifs ponderaux trop exigeants, peu utilisent un carnet alimentaire et 55 % interdisent la consommation de certains aliments aux enfants. Discussion Ces resultats, qui comportent les limites de donnees declaratives, temoignent d’une distorsion entre la theorie et la pratique lors de la prise en charge de l’obesite. La plupart des MG sont preoccupes par l’importance croissante de l’obesite qui leur parait relever de leur competence. Parallelement, les MG expriment un profond scepticisme sur leur efficacite. Ce sentiment d’echec est sans doute favorise par l’antagonisme des modeles de representation du surpoids des medecins et des patients.

Objective: To describe the current knowledge, attitudes, and practices of French general practitioners (GPs) in the field of adult overweight and obesity management. Research Methods and Procedures: A cross-sectional telephone survey interviewed a sample of 600 GPs, representative of the private GPs in southeastern France. A four-part questionnaire assessed personal and professional characteristics, attitudes and opinions about overweight and obesity, relevant knowledge and training, and practices (diagnostic methods, clinical assessments, weight loss objectives, types of counseling). Results: Most GPs knew that weight problems are health-threatening, and 79% agreed that managing these problems is part of their role. Nevertheless, 58% did not feel they perform this role effectively, and one-third did not find it professionally gratifying. Approximately 30% had negative attitudes toward overweight and obese patients; 57% were pessimistic about patients’ ability to lose weight; 64% often set weight loss objectives more demanding than guidelines call for; and neither food diaries nor nutritional education were used systematically. GPs’ feelings of effectiveness and attitudes toward obese patients were associated with some professional (training) and personal (BMI, personal diet experience) characteristics. Discussion: GPs’ feelings of ineffectiveness may stem from an underlying conflict between practitioners’ and patients’ representations of weight problems and the relationship problems this causes. Inadequate practices and health care system organization may also play a role.

Cet article propose un premier bilan des resultats de l’experience menee en region PACA depuis 2002 de constitution d’un « observatoire des pratiques » des medecins liberaux : le panel MG PACA de 600 medecins generalistes. Les questions traitees sont diverses : methodologiques : representativite et attrition statistiques caracterisant le suivi longitudinal d’une population ; socio-economiques : revenus et conditions de travail des medecins ; medicales : modalites de prise en charge de certaines pathologies. Une « analyse des correspondances multiples » fait apparaitre des profils de pratiques des medecins relativement marques, particulierement en ce qui concerne l’activite, les habitudes de prescription et l’acces a l’information medicale. Enfin, l’ambition d’un tel panel serait de constituer un dispositif perenne d’apprehension de la profession de medecin generaliste, puis de devenir un veritable outil d’aide a la decision de politique sanitaire : en quoi consiste aujourd’hui le metier de medecin generaliste ; peut-on le faire evoluer et comment ?

Background Because they undergo breast cancer screening (BCS) relatively infrequently, women with physical or mental impairments may be at higher risk of late-stage breast cancer than women without impairments. A panel of 600 general practitioners (GPs) in Provence (southeastern France) provided information from which barriers potentially associated with BCS practices for women with disabilities were evaluated. Methods In 2002, a telephone questionnaire collected data about GPs' personal and professional characteristics and their attitudes and practices regarding patients with disabilities. Analysis in 2003 used simple and multiple logistic regressions. Results More than a quarter of the GPs reported apparently inadequate BCS practices for people with disabilities. Feelings of discomfort when treating people with disabilities, lack of assistance, and communication difficulties were inversely associated with BCS for women with mental and physical impairments. General practitioners' information-seeking strategies were associated with BCS for women with mental impairments, and nursing home work experience was inversely associated with BCS for women with physical impairments. Conclusions Appropriate training sessions should be made available to improve primary health care quality and prevention practices and to reduce GPs' misperceptions of people with disabilities.

In France, since 1996, any general practitioner (GP) can prescribe high-dosage buprenorphine maintenance treatment (BMT) for opioid-dependent patients. The health authorities initially provided mandatory specific training, but since 1998, such training is only delivered by specialized networks and the pharmaceutical industry. Among a random sample of GPs from southeastern France (N=345), we found that many untrained GPs, as well as a significant minority of trained GPs, were likely to prescribe an ineffective dosage of buprenorphine or a potentially dangerous treatment (BMT+a short half-life benzodiazepine). These results highlight the necessity to edit clear guidelines, especially concerning situations of polyaddiction and psychiatric comorbidity, and to extend and improve BMT training in France with a renewed involvement of health authorities for quality control of such training. They even suggest that GPs' participation to specialized training sessions should become a mandatory prerequisite for prescribing BMT.

Position du probleme La prescription de la buprenorphine haut dosage comme traitement de substitution de la dependance aux opiaces a ouvert aux medecins generalistes en 1996 en France la possibilite de traiter les usagers de drogues pour leur addiction avec un support pharmacologique. Cet article identifie les determinants de la prescription de buprenorphine chez les medecins generalistes liberaux et les facteurs associes aux differences d’engagement dans la prise en charge de patients a l’aide de buprenorphine. Methodes Deux echantillons representatifs de medecins generalistes prescripteurs de buprenorphine (345 sur une population totale de 876) et de non-prescripteurs (355 sur 1 380) ont ete interroges par telephone dans les Bouches-du-Rhone en novembre-decembre 2002. Ils ont ete obtenus par sondage aleatoire stratifie selon le sexe, l’âge et le volume d’activite (taux de reponse : 65,5 %). Ces donnees ont ete completees par des donnees de l’Assurance-Maladie et d’environnement socio-economique de l’Insee. Resultats 37,5 % des medecins generalistes ont prescrit au moins une fois de la buprenorphine au cours de la periode consideree, mais 26 % des prescripteurs prennent en charge 75 % des patients. Les medecins prescripteurs de buprenorphine sont plus souvent des hommes, âges de moins de 49 ans, travaillant le plus souvent en secteur 1 et en cabinet de groupe. Ils sont aussi plus souvent membres d’un reseau de soins, plus nombreux que les autres a etre formes en toxicomanie et, d’un point de vue individuel, ont dans leur entourage des personnes atteintes d’un cancer, de l’hepatite C, du VIH ou toxicomanes. La precarite socio-economique de la zone dans laquelle les medecins exercent semble tout particulierement associee a la prescription de buprenorphine. Conclusions Les donnees etudiees montrent la forte concentration de l’offre de soins de substitution a l’aide de buprenorphine. Elles revelent aussi l’emergence de phenomenes de specialisation, qui n’etaient pas prevus ou explicitement encourages par les tutelles, qui coexistent avec des prescriptions plus dispersees realisees par des medecins en dehors de toute formation ou d’encadrement collegial. Ces constats invitent a interroger la coherence des dispositifs de soutien a la pratique medicale preconises par les pouvoirs publics avec les pratiques de terrain.

France presents a unique situation in which the take-off of a generic drug market depends, out of regulatory incentives, on whether physicians choose a prescription method (international non-proprietary names, INN) that can lead to the delivery of these drugs and on whether patients accept them. This paper is aimed at pointing out factors explaining general practitioners’ (GPs’) willingness to prescribe in INN through data collected from a South-Eastern France representative sample of 600 GPs in March 2002. The main results shed light on the key-role played by GPs’ information about drugs and the source which they take it from, by GPs’ volume of services and caseloads, and slightly by socio-economic characteristics of patients.

Previous research suggests that practising physicians are more likely than the general population to use psychotropic drugs. Hypnotic and tranquillizer use in France is among the highest in Europe; most hypnotic and tranquillizer prescriptions are written by general practitioners (GPs). The objective was to compare the hypnotic and tranquillizer use of GPs in private practice in Provence (south-eastern France) with that of the general population and to study factors associated with physicians' hypnotic and tranquillizer use. A cross-sectional telephone survey was carried out with a panel of 600 GPs in Provence. The data were collected with a 53-item questionnaire about their social and demographic status, family, occupation, training, information-seeking behaviour, job satisfaction, hypnotic and tranquillizer drug use, tranquillizer and antidepressant prescriptions. The data were analysed using univariate and backward multiple logistic regressions. We found that GPs in Provence use hypnotics and tranquillizers at a significantly higher rate than the general population. We found significant associations with hypnotic and tranquillizer use only among the older group of GPs (older than 48 years). In this group, this drug use was related to the volume of services provided (billing sector), job dissatisfaction, lack of training, the 'family burden' and tranquillizer prescriptions. The strains associated with both medical practice and family burden have some influence on hypnotic and tranquillizer use among GPs; individual factors may influence prescribing attitudes and patient care as well.

Resume Objectifs. – Cet article se propose d'etudier les connaissances, attitudes et pratiques des medecins dans la prise en charge des patients handicapes. Materiel. – Un echantillon de 600 medecins generalistes liberaux exercant en region Provence Alpes Cote d’Azur (PACA) a ete selectionne en 2002 par echantillonnage aleatoire stratifie sur l’âge, le sexe et la taille de l’unite urbaine d’exercice. Methode. – Les medecins ont ete questionnes de facon standardisee par telephone. Les pourcentages de reponses ont ete compares par des tests du χ2 de Pearson. Resultats. – Quatre-vingt-dix pour cent des medecins ont declare avoir a jouer un role social aupres des personnes handicapees (defense des droits, demarches administratives, conseiller de la famille…) ainsi qu’un role de coordonnateur des divers intervenants. Les medecins ont frequemment declare rencontrer des obstacles a la prise en charge des personnes handicapees : manque d'information (62,8 %), de temps (50,2 %), de coordination avec divers intervenants (37,7 %), de formation (37,7 %), problemes de communication avec le patient (20,7 %) et besoin d'aide pour les examens (16,2 %). Plus d'un quart des medecins a declare proposer moins souvent un depistage du cancer du sein (27,6 %), une contraception (29,5 %), ou une vaccination contre l’hepatite B (29,3 %) aux patients presentant un handicap qu’aux autres patients ; 25,8 % des medecins ont declare ne pas evaluer le degre de dependance fonctionnelle des patients handicapes. Conclusion. – Cette etude met en evidence les obstacles rencontres par les medecins generalistes pour la prise en charge des personnes handicapees. Un manque de connaissances peut expliquer des prises en charge des patients parfois inadequates. A partir de ce constat, le travail en reseau avec les divers professionnels de sante et la formation medico-sociale des medecins generalistes doivent etre encourages.

Objectives Emergency departments of French hospitals have been coping with increasing activity for ten Years. This study is aimed at describing patterns of health care consumption for people admitted to emergency departments and at linking them to their declared socio-economic status. Methods In May 2001, a survey was conducted in the emergency department of the Saint Roch Hospital in Nice, identifying the nature and motives of the persons admitted, health care consumption over the last Year and a set of socio-economic characteristics of the patients. Results A persisting gap in health care consumption still remains to the detriment of poor people. There also seems to be a threshold effect for patients whose income only slightly exceeds the upper limit of revenues entitling them to universal health insurance or other social redistribution mechanisms. For this category of the population, health care consumption is significantly less than that of the rest of the population, although visits to the emergency department are more often unjustified. Conclusion Emergency departments are the major access to health care for people excluded from, or on the borderline of the health system. The extension of health insurance to populations excluded up till now, appears to induce underprivileged health traps, but at the same time making up for lost time (only partially in this study). Such effects merit consideration in order to ensure a continuum in the management of health requirements in low income populations.

ACL-2; International audience; Geographic variation in use of elective surgeries has been widely studied in the US, where over-utilization is incentivized. We wanted to explore recent trends in the geographic variation of common surgical procedures in France – where a global budget, centralized planning process, and compulsory insurance scheme are in place – and to compare measures of variation there to those in the US and Britain. For 2008–2010, we calculated French age- and sex-adjusted per capita utilization rates and four measures of geographic variation for hip fracture admission (which is standard treatment and shows minimal geographic variation across countries) and 14 elective surgical procedures. We found substantial geographic variation in age-sex adjusted per capita admission rates for elective procedures: radical prostatectomy, spine surgery, and CABG showed the greatest variation, while hip fracture, colectomy, and cholecystectomy showed the least. Among older patients, most French admission rates were lower than those seen in the US. In general, measures of geographic variation were lower in France than those reported in the US or Britain. French policymakers could use analyses of geographic variation in service utilization to inform policy, to identify areas for intervention, or to measure the effectiveness of efforts designed to reduce variation in care.

ACL-1; International audience; INTRODUCTION: We sought to determine whether there was evidence of supplier-induced demand in mainland France, where health care is mainly financed by a public and compulsory health insurance and provided by both for-profit and not-for-profit hospitals. METHODS: Using a dataset of all admissions to French hospitals for 2009 and 2010, we calculated department-level age-adjusted and sex-adjusted per capita admission rates for hip replacement, knee replacement, and hip fracture for 2 age groups (45-64 and 65-99 y old), for-profit and not-for-profit hospitals. We used spatial regression analysis to examine the relationship between ecological variables, procedure rates, and supply of surgeons or sector-specific surgical beds. RESULTS: The large majority of hip and knee replacement surgeries were performed in for-profit hospitals, whereas the large majority of hip fracture admissions were in not-for-profit hospitals; nonetheless, we found approximately 2-fold variation in per capita rates of hip and knee replacement surgery in both age groups and settings. Spatial regression results showed that among younger patients, higher incomes were associated with lower admission rates; among older patients, higher levels of reliance on social benefits were associated with lower rates of elective surgery in for-profit hospitals. Although overall surgical bed supply was not associated with admission rates, for-profit-specific and not-for-profit-specific bed supply were associated with higher rates of elective procedures within a respective hospital type. DISCUSSION: We found evidence of supplier-induced demand within the French for-profit and not-for-profit hospital systems; however, these systems appear to complement one another so that there is no overall national supplier-induced effect.

ACL-2; International audience; Background: Admissions for ambulatory care sensitive conditions (ACSCs) are considered preventable and indicators of poor access to primary care. We wondered whether per-capita rates of admission for ACSCs in France demonstrated geographic variation, were changing, were related to other independent variables, or were comparable to those in other countries; further, we wanted to quantify the resources such admissions consume. Methods: We calculated per-capita rates of admission for five categories (chronic, acute, vaccination preventable, alcohol-related, and other) of ACSCs in 94 departments in mainland France in 2009 and 2010, examined measures and causes of geographic variation in those rates, computed the costs of those admissions, and compared rates of admission for ACSCs in France to those in several other countries. Results: The highest ACSC admission rates generally occurred in the young and the old, but rates varied across French regions. Over the 2-year period, rates of most categories of ACSCs increased; higher ACSC admission rates were associated with lower incomes and a higher supply of hospital beds. We found that the local supply of general practitioners was inversely associated with rates of chronic and total ACSC admission rates, but that this relationship disappeared if we accounted for patients’ use of general practitioners in neighboring departments. ACSC admissions cost 4.755 billion euros in 2009 and 5.066 billion euros in 2010; they consumed 7.86 and 8.74 million bed days of care, respectively. France had higher rates of ACSC admissions than most other countries examined. Conclusions: Because admissions for ACSCs are generally considered a failure of outpatient care, cost French taxpayers substantial monetary and hospital resources, and appear to occur more frequently in France than in other countries, policymakers should prioritize targeted efforts to reduce them.