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Contexte Places sous l’autorite des maires, les services de police municipale executent des missions de prevention et de surveillance du bon ordre, de la tranquillite, securite, surete et salubrite publiques. Les effectifs de policiers municipaux sont en constante augmentation depuis 2014. Les attentats de 2015 et la mise en place de l’etat d’urgence ont incite les maires a renforcer les effectifs de policiers municipaux (PM) et d’agents de surveillance de la voie publique (ASVP) ainsi que l’armement de leurs services de police municipale : 30 556 PM et ASVP etaient recenses en 2016, soit +8,6 % par rapport a 2015 ; en 2015, 39 % des policiers municipaux etaient equipes d’une arme a feu. Les PM et les ASVP sont exposes a de nombreux risques professionnels, encore mal evalues. Dans ce contexte, les questions des modalites de la surveillance medicale et de la determination de l’aptitude medicale de ces agents publics territoriaux, notamment l’aptitude au port d’armes en articulation avec la medecine agree, se posent aux services de medecine preventive. Methode Il est propose de decrire les risques auxquels sont exposes les PM a partir de l’analyse de documents uniques d’evaluation des risques professionnels, de rapports d’inspection, de donnees d’accidentologie et de donnees recueillies au cours d’actions sur le milieu du travail, de faire le point sur la reglementation encadrant la determination l’aptitude medicale des PM et de tirer les enseignements utiles en matiere de suivi medical pour les policiers nationaux en Fonction Publique d’Etat. Resultats et conclusion A partir de l’ensemble de ces elements, des preconisations en matiere de sante au travail et de prevention des risques professionnels et une ordonnance de prevention seront proposees.

Summary Objectives To administer a social handicap questionnaire associated with French DRGs (PMSI) to determine the social handicaps of a population hospitalized in a public health establishment and to measure the cost implications for the establishment due to increased length of stay (DMS). Method A prospective pilot study has been carried out in the Lariboisiere–Fernand Widal Hospital Group in Paris targeting users 50 or more years old hospitalized for short stays in medicine, surgery and obstetrics. Data of the PMSI and answers to the questionnaire for hospitalisations longer than 24 hours have been exploited. Results Two hundred twenty-two stays from 8 to 23 November 2005 have been analyzed: 140 pertained to patients aged 50–69 years (27.8%) and 82 to patients aged 70 or more years (16.3%). Three-fourths of the persons aged 50–69 and 70 or over presented a social handicap: 45% showed a strong handicap and a third an average handicap. The three indicators “renter/owner”, “interior comfort” and “family relations” were the major determinants of social handicap for those aged 70 or more, 50–69 and 50 or more years. For the patients 70 years and over and those 50–69 years, with an average handicap, the indicator was “income” with the domain “patrimony.” For strong handicaps, it was the indicator “scolarisation” for the 70 or more years and the indicator “income” for the 50–69 years old. When all classes and populations were pooled, the DMS was significantly lower than that of the ENC (p Conclusion This pilot study with a questionnaire disability social PMSI proposing specific aid, but also reducing the DMS, provides several promising information but also indicates the limits of our approach. Among these, we note in particular: (a) its regular feasibility requires constant supervision, wider and well-trained, (b) that the measurement of our tool can only be affirmed after its use in many patients, and (c) the classification of disability in social class could even be discussed again. We still wanted to explore whether through this initiative without much logistical, markers of interest had emerged, which seems to be the case.

Introduction Des etudes anciennes ont retrouve des niveaux d’exposition au bruit dans les piscines couvertes depassant 90 dB (A) sur 8 h. L’objectif de l’etude est double: mesurer l’exposition au bruit dans 11 piscines couvertes ainsi qu’evaluer la fonction auditive chez des maitres-nageurs sauveteurs y travaillant. Materiel et methode Pour cela, nous avons realise des dosimetries de bruit dans chacune des piscines sur une journee unique, representative de l’activite du metier de maitre-nageur. De plus, nous avons recu les agents en visite periodique et realiser des audiometries tonales en conduction aerienne au cabinet de consultation. Nous avons mesure la moyenne arithmetique des deficits auditifs sur les frequences 3000 Hz, 4000 Hz, 6000 Hz, soit l’indicateur precoce d’alerte (IPA), que nous avons compare aux valeurs de reference par âge en population generale. Resultats des audiometries Nous avons recu 58 maitres-nageurs en consultation entre fevrier et mars 2015. Cinquante et un audiometries ont ete conservees pour analyse, 7 n’ont pas ete retenues pour cause d’antecedents ORL notables ou d’exposition anterieure au bruit professionnelle ou extra-professionnelle. Parmi ces 51 maitres-nageurs, 23 (45 %) avaient une valeur de l’IPA superieure a la valeur maximum attendue pour l’âge et un maitre-nageur presentait un deficit auditif de 35 dB sur la meilleure oreille sans exposition extra-professionnelle susceptible d’interferer. Resultats des dosimetries Nous avons mesure des Lex, 8 h allant de 79 dB (A) a 91,5 dB (A) sans depassement des niveaux de crete reglementaires. Discussion La principale limite ici vient du fait que les audiometries n’ont pas etes realisees en cabine insonorisee, il serait interessant de confirmer ces resultats par des mesures en cabine insonorisee. Bien que les dosimetries nous paraissent fiables et comparables aux resultats de mesures anterieures dans ces piscines ainsi qu’aux donnees de la litterature, la repetition des mesures sur des durees d’enregistrement plus longues viendrait renforcer ces resultats. Conclusion Les donnees suggerent que les maitres-nageurs sont exposes a des niveaux de bruit superieurs au seuil de danger reglementaire pour l’audition et qu’un nombre important d’agents souffre d’une perte auditive excessive compte tenu de leur âge. A la lumiere de ces resultats, nous conseillons une surveillance medicale renforcee avec audiometrie tonale tous les 2 ou 3 ans ainsi qu’un controle des niveaux de bruit dans les piscines couvertes et un renforcement si necessaire des moyens de prevention collective et individuelle.

The services of general interest provided by hospitals, such as free HIV clinics, have been funded since 2005 by a lump sum covering all costs. The allocation of the budget was initially determined based on historical and declarative data. However, the French Ministry of Health (MoH) recently outlined new rules for determining the allocation of financial resources and contracting hospitals for each type of services of general interest provided. The aim of this study was to estimate the annual cost of a public free anonymous HIV-testing center and to assess the budgetary implications of new financing systems. Three financing options were compared: the historic block grant; a mixed system recommended by the MoH associating a lump sum covering the recurring costs of an average center and a variable part based on the type and volume of services provided; and a fee-for-services system. For the purposes of this retrospective study, the costs and activity data of the HIV testing clinic of a public hospital located in the North of Paris were obtained for 2007. The costs were analyzed from the perspective of the hospital. The total cost was estimated at 555,698 euros. Personnel costs accounted for 31% of the total costs, while laboratory expenses accounted for 36% of the total costs. While the estimated deficit was 292,553 euros under the historic system, the financial balance of the clinic was found to be positive under a fee-for-services system. The budget allocated to the HIV clinic under the system recommended by the MoH covers most of the current expenses of the HIV clinic while meeting the requirements of free confidential care.

Les Centre de Depistages Anonymes et Gratuits (CDAG) sont une des Missions d’Interet Gener al hospitalieres (MIG). Les MIG sont ?nancees par une dotation dediee, initialement determinee a partir de retraitements comptables. Le ministere de la Sante (DHOS) a propose un nouveau modele pour le calcul de la dotation ?nanciere des CDAG, associant part ?xe et part variable en fonction de l’activite. L’objectif de cette etude est d’estimer le cout de fonctionnement d’un CDAG hospitalier et de mesurer l’impact sur son equilibre ?nancier des 3 scenarios de ?nancement suivants : le modele « historique » mis en place en 2005, celui propose par la DHOS en 2008, et une facturation a l’acte similaire aux consultations externes. Il s’agit d’une enquete retrospective concernant les consultations realisees au CDAG de l’hopital Lariboisiere en 2007. L’estimation du cout a ete realisee par la methode des couts complets du point de vue de l’hopital. L’estimation des ?nancements a ete realisee en appliquant a l’activite constatee les differentes regles de tari?cation et de calcul de la dotation. Le cout total du CDAG etait de 555 698 euros, avec les examens de biologie et les depenses de personnels comme principaux postes (36 % et 31 % du cout total). Le bilan ?nancier du CDAG etait negatif avec le modele historique (– 292 553 euros), positif avec une facturation a l’acte et proche de l’equilibre avec le modele mixte de la DHOS. Ce dernier permet de mieux valoriser ?nancierement l’activite d’un CDAG, tout en respectant les notions de gestion de l’anonymat et de gratuite des prestations delivrees. Toutefois, il ne permet pas d’atteindre l’equilibre ?nancier et certaines activites sont peu ou pas valorisees.

Summary Background Since the beginning of 2008, the implementation of a 100% activity-based payment system, has made efficiency one of the prime concern for the French health-care providing institutions. We therefore assessed the real cost of a scheduled total hip replacement (THR) in a teaching hospital and compared findings with French national data (and with the Government Healthcare Insurance System allowance). Hypothesis The study should suggest possible means to optimize organization of management and/or clinicians’ practice. Material and methods This is a retrospective full-cost economic study. Patients were included only if fulfilling the following criteria: admitted in 2006; classified in Diagnosis-Related Group (DRG) 08C23 V or 08C23W (respectively THR without and with associated comorbidity); treated in a single department; admitted from home; and having undergone a THR (coded as NEKA020 in the french CPT) that same year. Treatment-cost was established on the basis of data collected from two main sources: the Information Systems Medicalization Program (ISMP) data-base, and the finance department data, which were taken into account in line with the French National Costs Study (NCS) structure. Results The methodology employed here follows the 2006 National Costs Scale structure. Treatment costs (excluding the cost of implantable medical devices or IMDs) were estimated at €8,104.72 for DRG 08C23W and €7,529.19 for DRG 08C23 V. These figures were higher than the rates authorized in 2006 (excluding IMDs), which were €7,677.92 for 08C23W and €6,358.97 for 08C23 V (taking the 7% geographic coefficient into account) and than the 2005 NCS figures (excluding IMDs) of respectively €7,536.13 and €6,083.59. Discussion Clinical units and departments need to be able to assess costs for the pathologies they treat, as health-care institutions have to balance their expenditure against their income, which largely comes from their hospital-care activity. The methodology put forward here, of cost comparison according to the NCS structure, enables the total cost to be known. Comparing results (expenditure line by expenditure line) against national data, selectively highlights the areas in which efficiency can be improved. The exactitude of the obtained results remains, however, limited by the rules currently in use at each individual hospital's accounting department. Level of evidence Level IV, retrospective economic and decision analysis study.

To administer a social handicap questionnaire associated with French DRGs (PMSI) to determine the social handicaps of a population hospitalized in a public health establishment and to measure the cost implications for the establishment due to increased length of stay (DMS).A prospective pilot study has been carried out in the Lariboisière-Fernand Widal Hospital Group in Paris targeting users 50 or more years old hospitalized for short stays in medicine, surgery and obstetrics. Data of the PMSI and answers to the questionnaire for hospitalisations longer than 24 hours have been exploited.Two hundred twenty-two stays from 8 to 23 November 2005 have been analyzed: 140 pertained to patients aged 50-69 years (27.8%) and 82 to patients aged 70 or more years (16.3%). Three-fourths of the persons aged 50-69 and 70 or over presented a social handicap: 45% showed a strong handicap and a third an average handicap. The three indicators "renter/owner", "interior comfort" and "family relations" were the major determinants of social handicap for those aged 70 or more, 50-69 and 50 or more years. For the patients 70 years and over and those 50-69 years, with an average handicap, the indicator was "income" with the domain "patrimony." For strong handicaps, it was the indicator "scolarisation" for the 70 or more years and the indicator "income" for the 50-69 years old. When all classes and populations were pooled, the DMS was significantly lower than that of the ENC (p0.001 for the 70 years and over; p0.05 for the 50-69 years). With again all classes and populations pooled, patients 70 and over stayed in hospital 6.50 days less on average compared to data published by the ENC; those 50-69 years stayed 3.57 days less. Persons aged 50 and over with a social handicap remained hospitalized on average more than 2.5 days: 2.2 days for the 70 and over and 3.1 days for the 50-69 years group. In terms of hospital days that produces an increase of 18%, corresponding to a supplementary expenditure attributable to social handicap of approximately 5.9 million euros.This pilot study with a questionnaire disability social PMSI proposing specific aid, but also reducing the DMS, provides several promising information but also indicates the limits of our approach. Among these, we note in particular: (a) its regular feasibility requires constant supervision, wider and well-trained, (b) that the measurement of our tool can only be affirmed after its use in many patients, and (c) the classification of disability in social class could even be discussed again. We still wanted to explore whether through this initiative without much logistical, markers of interest had emerged, which seems to be the case.