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Objectives Health information technology (HIT) can help coordinate health and social actors involved in patients’ pathways. We assess five regional HIT-based programmes (‘ Territoires de Soins Numériques’ or TSN) introduced in France, covering the period 2012–2018. Methods This was a quasi-experimental controlled before/after mixed design. We used data from the French National Health Insurance database, qualitative and quantitative surveys, and information extracted from project documents and databases. We assessed the impact of TSN using four main impact indicators: emergency room visits, unplanned hospitalizations, avoidable hospitalizations and rehospitalization within 30 days. We also collected qualitative and secondary quantitative data covering perceived needs, knowledge, use, satisfaction, adoption and understanding of projects, pathway experience, impact on professional practices and appropriateness of hospitalizations. Results TSN implemented a heterogeneous mix of HIT. Implementation was slower than expected and was not well documented. Users perceived the HIT as having a positive but weak overall effect. There were no significant differences in trends for the main impact indicators, nor on the appropriateness of hospitalizations, but favourable trends on secondary polypharmacy indicators. Conclusions If similar innovations take place in future, they should be based on a logical framework that defines causal, measurable links between services provided and expected impacts. more...

Au 1er mars 2016, la loi sur l’adaptation de la societe au vieillissement est entree en vigueur, reformant le dispositif de l’APA a domicile. L’objectif est d’etudier son effet sur les montants de plans proposes par les equipes medico‑sociales (EMS), d’abord theoriquement, puis empiriquement a partir des donnees des Remontees Individuelles (DREES) portant sur plus de 300 000 beneficiaires en 2011 et en 2017. Le montant moyen propose aux beneficiaires en groupe iso‑ressources (GIR) 3, 2 et 1 a augmente de 16, 49 et 57 € respectivement entre 2011 et 2017. Celui propose a la plupart des beneficiaires en GIR 4 a diminue, a caracteristiques donnees. Au sein de chaque GIR, en 2017, les distributions des montants sont plus etalees, y compris a gauche, laissant supposer que les contraintes budgetaires pesant sur les conseils departementaux ont conduit les EMS a reduire les montants proposes aux personnes relativement plus autonomes pour financer la hausse de ceux notifies aux personnes les plus severement dependantes. more...

L’arrivée récente de thérapies innovantes et coûteuses dans divers champs thérapeutiques suscite des espoirs importants du point de vue de la santé publique. Offrir un accès équitable à ces innovations entre toutefois en concurrence avec d’autres investissements publics qui font également l’objet d’attentes sociales fortes. Elle contraint donc les acteurs à définir le montant maximum que la collectivité est prête à dépenser pour des gains de santé donnés. Survient alors la question de savoir si ce montant maximum varie en fonction des circonstances qui entourent les individus, notamment la rareté de la maladie, leurs modes de vie, les inégalités sociales qu’ils ont subies tout au long de leur vie... Nous nous intéressons dans le cadre de cet article à une priorité particulière, celle accordée aux populations les plus jeunes et qui est le plus souvent désignée, à la suite des travaux de Harris, sous le terme fair innings. Nous nous demandons ce qui pourrait justifier une telle priorisation. Dans le cadre de cet article nous examinons trois arguments. Dans un premier temps nous proposons de justifier le critère de fair innings au nom d’un objectif d’égalisation des possibilités de bien-être dans la population. Dans un deuxième temps, nous proposons de le justifier au nom d’un objectif d’égalisation du temps offert aux individus pour réaliser leurs plans de vie, conformément à la théorie de la justice comme équité de Rawls. Enfin, nous proposons de le justifier au nom d’un objectif d’égalisation du temps offert aux individus pour accepter la mort. Ces trois arguments présentent bien sûr de nombreuses limites et nous soulignons certaines d’entre elles. L’objectif que nous poursuivons dans cet article n’est pas de convaincre de la supériorité d’un argument par rapport aux autres. Nous cherchons plutôt à contribuer aux discussions sur les critères de priorisation en santé, en explicitant ce qui pourrait justifier un des critères particuliers : celui de l’âge., Financing innovative and costly treatments in various therapeutic fields entails a number of problems in countries where costs are covered by public services. Providing these drugs is forcing actors to define the maximum sums of money society is willing to spend for given health improvements. This raises the question of whether maximum financing should vary according individuals’ circumstances, such as the rareness of a disease, lifestyles, social inequalities experienced over a life time, etc. This article examines a particular priority, namely that given to the youngest patients, such prioritising usually refers to the “fair innings argument” (FIA). We question what could justify such a prioritization criterion. Three arguments are considered. At first we consider that FIA could be justified by the objective of equalizing the opportunities of well-being. Next, we proposed justifying the fair innings argument with the aim of equalizing the time provided to individuals to achieve their plan of life, in accordance with Rawls’s theory of justice as fairness. Finally, we proposed considering the FIA as being justified because of the goal of equalizing the time provided to individuals to accept death. These three arguments, of course, have many limitations, some of which we have highlighted. This article doesn’t aim to convince about the superiority of one argument over the other ones. We seek to contribute to the discussions which could happen on prioritization criteria regarding health care, by making explicit what could justify one specific criterion: the age criterion. more...

International audience; Objective. In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it. The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues. Methods. We searched for all articles published until 6th of February 2020, mentioning “Proportionate Universalism” or its synonyms “Targeted universalism” OR “Progressive Universalism” as a topic in all Web of Science databases. Results. This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs. Conclusion. This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.; Objetivo. En 2010 se propuso el principio del universalismo proporcional como solución para reducir las desigualdades en materia de salud. Aunque tuvo una gran resonancia, no parece haber sido aplicado ampliamente y no existen directrices sobre cómo aplicarlo. Los dos objetivos específicos de esta revisión sistemática exploratoria fueron: 1) describir el contexto teórico en el que se estableció el universalismo proporcional, y 2) describir cómo los investigadores aplican el universalismo proporcional y las cuestiones metodológicas relacionadas. Métodos. Se buscó en todas las bases de datos de la Web of Science los artículos publicados hasta el 6 de febrero de 2020 que tuvieran como tema “universalismo proporcional” o sus sinónimos “universalismo dirigido” o “universalismo progresivo”. Resultados. Esta revisión de 55 artículos permitió tener una visión global del universalismo proporcional en cuanto a sus fundamentos teóricos y su aplicación práctica. El principio del universalismo proporcional se basa en las teorías sociales del universalismo y el direccionamiento, y propone vincular estos dos aspectos para lograr una reducción efectiva de las desigualdades en materia de salud. Respecto de su aplicación práctica, las intervenciones basadas en este principio son poco frecuentes y dan lugar a diferentes interpretaciones. Todavía existen muchos desafíos metodológicos y éticos en relación con la concepción y la evaluación de las intervenciones relacionadas con el universalismo proporcional, incluida la forma de aplicar la proporcionalidad y la identificación de las necesidades. Conclusión. En esta revisión se llevó a cabo un mapeo de la literatura científica disponible sobre el universalismo proporcional y sus conceptos relacionados. Este principio se basa en teorías sociales. Tal como lo destacaron autores que implementaron intervenciones de universalismo proporcional, su aplicación plantea muchos desafíos, desde el diseño hasta la evaluación. El análisis de las aplicaciones del universalismo proporcional presentado en esta revisión respondió a algunos de ellos, pero los desafíos metodológicos restantes requieren ser abordados en futuras investigaciones. more...

Introduction Health systems in several countries have integrated information and communication technologies into their operations. Electronic medical records (EMRs) are at the core of patient care. The working of these EMRs requires their acceptance and use by medical and paramedical personnel. The objective of this study was to empirically evaluate the intention of health professionals to use these EMRs. Materials and Methods A questionnaire on the intention of health professionals to use the EMR was developed following a Likert scale. The survey was done via in-person interviews of health professionals in major health facilities in the cities of Libreville and Owendo in Gabon. The technology acceptance model (TAM) was tested using a step-down logistic regression analysis to identify the main factors explaining the intention of health professionals to use the EMR. Results A total of 218 health professionals responded to the questionnaire. Thirty-eight percent (38%) of respondents were male. The average age was 41.33 years (±8.98 years) and the average length of service at work in the system was 12.02 years (±8.47 years). The integrated model showed that the intention to use the EMR was significantly associated with the perceived usefulness, the subjective standard, and experience. No socio-demographic variables explained the intention to use the EMR. Conclusion The perceived ease, familiarity with the computer, and motivation are not associated with the intention to use the EMR. Actions should be taken to raise awareness and train health professionals to motivate them to accept and use EMRs in their medical practices. more...

Summary Since 2013, the process of pricing of innovative drugs by the French National Health Insurance has considered both cost-effectiveness and budget impact. CAR-T cell therapies were first subject to economic evaluation from 2019 in France. We aim to describe the process and results of the economic evaluation of tisagenlecleucel and axicabtagene ciloleucel as well as the challenges these evaluations raised. Evaluations submitted by the firms were reviewed by HAS and submitted to the Committee of Economic Evaluation and Public Health (CEESP). The CEESP issued opinions related to: (1) the methodological quality of economic evidence and, (2) the cost-effectiveness and budget impact of the drugs. The CEESP invalidated the estimated incremental cost-utility ratios (ICUR) of tisagenlecleucel due to the insufficient clinical evidence and methodological quality to extrapolate the long-term progression of the disease after treatment and compare tisagenlecleucel with alternatives. The CEESP concluded that tisagenlecleucel was not proven cost-effective. The estimated ICUR of axicabtagene ciloleucel at €114,509/QALY vs. chemotherapies was associated with an acceptable level of methodological quality despite being based on a weak indirect comparison and limited data on quality of life. The CEESP considered axicabtagene ciloleucel ICUR to be “very high” and questioned the societal/community willingness-to-pay of the claimed price. The primary source of uncertainty surrounding the ICUR estimates of both drugs was the lack of hindsight on effectiveness. The economic evaluation of CAR-T cell therapies highlights the risk of inefficient resource allocation driven by limited clinical data. It calls for payment schemes accounting for this risk and effective collection of post-marketing data. more...

Face au vieillissement de la population dans les pays de l’OCDE, une grande partie des politiques publiques encouragent le recours a l’aide professionnelle a domicile pour les personnes âgees residant a domicile. En France, ces politiques financent la demande d’aide dite formelle sous la forme de subventions mais regulent egalement, du cote de l’offre, une partie des producteurs dans le secteur de l’aide a domicile. Cet article etudie le lien entre la regulation de l’offre et le recours a l’aide a domicile des personnes âgees a domicile. Dans le contexte d’une regulation decentralisee au niveau des conseils departementaux, nous utilisons les variations territoriales du niveau de regulation pour estimer les determinants du recours a l’aide formelle. Nous exploitons une enquete departementale originale pour enrichir l’enquete nationale Handicap Sante Menages. Lorsque les producteurs non regules — dont la qualite est peu controlee et le prix n’est pas regule — dominent le marche, le recours a l’aide formelle est plus faible. Cet effet est toutefois concentre sur les personnes âgees de 60 a 70 ans et n’est pas observe pour les populations plus âgees. Ces resultats contribuent a discuter les questions soulevees par la decentralisation d’une politique nationale ainsi que les effets de la recente reforme du secteur de l’aide a domicile augmentant le niveau de regulation du marche. more...

Nos connaissances sur l’acces et le recours aux soins des etudiants en France sont tres parcellaires, alors que la population etudiante est confrontee pour une partie d’entre elle a des situations de precarite economique. A partir de l’exploitation des donnees de l’etude i-Share (Internet-based students health research enterprise) cet article propose d’analyser les determinants du renoncement aux soins pour raisons financieres des etudiants francais. Trois types de soins sont consideres : la consultation d’un medecin (generaliste ou specialiste), celle d’un dentiste et l’achat de lunettes. Les resultats sont coherents avec ceux de la litterature et suggerent l’existence d’inegalites marquees d’acces aux soins au sein de la population etudiante. Les analyses realisees montrent que l’avancee en âge des etudiants est liee a une plus forte probabilite de renoncer a des soins pour raisons financieres. Elles mettent egalement en evidence que le renoncement financier est lie a un ensemble de variables caracterisant la situation materielle, sociale et financiere des etudiants (type de logement, activite remuneree, aides financiere de la famille, statut de boursier, etc.) Ces resultats invitent a evaluer l’impact a moyen et long terme de ces difficultes d’acces aux soins ainsi qu’a suggerer des politiques publiques adaptees, notamment en ameliorant le recours des etudiants a leurs droits et a l’obtention d’une complementaire sante. Classification JEL : I14, I13 more...

The financial risk associated with long-term care (LTC) is partially insured in France and in all European countries. However, the level of coverage across all countries is significantly lower compared to health risk. Public coverage varies widely from country to country, although in most cases households are left to bear a significant proportion of the cost burden. Since LTC risk occurs at the end of life, the use by households of their financial and housing assets to finance their LTC expenses – in other words, self-insurance – may appear as one solution. Using data from the SHARE survey, the study by Carole Bonnet, Sandrine Juin and Anne Laferrère aims to address this question head-on and to assess the extent to which self-insurance could meet the financing needs of long-term care in Europe. This comment considers the approach taken by the authors before discussing the implications of their analysis., Wittwer Jérôme. Comment – Is Self‑Insurance for Long‑Term Care Risk a Solution?. In: Economie et Statistique / Economics and Statistics, n°507-508, 2019. pp. 25-30. more...

IntroductionSince 2013, the coverage of innovative and expensive drugs by the French National Health Insurance considers cost-effectiveness and budget impact, as assessed by the National Authority for Health (HAS) on the basis of an evaluation submitted by the firm. First CAR-T cell therapies were subject to economic evaluation in 2019 in France. We aim at describing the process and results of the economic evaluation of tisagenlecleucel and axicabtagene ciloleucel and the challenges these evaluations raised.MethodsPrimary evaluations were submitted by the firms to be reviewed by HAS. The final analyses were submitted to the Committee of Economic Evaluation and Public Health (CEESP), composed of independent economists, clinicians and patients’ representatives. The CEESP issued Opinions related to i) the methodological quality of economic evidence and ii) the cost-effectiveness and budget impact of the drugs under review.ResultsThe estimated incremental cost-utility ratio (ICUR) of tisagenlecleucel were rejected, being based on insufficient clinical evidence to estimate and extrapolate the long-term progression and to compare tisagenlecleucel with alternatives. Thus, the CEESP concluded that tisagenlecleucel was not proved cost-effective. The estimated ICUR of axicabtagene ciloleucel at 114,509EUR/QALY vs. chemotherapies was associated with an acceptable level of evidence despite being based on a frail indirect comparison and limited data on quality of life. In a context where France has no official cost-effectiveness threshold, the CEESP considered axicabtagene ciloleucel ICUR to be “very high” and questioned the collective acceptability of the claimed price.The CEESP stressed that the main source of uncertainty surrounding the ICUR estimates of both drugs was related to the lack of hindsight on effectiveness, especially in terms of overall survival and safety.ConclusionsThe economic evaluation of CAR-T cell therapies highlights the sources of uncertainty underlying the decision and the risk of inefficient resource allocation driven by limited clinical data. It calls for payment schemes accounting for the uncertainty, and effective collection of relevant post-marketing data. more...

Background: The increasing incidence of recorded stroke cases is straining the economies of many developing countries. Very few studies have assessed the financial burden of stroke management in Gabon. The aim of this study was to assess the direct costs of stroke management in the neurology and cardiology departments at the University Hospital of Libreville.Methods: This retrospective study was based on a detailed review of financial records directly associated with the management of stroke cases admitted and treated in the CHUL between January 2018 and December 2019. The records reviewed were those of all stroke patients admitted and treated in the aforementioned timeframe, regardless of treatment outcome. The analysis of data focused on direct hospital cost.Results: Three hundred and thirteen stroke patients were admitted over the aforementioned period, 72.52% in neurology and 27.48% in cardiology. The average age of the patients was 58.44 (± 13.73) years. 56.23% of patients had health insurance. Ischemic stroke was more common than hemorrhagic stroke, 79.55% and 20.45% respectively. The expenditure per patient was estimated at 570,023 CFA francs.Of this global direct cost, government assistance in the form of health insurance was estimated at 422,883 CFA francs while the balance of approximately 147,140 CFA francs was paid by the patient.Conclusion: The hospital cost of stroke is very high for both patients and administrations. This observation pleads for the implementation of prevention programs for this pathology. The results of this study may be useful for work on the efficiency of these programs. more...

L’objet de cette contribution est de revenir sur le role theorique de l’evaluation economique des medicaments innovants dans le cadre d’une regulation du marche des medicaments fondee sur une protection par brevet des innovations. Apres un rappel sur les mecanismes incitatifs d’une regulation d’un marche par brevet, le role de l’evaluation economique dans ce cadre de regulation est precise. Le contexte specifique de la fixation du prix du medicament en France et la place qu’y trouve l’evaluation economique sont etudies dans un dernier temps. more...

Introduction Les etrangers en situation irregulieres en France sont inegalement touches par les maladies infectieuses en lien avec les pays d’origine mais aussi les mauvaises conditions d’accueil. Cependant, bien que les maladies infectieuses ressortent comme un des premiers motifs de consultations dans les structures d’accueil socio-sanitaire, aucune etude n’a a ce jour evalue la frequence de ces maladies infectieuses dans un echantillon non selectionne d’etrangers en situation irreguliere. Materiels et methodes L’enquete Premiers Pas est une enquete epidemiologique transversale realisee aupres d’un echantillon aleatoire (plan de sondage a 2 degres) d’etrangers en situation irregulieres recrutes a Paris et dans l’agglomeration de Bordeaux dans des lieux et structures susceptibles d’etre frequentes par des personnes sans titre de sejour. Les pourcentages ont ete ponderes. L’analyse a ete realisee a l’aide du logiciel Stata 15.0. Resultats Au total, 1223 etrangers sans titre de sejour ont ete recrutes dans 63 lieux et structures (selectionnes parmi 736 lieux et structures). L’entretien s’est deroule en francais dans 75 % des cas. L’echantillon etait compose d’hommes a 65 %, âges de 30 a 40 ans (36 %), originaires d’Afrique subsaharienne (63 %), d’Afrique du Nord (24 %) ou d’Amerique (6 %) ; 38 % etaient arrives en France depuis moins d’un an et 22 % depuis plus de 5 ans. Parmi les participants, 24,8 % declaraient un mauvais ou tres mauvais etat de sante percu, 33,5 % un probleme de sante chronique et 68,2 % un probleme de sante au moment de l’enquete. Mis a part les infections dentaires (caries, infection ou douleur) qui concernaient 43,2 % des participants, 12,9 % des repondants ont declare souffrir d’une maladie infectieuse : infection par le VIH (3,5 %), infection chronique par le VHB (3,1 %), infection de la sphere ORL (1,7 %), mycose cutanee (1,2 %), infection de la peau et des tissus mous (0,8 %), infection par le VHC (0,8 %), infection urinaire (0,7 %), infection bronchopulmonaire (0,7 %), gale (0,3 %), tuberculose maladie (0,2 %), mycose vaginale 0,6 % et herpes 0,1 %. Concernant les infections par le VIH, le VHB et le VHC, 56 %, 71 % et 89 % respectivement declaraient avoir ete diagnostiques apres leur arrivee en France. C’etait egalement le cas des quelques cas de tuberculose maladie. En analyse multivariee, le risque d’etre atteint d’une virose chronique etait plus frequent parmi les participants les plus jeunes, arrives en France depuis moins de 3 ans, originaires d’Afrique ou d’Amerique du Sud, en situation d’insecurite alimentaire et recrutes dans les associations ou les structures de soins primaires. Conclusion Cette etude originale aupres d’un echantillon tendant vers la representativite confirme la frequence des maladies infectieuses chez les personnes etrangeres sans papiers en France et l’importance d’integrer leur depistage et leur prise en charge dans une logique plus globale d’acces aux soins precoce et de prise en charge inclusive medico-psychosociale. more...

Background For financial reasons, dental prosthetics is one of the major unmet dental healthcare needs [Financial-SUN (F-SUN)]. Private fees for dental prosthetics result in significant out-of-pocket payments for users. This study analyzes the impact of geo-variations in protheses fees on dental F-SUN. Methods Using a nationwide French declarative survey and French National Health Insurance administrative data, we empirically tested the impact of prosthetic fees on dental F-SUN, taking into account several other enabling factors. Our empirical strategy was built on the homogeneous quality of the dental prosthesis selected and used to compute our price index. Results Unmet dental care needs due to financial issues concern not only the poorest but also people with middle incomes. The major finding is the positive association between dental fees and difficulty in gaining access to dental care when other enabling factors are taken into account (median fee in the highest quintile: OR = 1.35; P value = 0.024; 95% CI 1.04–1.76). People with dental F-SUN are those who have to make a greater financial effort due to a low/middle income or a lack of complementary health insurance. For identical financial reasons, the tendency to give up on healthcare increases as health deteriorates. Conclusions The results underscore the need for fee regulation regarding dental prosthetics. This is in line with the current French government dental care reform. more...

Background The French health insurance system is universal but 95% of the population is also covered by a complementary private health insurance (CHI). The CHI take up is not uniform across the income distribution and health care access is partly conditioned by its coverage. The Complementary Universal Health Coverage (CMU-C) and the Health Insurance Vouchers Scheme (ACS) are mean tested programs providing CHI to the poor. The former is free while the latter takes the form of a voucher to buy private CHI. Our objective is to study and compare the evolution of health care use and consumption associated with the take up of the CMU-C or the ACS. Methods In a nationwide cohort of ACS and CMU-C beneficiaries we compute bi-annual expenditures, out of pockets expenditures and rates of use for different types of care: outpatient, inpatient, dental, optical and audiology. We use panel data regression methods to model the evolution of health care use and expenditures before, during and after the coverage periods of both programs. Results Our population is composed with about 10 million individuals benefiting at least once from either the ACS or the CMU-C on the 2012-2017 period. Preliminary results suggest that inpatient expenditures are increasing concomitantly with the take up of any program whereas outpatient expenditures tend to increase after. Results will be provided for the conference on the variations of the consumption according to the program (CMU-C or ACS), type of care, individual characteristics and health status. Conclusions Free or subsidized complementary health insurance may play an important role in the access to care for poor population, even in the presence of mandatory coverage. The take up of complementary health insurance for the poor population could be partly driven by the use of inpatient services but coverage may impact positively outpatient expenditures. Key messages Unlocking poor individuals financial constraint tends to increase their use of medical services. Generous insurance coverage targeting financially constrained individuals could be a tool to reduce health care use inequalities. more...

Aux Etats-Unis, les principales mesures de l’Affordable Care Act (ACA), mieux connu en France sous le nom d’« Obamacare », sont entrees en vigueur au debut de l’annee 2014. Il est des maintenant possible de tirer un bilan des premiers mois d’application de cette reforme ambitieuse. Apres avoir dresse un rapide constat du systeme de sante americain avant la reforme et rappele les objectifs centraux de l’ACA, les principaux dispositifs de la reforme et leurs difficultes de mise en œuvre sont discutes. Dans un dernier temps sont detailles les effets de l’ACA tels qu’ils commencent a etre mesures dans la litterature, en particulier les effets sur le taux de couverture par une assurance sante de la population americaine. more...

This paper assesses the impact of eligibility for a free means‐tested complementary health insurance plan, called Couverture Maladie Universelle Complémentaire (CMUC), on doctor visits. We use information on the selection rule to qualify for the plan to identify the effect of eligibility and adopt a regression discontinuity approach. Our sample consists of low‐income individuals enrolled in the Health Insurance Fund and recipients of social benefits from the Family Allowance Fund of an urban area in Northern France. Our findings do not show significant impacts of the CMUC threshold on the number of doctor visits within the full sample. Among the subsample of adults under 30 years old, however, eligible individuals are more likely to see a specialist and have, on average, significantly more specialist visits than non‐eligible individuals. This specific impact of the CMUC cut‐off point among young adults may be explained by the fact that young adults are less likely to be covered by a complementary health insurance plan when they are not recipients of the CMUC plan. © 2017 The Authors. Health Economics Published by John Wiley & Sons, Ltd. more...

There is a growing interest in developing tailored non-pharmacological strategies to face patients’ needs in dementia. Occupational therapy (OT) may contribute to promote self-empowerment of both patients and caregivers. France has implemented nationwide OT over a short-term period of 3/4 months. The main objective of the MatheoAlz study is to measure the impact of maintaining OT over 4 supplementary months on patients’ neuropsychiatric symptoms. The MatheoAlz trial (Maintenance of Occupational Therapy in Alzheimer’s disease) is a multi-center, pragmatic randomized controlled trial testing maintenance of OT over 4 supplementary months compared to routine OT delivered as recommended. This paper describes the study protocol. MatheoAlz plans to enroll 240 dyads, i.e. dementia patients and caregivers, whose main inclusion criteria are: prescription for routine OT, patients with mild or moderate dementia, living at home, receiving support from an informal caregiver. The study will compare a control group of patients benefiting from 12 to 15 initial sessions of OT over 3/4 months and an intervention group of patients benefiting from these initial sessions plus 8 extra home sessions over 4 supplementary months. The main outcome is the patient’s neuropsychiatric symptoms assessed by the Neuropsychiatric Inventory at 8 months. Several clinical outcomes and economic consequences are measured at 4, 8 and 12 months. This is the first trial designed to assess the specific impact of the maintaining OT on the patients’ neuropsychiatric symptoms burden. The results will inform policymakers on strategies to implement in the near future. This trial was registered at ClinicalTrials.gov on February 16, 2018, identifier: NCT03435705 . more...

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

Health information technology is developing rapidly, due to a profusion of actors and support from public policies. It generates new uses and functions, for both patients and professional users, thereby suggesting a "digital revolution" is coming. Nevertheless, e-Health's development meets with a particularly complex healthcare system, especially when it comes to primary care services. This situation creates four types of challenges. Firstly, an organizational challenge, meaning e-Health implementation needs to take into account the organization in which it intends to integrate. Secondly, a social and territorial concern, as the burden of inequalities is one of healthcare system's major issues. The third challenge is about economics, as we need to search for new methods for globally apprehending e-Health's business model and long-term sustainability. Lastly, the fourth challenge relates to new technical and legal issues. more...

Health information technology is developing rapidly, due to a profusion of actors and support from public policies. It generates new uses and functions, for both patients and professional users, thereby suggesting a "digital revolution" is coming. Nevertheless, e-Health's development meets with a particularly complex healthcare system, especially when it comes to primary care services. This situation creates four types of challenges. Firstly, an organizational challenge, meaning e-Health implementation needs to take into account the organization in which it intends to integrate. Secondly, a social and territorial concern, as the burden of inequalities is one of healthcare system's major issues. The third challenge is about economics, as we need to search for new methods for globally apprehending e-Health's business model and long-term sustainability. Lastly, the fourth challenge relates to new technical and legal issues. more...

International audience; L'évaluation économique en santé au prisme de l'économie normative : principes allocatifs et règles de priorisation Résumé Depuis 2012, en France, les industries pharmaceutiques qui sollicitent l'admission au remboursement pour un traitement innovant, sont contraintes de soumettre une évaluation économique auprès de la Commission d'évaluation économique et de santé publique (CEESP) de la Haute Autorité de Santé (HAS) afin qu'un avis sur son efficience puisse être rendu. Comme dans la plupart des pays européens, le résultat de ces évaluations est mis en perspective, dans le cadre des délibérations, avec d'autres critères de décisions plus ou moins explicites, telles que la sévérité de la maladie, l'âge des patients, les situations de fin de vie, etc. L'objectif de cet article de rapporter ces critères mobilisés par les agences pour moduler l'utilisation des ratios coût/résultat à quelques grands principes normatifs de l'économie du bien-être. Cette analyse permet d'expliciter les motivations distributives du régulateur et d'évoquer les voies possibles d'amendement du calcul économique en santé pour prendre en considération les critères de priorisation mobilisés par les agences dans leurs processus de décision, tels que la priorité accordée aux patients les plus sévèrement atteints ou encore ceux dont l'espérance de vie est la plus diminuée. L'article rend ainsi compte des possibilités pratiques proposées dans la littérature. Dans quelle mesure ces approches pourraient-elles favoriser l'acceptabilité sociale des méthodes d'évaluation économique auprès des différentes parties prenantes (décideurs, communautés médicales, patients, grand public) et accroître l'utilisation des conclusions de ces évaluations dans les décisions en matière de fixation des prix et de remboursement des produits de santé ? more...

Background This article will explore the ability of partners to prevent nursing home entry for their disabled relatives: does the role played by partners vary with age and the type of disability affecting the relatives they care for? Methods We used data from a French cohort study, which included 3777 seniors who were initially living in the community in two French districts (Gironde and Dordogne) and who were followed for 22 years, between 1989 and 2011. Three Cox competing risks models are estimated. Results The presence of a partner reduces the risk of nursing home admission by 40% for an elderly individual who is 80 years old. However, that protective effect of partners is no longer significant at the 5% level when the elderly suffers from limitations in fundamental activities of daily-living or after the age of 84 when the individual is cognitively impaired. Conclusions The low protective effect of partners against the risk of nursing home entry for the oldest-old or severely disabled should lead to a reassessment of the relevance of informal support for this specific group of individuals. more...

Risky health behaviours substantially increase medical and social costs. We document the extent to which a sample of European students (from Denmark, France, Italy and Sweden) consider that individuals should assume the financial burden of paying the costs of risky behaviour. We test the acceptability of different ways of financing costs because of ill health that is more or less associated with risky behaviour in accordance with a normative framework relating to responsibility-sensitive fairness. We find that the majority of students agree with assuming financial responsibility for risky behaviours and that there should be compensation for unfavourable circumstances. Students agree that two individuals with the same responsibility variables should make an equal financial contribution and that more effort in maintaining health for given circumstances should be rewarded with a lower financial contribution. The specific health context and the type of risky behaviours involved matter in determining perceptions of justice in health financing. more...

In 2005, France implemented a gatekeeping reform designed to improve care coordination and to reduce utilization of specialists’ services. Under this policy, patients designate a médecin traitant, typically a general practitioner, who will be their first point of contact during an episode of care and who will provide referrals to specialists. A key element of the policy is that patients who self-refer to a specialist face higher cost sharing than if they received a referral from their médecin traitant. We consider the effect of this policy on the utilization of physician services. Our analysis of administrative claims data spanning the years 2000–2008 indicates that visits to specialists, which were increasing in the years prior to the implementation of the reform, fell after the policy was in place. Additional evidence from the administrative claims as well as survey data suggest that this decline arose from a reduction in self-referrals, which is consistent with the objectives of the policy. Visits fell significantly both for specialties targeted by the policy and specialties for which self-referrals are still allowed for certain treatments. This apparent spillover effect may suggest that, at least initially, patients did not understand the subtleties of the policy. more...

BACKGROUND There is a growing interest in developing non-pharmacological approaches in dementia. Clinical efficacy of occupational therapy (OT) under routine care conditions has not been investigated yet. OBJECTIVE To analyze the short-term effects of OT in patients with dementia; and to identify factors related to greater benefit. METHODS Patients referred to OT were evaluated before starting a 3-month intervention and at 3 and 6 months later. Measures included: Mini-Mental State Examination (MMSE), Disability Assessment in Dementia (DAD), Neuropsychiatric Inventory (NPI) Questionnaire, patients' quality of life (EQ 5D-VAS), caregivers' burden (Zarit scale), and amount of informal care. Linear mixed models were used to analyze trajectories of outcomes. Logistic regressions with stepwise descending selection were used to study factors associated with benefits. RESULTS 421 dementia patients benefited from OT (mean MMSE = 17.3). Patients remained cognitively stable over time. Functional performances also remained stable at 3 months and significantly decreased at 6 months (crude reduction of 2.8 points, p more...

Background University students aged 18-30 years are a population group reporting low access to health care services, with high rates of avoidance and delay of medical care. This group also reports not having appropriate information about available health care services. However, university students are at risk for several health problems, and regular medical consultations are recommended in this period of life. New digital devices are popular among the young, and Web-apps can be used to facilitate easy access to information regarding health care services. A small number of electronic health (eHealth) tools have been developed with the purpose of displaying real-world health care services, and little is known about how such eHealth tools can improve access to care. Objective This paper describes the processes of co-creating and evaluating the beta version of a Web-app aimed at mapping and describing free or low-cost real-world health care services available in the Bordeaux area of France, which is specifically targeted to university students. Methods The co-creation process involves: (1) exploring the needs of students to know and access real-world health care services; (2) identifying the real-world health care services of interest for students; and (3) deciding on a user interface, and developing the beta version of the Web-app. Finally, the evaluation process involves: (1) testing the beta version of the Web-app with the target audience (university students aged 18-30 years); (2) collecting their feedback via a satisfaction survey; and (3) planning a long-term evaluation. Results The co-creation process of the beta version of the Web-app was completed in August 2016 and is described in this paper. The evaluation process started on September 7, 2016. The project was completed in December 2016 and implementation of the Web-app is ongoing. Conclusions Web-apps are an innovative way to increase the health literacy of young people in terms of delivery of and access to health care. The creation of Web-apps benefits from the involvement of stakeholders (eg, students and health care providers) to correctly identify the real-world health care services to be displayed. more...

L’objectif de cet article est d’analyser les Jugements lies a la mise en œuvre contentieuse de l’obligation alimentaire ascendante pour les depenses d’hebergement en institution. L’analyse d’un echantillon de decisions judiciaires concernant 305 personnes soumises a cette obligation montre que la fixation des contributions repond largement a une logique economique simple, fonction des besoins du creancier et des ressources de ces obliges. Sur la sous-population confrontee de fait au besoin de financement d’un aieul, la regle de mise a contribution estimee s’avere redistributive a l’echelle intrafamiliale mais anti-redistributive a l’echelle inter-familiale. L’utilisation d’un echantillon micro-simule de 6366 obliges alimentaires de personnes âgees de 75 ans et plus, fourni par l’INSEE, permet d'etudier la norme qui modele les pratiques judiciaires en mesurant ses effets redistributifs sur une population representative, tout en tenant compte du fait que le risque d'avoir a contribuer, spontanement ou contentieusement, est loin d'etre homogene dans la population.Le caractere anti-redistributif de la regle elle-meme s’ajoutant au fait que les creances pesent plus frequemment sur les menages modestes et pour des montants plus eleves, le taux de contribution moyen dans le premier quintile est cinq fois plus eleve que dans le dernier. L'effort collectif exige implicitement par cette norme represente a peine 0,6% du niveau de vie, a l'echelle de l’ensemble des enfants de personnes âgees d’au moins 75 ans. more...

Apres un rappel du contexte theorique de leurs recherches, les auteurs presentent les cas de deux familles d’anciennes ouvrieres agricoles du Bordelais, confrontees au principe francais de l’obligation alimentaire envers les ascendants. Deux vieilles dames sont placees en institution alors qu’elles vivaient au domicile d’une fille ou d’une petite-fille ; les autres enfants sont ensuite condamnes par un juge a participer aux frais. L’enquete permet d’expliciter les principes qui justifient les conduites. Au-dela du principe republicain de l’egalite entre enfants, le rang dans la fratrie, le sexe de l’enfant concerne, l’histoire de ses relations passees avec la personne devenue dependante, jouent un role dans la construction d’une vocation d’aidant(e) ainsi que dans les conflits nes d’une remise en cause de la routine. La formalisation microeconomique proposee, qui sera appliquee sur des donnees issues d’une enquete ad hoc, permet de rendre compte du poids relatif de chacun dans la prise de decision. more...

In a partial equilibrium framework, Sharkey and Sibley [1993] show paradoxally that all redistributive optimal two-part pricings are sustainable. They also suggest the extension of their main result to nonlinear pricing. In this paper, it is shown that in fact their result doesn't extend generally to non-linear pricing. First, a numerical example yielding negative results is put forward, secondly, the robustness of this negative result to variations of equilibrium solutions is analyzed. more...

This note analyzes some properties of optional two-part pricing in a two-type economy. First, the optimal contracts along the Paretian frontier are described. Then, the duality relation between the Rawlsian program and the discriminating monopoly is demonstrated. Last, this property is used to build a mutualist mechanism implementing the constrained Pareto optima. more...

Freedom of choice : an alternative measure of well-being This article proposes a conceptual and theorical reflection on freedom of choice. From axiomatic developments of the recent literature, it leads up to propose a general definition of this notion on the basis of a result of Kreps [1979]. An axiomatic construction of a measure of freedom of choice fitting with this definition is then undertaken in a social choice setting., La liberté de choix. Une mesure alternative du bien-être Cet article propose une réflexion conceptuelle et théorique sur la notion de liberté de choix en économie normative. Fondée sur les développements axiomatiques de la littérature récente, elle conduit à proposer sur la base d'un résultat de Kreps [1979] une définition générale de cette notion. Une construction axiomatique d'une mesure de la liberté de choix répondant à cette définition est alors entreprise dans un cadre de choix social., Wittwer Jérôme. La liberté de choix. Une mesure alternative du bien-être. In: Revue économique, volume 49, n°5, 1998. pp. 1227-1240. more...

International audience; This paper is based on a randomised social experiment conducted in order to understand the low take-up rate of a Complementary health-insurance voucher program for the poorest in France (the Aide Complémentaire Santé: ACS). We explore two of the main hypotheses put forward to explain low enrolment: a lack of information about the program and a voucher amount considered to be too low. A sample of eligible individuals living in an urban area in Northern France were randomly split into three groups: a control group who benefited from the standard level of financial aid; a group benefiting from an increase in the value of the voucher; and a third group benefiting from the same increase along with an invitation to an information meeting regarding ACS. We show that the voucher increase has a small but statistically significant effect on ACS take-up. The invitation to the meeting appears to cancel out the positive effect of the voucher increase. Using an instrumental variable model to control for potential selection bias, we find ambiguous evidence of the meeting attendance on ACS take-up. This study confirms the difficulties that are faced in increasing the health insurancecoverage of poor populations via subsidy programs. more...