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Biomedical subjects

Jean-Paul Moatti

Publications and source records attributed to Jean-Paul Moatti.

17 recordsLinked to original sources
PubMed2003

Health-related quality of life after 1 year of highly active antiretroviral therapy.

OBJECTIVE: We investigated the impact of the first year of highly active antiretroviral therapy (HAART) on health-related quality of life (HRQL). METHODS: Medical data for patients in the French APROCO cohort were collected at enrollment (M0) and month 12 (M12). A self-administered questionnaire gathered information about HRQL (Medical Outcome Study 36-Item Short Form Health Survey) and toxicity-related symptoms. Using the twenty-fifth percentile of HRQL scales in the French population as a threshold, patients with normal values in at least three mental and three physical scales were considered to have a "normal HRQL." RESULTS. Of the 1053 patients followed through M12, HRQL data at M0 and M12 were available for 654. Among the 233 patients with a normal baseline HRQL, 63 (27.0%) experienced a deterioration of HRQL at M12. Among the 421 patients with a low baseline HRQL, 121 achieved a normal HRQL at M12. Logistic regression showed that factors independently associated with a normal HRQL at M12 were normal baseline HRQL, baseline CD4 count <500 cells/mm, time since HIV diagnosis <8 years, undetectable HIV-RNA at M12, and lower number of self-reported symptoms at M12. CONCLUSION: An assessment of HRQL should be integrated to efficacy outcomes to evaluate and compare long-term strategies properly and to optimize the durability of response to antiretroviral therapy.

Adult↗
PubMed2003

Eliciting several willingness to pay in a single contingent valuation survey: application to health care.

The usual implementation of contingent valuation (CV), in the context of priorities setting for allocation of public funds in health care, is to develop as many surveys as there are programmes, i.e. to perform separate evaluations (SE). In the EuroWill project, three health programmes (for heart disease, breast cancer and a service of helicopter ambulance) were however simultaneously evaluated, i.e. a joint evaluation (JE) was performed. The paper examines the issue of the econometric techniques that should be used to estimate WTP values obtained in the context of JE by comparing the application of independent OLS regressions for each programme versus simultaneous estimations using seemingly unrelated regressions (SUR) on data of the French EuroWill survey. It shows that separate estimations may lead to misspecifications because they cannot take into account that JE exogenously provides a reference structure to the respondent which affects the estimates of WTP for each programme. Therefore, the potential advantage of JE versus SE as an elicitation technique in CV studies applied to health care (to better control the referents used by respondents for evaluating different programmes) only holds if simultaneous rather than independent techniques are used in the estimation of WTPs.

Air Ambulances↗
PubMed2003

Impact of gene patents on the cost-effective delivery of care: the case of BRCA1 genetic testing.

BACKGROUND: In 1994/95, two genes, BRCA1/2, associated with a predisposition to breast or ovarian cancer were identified. Genetic testing of deleterious BRCA1/2 mutations consequently can be proposed to individuals with a family history of breast or ovarian cancer to identify who is at risk. The granting of U.S. patents on BRCA1/2 to a privately owned company has led to the monopoly use of a unique technique (Direct Sequencing of the gene, DS) for BRCA1/2 testing in this country. Alternative strategies using prescreening techniques, however, have been experienced worldwide. METHODS: On the basis of data collected at three laboratories of French public hospitals, we carried out a cost-effectiveness study comparing DS to 19 alternative strategies with the number of deleterious BRCA1 mutations detected as the outcome. RESULTS: Results show that the DS strategy presents the highest average cost per mutation detected (9,882.5 Euro) and that there exist strategies using prescreening techniques that can reach similar effectiveness while reducing total costs. Moreover, other strategies can obtain a four- to sevenfold reduction in the average cost per mutation detected as soon as some rates of false negatives (2% to 13%) are deemed to be acceptable. CONCLUSIONS: Results suggest that gene patents with a very broad scope, covering all potential medical applications, may prevent health care systems from identifying and adopting the most efficient genetic testing strategies due to the monopoly granted for the exploitation of the gene. Policy implications for regulatory authorities, in the current context of the extension of BRCA1/2 patents in other countries, are discussed.

Breast Neoplasms↗
PubMed2003

Socio-economic and health characteristics of HIV-infected patients seeking care in relation to access to the Drug Access Initiative and to antiretroviral treatment in Côte d'Ivoire.

OBJECTIVE: To compare socio-economic and health characteristics of HIV-infected patients in Côte d'Ivoire whether or not they had access to the Drug Access Initiative (DAI) and to antiretroviral drug (ARV) treatment. DESIGN AND METHODS: Cross-sectional survey using medical files, blood sampling for CD4 cell counts and face-to-face interviews among all patients, informed of their HIV status, who attended during a 6-week period in the five DAI referral centres and three additional centres in charge of HIV care in Abidjan and Bouaké (participation rate = 65.4%). Multiple logistic regression using generalized estimating equations (GEE) to identify factors related to non-access to DAI and to ARV treatment. RESULTS: Among the 711 respondents, 23.0% were ARV-treated, 14.2% had been included in the DAI but were still waiting for initiation of ARV, and 62.7% were neither part of the DAI nor ARV-treated. In this latter group, less than one-third (29.6%) declared that they knew about the existence of the DAI. Among the 164 ARV-treated patients, 59.1% had benefited from DAI public subsidies partially covering the costs of drugs. In the non-DAI-non-ARV-treated group, 86% could have qualified for ARV treatment according to the DAI medical criteria (CD4 cell counts < 500 x 10(6) cells/l), and only 32.9% of those medically eligible were prescribed cotrimoxazole prophylaxis. In multivariate analysis, not being in the DAI and not being ARV-treated was related to: being a male, not having health care insurance, having a low level of education, living in poor housing conditions (absence of refrigerator in the household, absence of ventilation in patient's bedroom), and not being under cotrimoxazole prophylaxis. CONCLUSION: The Ivoirian DAI has facilitated access to ARV treatment for a significant number of patients with limited ability to pay. The majority of HIV-infected patients seeking care however face persisting socio-economic and informational barriers to access to these treatments.

Adult↗
PubMed2003

Access to antiretroviral treatment and sexual behaviours of HIV-infected patients aware of their serostatus in Côte d'Ivoire.

OBJECTIVE: To compare sexual behaviours of HIV-infected patients in Côte d'Ivoire whether or not they had access to antiretroviral treatment (ARV). DESIGN AND METHODS: Cross-sectional survey using face-to-face interviews among all patients, informed of their HIV serostatus, attending the eight health centers in charge of HIV care in Abidjan and Bouaké. Univariate comparisons of declared sexual behaviours during the prior 6 months between the 164 ARV-treated and the 547 non-ARV-treated respondents. Multiple logistic regressions to identify factors related to sexual abstinence in the total sample and to unprotected sexual intercourse in the subsample of sexually active respondents during the same period were performed. RESULTS: More than half of the 711 respondents (53.0%) declared an absence of sexual activity during the previous 6 months, with this proportion being significantly higher among women (60.6%), and among both men (85.7%) and women (92.4%) who were not living in a stable relationship. Among the 334 sexually active patients, 49.7% declared a low frequency of sexual intercourse ('once a month or less'), and 43.7% declared at least one episode of unprotected sexual intercourse. In multivariate analysis, recent diagnosis of HIV infection (< 9 months), having only one sexual partner and not knowing her/his serostatus, high alcohol consumption, absence of episodes of acute morbidity, not participating in household's expenditures and not being ARV-treated were significantly related to a higher likelihood of HIV-related risky sexual behaviours. CONCLUSION: Sexual abstinence is the preventive strategy of choice for a majority of HIV-infected patients aware of their serostatus and consulting for care in Côte d'Ivoire. In these patients, access to ARV is not associated with an increase in HIV-related risky sexual behaviours.

Adult↗
PubMed2003

Impact of early versus late adherence to highly active antiretroviral therapy on immuno-virological response: a 3-year follow-up study.

OBJECTIVE: To assess the impact of different patterns of adherence to highly active antiretroviral therapy (HAART), in particular, the relative impact of early and late adherence, on long-term immuno-virological response in HIV-infected individuals started on a protease inhibitor-containing regimen. DESIGN: Clinical, immuno-virological and self-reported adherence data were collected at 4 (M4), 12 (M12), 20 (M20), 28 (M28) and 36 (M36) months after HAART initiation in the French APROCO cohort. METHODS: A standardized self-administered questionnaire classified patients as non-adherent, moderately or highly adherent at each visit. Stable viral suppression at both M28 to M36, and a CD4 cell increase > 200 between M0 and M36 were used as outcome measures. RESULTS: Of the 582 patients followed regularly through M36, 360 patients had complete adherence data. Although 59.2% were highly adherent at M4, only 25.8% maintained consistent high adherence throughout the follow-up. High adherence at M4 was independently associated with both stable viral suppression at M28-M36 [OR (95% CI): 2.8 (1.4-5.5)] and a CD4 cell increase > 200 during the same period [OR (95% CI): 3.9 (1.7-9.7)]. However, 'moderately adherent' patients between M12 and M36 had the same likelihood [OR (95% CI): 1.9 (1.1-3.2)] as patients who were always high adherent [OR (95% CI): 1.9 (1.1-3.2)] of achieving stable viral load suppression, relative to those who reported non-adherence episodes. CONCLUSION: Optimizing adherence in the early months of treatment is crucial to ensure long-term immuno-virological high adherence during follow-up have a less negative impact. Priority should be given to interventions aimed to improve adherence in the early months of HAART.

Acquired Immunodeficiency Syndrome↗
PubMed2003

Can sequential administration minimise the cost of high dose chemotherapy? An economic assessment in inflammatory breast cancer.

OBJECTIVE: To evaluate the potential cost savings of using sequential high dose chemotherapy (HDC), with granulocyte colony-stimulating factor (filgrastim) and stem cell support, rather than single course administration of HDC with bone marrow transplantation (BMT) or peripheral blood stem cell transplantation (PBSCT). PERSPECTIVE: French public hospital perspective. METHODS: Direct medical costs of sequential treatment, estimated on the basis of physical quantities of resources consumed by 95 patients with inflammatory breast cancer (IBC) included in a French pilot multicentric trial (PEGASE 02), were compared with those of historical control groups of patients treated with single course HDC, either with BMT (n = 27) or PBSCT (n = 14). Costs were evaluated in 1998 French francs (1 Euro = 6.55957 French francs). RESULTS: The total cost of sequential HDC was significantly lower than that for single course HDC both with BMT (-29%; 22,755 Euros vs 32,284 Euros; p < 0.001) or PBSCT (-16%; 22,755 Euros vs 27,209 Euros; p = 0.026). This was mainly due to a reduction in the length of hospitalisation in transplantation units. CONCLUSION: According to our results, economic arguments cannot be used against the widespread use of sequential HDC for patients with IBC. However, further economic evaluations based on overall and disease-free survivals alongside a randomised clinical trial are still needed to definitively establish the cost effectiveness of sequential administration of HDC.

Adolescent↗
PubMed2003

[The "Plan Cancer" in France: an economists' point of view].

To answer patients, caregivers and professionals needs, the "Plan Cancer" has been presented by the French President on the 24 March 2003. This plan's measures form the concrete elements of a modern health care policy against cancer. It's likely that a plan cancer succeeding to improve patients' survival and quality of life would not be associated with a decrease in health care expenses. However, the plan cancer should target to improve our health care system productivity, i.e. to ensure that the gain in years of life (and in welfare) for each Euro invested would increase. To reach this objective, the plan cancer should consider four problems that health economics may highlight. The impact of biomedical innovations in terms of returns; the question about the rational threshold for allocating resources; the influence of the heterogeneity of the medical practice; the role of patients' preferences. We expect that emphasising these difficulties would allow for health economics to be better considered in the research against cancer and to be clearly distinguished from opinion surveys. It's the best way for social surveys based on direct interview of representative samples of patients' and their relatives to give a useful tool for democratic reflection.

Cost-Benefit Analysis↗
PubMed2002

Nonadherence among HIV-infected injecting drug users: the impact of social instability.

The authors tested the impact of social instability on adherence to highly active antiretroviral therapy (HAART) among patients infected with HIV through injection drug use (IDU; MANIF2000 cohort). In the study, they analyzed sociodemographic baseline characteristics to develop an indicator of social instability. Information concerning adherence to HAART was collected through questionnaires during a 2-year follow-up period. Factors associated with nonadherence were studied in two different groups: 1) patients who had stopped injection drug use (ex-IDUs) and who were not in drug maintenance programs (DMT) during the entire follow-up period, and 2) those who were still opiate dependent. Among the 210 eligible patients, 114 were classified as ex-IDUs and 96 as opiate dependent. Ex-IDUs reported nonadherence behaviors in 96 of 384 visits (25.0%), while opiate-dependent patients were nonadherent in 111 of 308 visits (36.0%; p = .02). Among ex-IDUs, the only factor associated with nonadherence was social instability, while among opiate-dependent patients, injection behavior was the only determinant of nonadherence behavior. For opiate-dependent patients, DMT may enhance adherence to HAART, but only if it is successful in reducing abuse of injection practices. For ex-IDUs, it is very important that the management of social difficulties be taken into account to increase adherence to HAART.

Adult↗
PubMed2002

[The appropriateness of the indications and diagnostic efficiency of colonoscopy. Results of a survey conducted in all the hospital centers of the Provence-Alpes-Côte d'Azur area].

OBJECTIVE: To evaluate the appropriateness of indications and the diagnostic efficiency of colonoscopy taking into account available guidelines. METHODS: This was a retrospective study conducted by the Union Régionale des Caisses d'Assurance Maladie de Provence-Alpes-Côte d'Azur (URCAM-Paca) aimed at assessing the appropriateness of the indications and diagnostic efficiency of colonoscopy. Anonymous data concerning near totality of the colonoscopies carried out during one week in all the establishments (public and private) of the area, were collected by consulting the medical records. RESULTS: The indications for colonoscopy were first analyzed with regard to the guidelines for good clinical practices (références médicales opposables and consensus conference) according to two scales of reading (literal interpretation and broad interpretation). We noted that the available guidelines do not cover the totality of the colonoscopies performed, that their formulation does not make them all controllable, and that the colonoscopies, which respect them, range from 27.5% (strict reading) to 74.1% (broad reading). When taking into account not only the quality of the preparation, but also the result of the examination after re-classification into benign, pathological or normal examinations, the differences in efficiency appear only when one retains the broad interpretation of the reference guidelines. The efficiency analysis makes it possible to highlight a defect of predictability of the recommendations with regard to the pathologies considered as serious. It also appears that approximately 10% of the colonoscopies are, at the same time, out of the reference and have a normal result, and thus can be considered as absolutely not justified. CONCLUSION: Better compliance of the practitioners to colonoscopy recommendations would initially be generated by improvement in the predictability and the legibility of the current reference guidelines.

Colonoscopy↗
PubMed2002

Predictors of virological rebound in HIV-1-infected patients initiating a protease inhibitor-containing regimen.

OBJECTIVE: To study the predictors of virological rebound in patients having early virological response to protease inhibitor (PI)-containing regimen. DESIGN AND METHODS: APROCO cohort study prospectively enrolled 1283 HIV-infected patients starting a PI-containing regimen in 1997-1999. Adherence to therapy was measured with self-administered questionnaires after 4 months of therapy (M4). Virological rebound was defined as a viral load (VL) > 500 copies/ml in patients having early virological response, defined as a VL < 500 copies/ml at M4. Predictors of time to virological rebound were studied with multivariate proportional hazards model. RESULTS: During a median follow-up of 20 months, virological rebound was observed in 32% of the 830 patients with early virological response. Virological rebound was more frequent when patients had received previous antiretroviral treatment [adjusted hazards ratio (HR) = 2.4; P < 0.0001], were younger (HR = 1.4 per each 10 years younger; P < 0.0001), had baseline CD4 cell count < 500 x 106/l (HR = 2.3; P < 0.001), had higher baseline VL (HR = 1.4 per each log10 copies/ml higher; P < 0.001), reported low adherence to therapy at M4 (HR = 2.1; P < 0.001) or had stopped PI at M4 (HR = 1.7; P = 0.04). CONCLUSION: Initiation of treatment at a stage of preserved immunity is associated with a more durable virological response under protease inhibitor. Every effort should be made to monitor and strengthen adherence to therapy, even in patients having early virological response.

Adult↗
PubMed2002

Adherence to highly active antiretroviral therapies (HAART) in HIV-infected patients: from a predictive to a dynamic approach.

To-date, most socio-behavioural research about HTV-infected patients' adherence to highly active antiretroviral therapies (HAART) has been based on cross-sectional studies. The French APROCO cohort gave us the opportunity to conjointly analyse the relationships between short-term adherence to HAART and HIV-infected patients' characteristics before initiation of treatment on the one hand, factors related to patients' subjective experience with HAART on the other hand. At the fourth-month follow-up visit (M4) after first prescription of HAART (M0), 26.7% of our sample of 445 patients self-reported non-adherence behaviour. Some patients' characteristics at M0 (younger age, poor housing conditions, lack of social support, and problems of adherence with previous antiretroviral regimens) were related to non-adherence at M4 in multivariate analysis. Non-adherence at M4 was, however, also related to the evolutions that affected a number of factors between M0 and M4: levels of depression, symptoms associated with treatment side effects, perception of individual state of health, beliefs towards effectiveness and toxicity of HAART. increases in alcohol and tobacco consumption, as well as contacts with other physicians than hospital HAART prescribers. Our prospective study brings additional evidence that even short-term non-adherence cannot be reliably predicted on the sole basis of a few a priori patient characteristics that clinicians could easily identify before initiation of HAART. It suggests that a dynamic approach to adherence, continuously monitoring the impact of experience with HAART on patients' daily lives, is needed for improving management of HIV/AIDS care.

Adult↗
PubMed2002

Testing for BRCA1 mutations: a cost-effectiveness analysis.

Breast carcinoma is the most common type of cancer affecting women in the Western world. The hereditary forms, which amount from 5 to 10% of all the cases of breast cancer, mainly involve BRCA1 or BRCA2 mutations. Due to the diagnostic strategy used by the patent owner, Direct DNA sequencing (DS) may become the only BRCA1/2 test procedure available, although there exist several alternative strategies. A cost-effectiveness study was carried out using BRCA1 testing as a model. The main techniques available for performing mutation searches were assessed: DS, denaturing high performance liquid chromatography (DHPLC), single-strand conformation polymorphism (SSCP), denaturing gradient gel electrophoresis (DGGE), heteroduplex analysis (HA), fluorescent assisted mismatch analysis (FAMA) and the protein truncation test (PTT). Twenty strategies involving the use of one or more techniques were then devised for performing the complete genetic analysis. DS was adopted as the 'gold standard' for effectiveness. All the strategies except for DS involved a two-step procedure. The first step consisted of pre-screening the 22 coding exons of BRCA1. The second step consisted of performing DS only on the variations detected in the coding sequence. The cost of the strategies tested, including a pre-screening stage, turned out to be 30 to 90% lower than that of DS, whatever annual use was made of the equipment. The most cost-effective strategy, ie, that corresponding to the lowest cost per mutation detected, was found to be a combination between PTT on exon 11 (60% of the coding sequence) and HA on the remaining 21 exons (PTT(11)+ HA(21)). However, since a high false negative rate is associated with this strategy, at least four other strategies are worth mentioning: PTT(11)+ DHPLC(21), DHPLC alone, FAMA(11)+ DHPLC(21) and FAMA alone. Our results on genetic testing for breast cancer show that DS is not the most cost-effective method available. The monopolist approach of the firm which owns the patents on the BRCA1/2 genes, may, therefore limit the use of the most cost-effective strategies.

Cost-Benefit Analysis↗
PubMed2002

[Factors related to screening of hepatitis C virus in general medicine].

UNLABELLED: Despite the high prevalence of hepatitis C in France ( approximately 1.2%), a large proportion of people infected with hepatitis C virus (HCV) are not known aware of their status. The objective of this study was to investigate the factors related to screening in general medicine. MATERIAL AND METHODS: Three hundred and one general practitioners were interviewed by phone in South-Eastern France about their HCV screening practices, knowledge of the epidemic, of the natural course of the disease, and opinions about health care for people infected with HCV. RESULTS: While general practitioners often offered HCV screening to intravenous drug users, screening for people who had received blood transfusion, and identification of risk factors among patients were not satisfactory. Multivariate analysis showed that certain characteristics in general practitioners were negatively and independently related to the frequency of HCV screening, especially: general practitioners older than 40 (odds-ratio: 3.12), general practitioners who did not care for intravenous drug users (odds-ratio: 2.24) and did not prescribe human immunodeficiency virus tests (odds-ratio: 5.55). Other characteristics such as awareness of the course of hepatitis C and health care were also associated with HCV screening. Conversely knowledge of the size of the epidemic was not related to better HCV screening practices. CONCLUSION: Our study shows that knowledge about the size of the epidemic and the natural history of hepatitis C, HCV screening practices and investigation of risk factors among patients are not satisfactory among South-eastern French general practitioners. Although HCV screening and health care must be improved among intravenous drug users, hepatitis C should not be considered as a disease of injecting drug users only by general practitioners and the population. Efforts should be made so that hepatitis C is recognized as a global public health issue, and training of general practitioners should be improved to investigate risk factors and offer HCV screening instead of merely dramatizing the situation.

Adult↗
PubMedDate not supplied

[Economic and socio-behavioural issues related to highly active antiretroviral therapies for HIV infection: the contribution of social science research].

This article presents a synthesis of the main topics covered by social science research (SSR) on HIV/AIDS, since the advent of highly active antiretroviral therapies (HAART) in 1996. SSR has shown that non-adherence cannot be reliably < > on the sole basis of a few a priori patient characteristics that clinicians could easily identify before initiation of HAART, and that a dynamic approach to adherence, continuously monitoring the impact of patients' subjective experience with HAART is needed. In relationship with the evolution of HIV infection toward a < >, SSR has dealt with the impact of HAART on all aspects of patients' daily lives (from employment and professional status to sexuality). It has also emphasised the potential contradictions between the hopes generated by these cost-effective therapeutic advances, on the one hand, and the high social vulnerability of a growing proportion of people living with HIV-AIDS, on the other hand. Finally, SSR suggests recommendations for < > AIDS public policies without losing the potential for innovations that the fight against this epidemic has introduced in health care and < > systems, as well as physician-patient's relationships.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Efficacy of an educational and counseling intervention on adherence to highly active antiretroviral therapy: French prospective controlled study.

PURPOSE: The objective was to evaluate the impact of an intervention for improving adherence to antiretroviral therapies (HAART) in HIV-infected patients. METHOD: We designed a prospective, controlled, randomized trial to assess the impact of an educational and counseling intervention in addition to standard of care. At M0, the study enrolled 244 HAART-treated patients who attended a medical consultation between September and December 1999 who were not included in another protocol. Patients in the intervention group (IG) were offered three individual sessions by trained nurses. The proportions of adherent patients at 6 months followup (M6) and the change in HIV RNA between M0 and M6 were measured. RESULTS: Between M0 and M6, HIV RNA significantly decreased in the 123 patients of the IG (mean difference = -0.22 log [+/-0.86], p =.013), while it increased (+0.12 log [+/-0.90], p =.14) in the 121 patients of the control group. However, the proportion of patients with HIV RNA <40 copies/mL remained similar in both groups. In an intent-to-treat analysis, the only significant predictor of 100% adherence at M6 was the intervention group (p =.05) after adjustment for baseline adherence (p =.001). Among the 202 patients with available data on adherence, the proportion of adherent patients was similar in both groups at M0 (58% vs. 63%, p =.59) but became higher in the IG at M6 (75% vs. 61%, p =.04). CONCLUSION: The educational and counseling intervention was efficient for increasing adherence to HAART and could be implemented in most clinical settings.

Adult↗