[Evidence data and importance of public health of the new antipsychotics].
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Ambulatory Care↗
Biomedical subjects
R Launois
Publications and source records attributed to R Launois.
Estimating the cost-effectiveness of stroke units in France compared with conventional care.
BACKGROUND AND PURPOSE: The incidence of stroke in France is estimated at between 120 000 and 150 000 cases per year. This modeling study assessed the clinical and economic benefits of establishing specialized stroke units compared with conventional care. METHODS: Data from the Dijon stroke registry were used to determine healthcare trajectories according to the degree of autonomy and organization of patient care. The relative risks of death or institutionalization or death or dependence after passage through a stroke unit were compared with conventional care. These risks were then inserted with the costing data into a Markov model to estimate the cost-effectiveness of stroke units. RESULTS: Patients cared for in a stroke unit survive more trimesters without sequelae in the 5 years after hospitalization than those cared for conventionally (11.6 versus 8.28 trimesters). The mean cost per patient at 5 years was estimated at 30 983 for conventional care and 34 638 in a stroke unit. An incremental cost-effectiveness ratio for stroke units of 1359 per year of life gained without disability was estimated. CONCLUSIONS: The cost-effectiveness ratio for stroke units is much lower than the threshold (53 400 ) of acceptability recognized by the international scientific community. This finding justifies organizational changes in the management of stroke patients and the establishment of stroke units in France.
Cohort Studies↗
Translation and validation of a quality of life questionnaire for chronic lower limb venous insufficiency into greek.
AIM: In order to provide a practical instrument for quality of life measures, for researchers and primary care physicians in Greece, we decided to translate and validate the published postal questionnaire CIVIQ (Chronic Venous Insufficiency Questionnaire) into the Greek language. METHODS: The study took place in 2 vascular surgical clinics. Fifty patients with known chronic venous insufficiency (CVI) were asked to complete the questionnaire. A debriefing method was used for the cultural adaptation. To measure test-retest reliability, 50 patients with known CVI disease, were asked to complete the questionnaire. RESULTS: The adaptation of CIVIQ questionnaire in the Greek language demonstrated its good validity (Cronbach's alpha=0.92) and reproducibility (coefficient = 0.98). CONCLUSIONS: CIVIQ seems to be a reliable tool in helping to assess the health status of the Greek general population and could be used to contribute to the identification of the magnitude of the problem of CVI in the Greek setting.
Adult↗
[Lymphedema and quality of life].
Quality of life measurement shows interesting parameters in chronic lymphedema, related to the illness consequences and therapeutic strains. The ULL27 specific scale is an evaluation instrument which adds to the information about the patient and enables adaptation of the therapeutic strategy and also measurement of the treatment's impact of lymphedema.
Breast Neoplasms↗
Quality of life (Spain and France): validation of the chronic venous insufficiency questionnaire (CIVIQ).
A health-related quality of life (HRQOL) assessment is particularly necessary for patients with chronic venous insufficiency (CVI), as is an assessment of the objective signs (edema, dilated veins, ulceration and other lesions). A comprehensive 3-year research program was undertaken in France to construct and validate the Chronic Venous Insufficiency Questionnaire (CIVIQ), a questionnaire designed specifically to evaluate the quality of life for CVI sufferers. The next step was to implement a program of cross-cultural validation in several countries. Translation into Spanish was undertaken following international guidelines. Face validity was verified with a pilot test among 12 Spanish patients. Psychometric validation was performed in Spain (n = 476 patients with CVI). The Spanish CIVIQ demonstrated very good internal consistency, high reproducibility and responsiveness, as well as longitudinal clinical validity. It appears to be a valuable instrument for assessing improvement in patient quality of life in response to both therapy in clinical practice and clinical trials.
Chronic Disease↗
A cost-effectiveness analysis of stays in intensive care units.
OBJECTIVE: To evaluate patient outcome and the efficiency of stays in intensive care units (ICUs). DESIGN: Prospective study. SETTING: Seven ICUs of teaching hospitals in the Paris area. PATIENTS: Two hundred eleven stays including one in three consecutive patients admitted from September to November 1996. MEASUREMENTS AND MAIN RESULTS: For each patient, the following information was collected during the ICU stay: diagnosis, severity scores, organ failures, workload, cost and mortality. A cost-effectiveness ratio was computed for 176 stays with at least one organ failure, at hospital discharge and 6 months later. Quality of life was measured with EuroQol questionnaires 6 months after discharge in 64 patients representing 62 % of the patients contacted. The mean total ICU cost per stay was US$ 14,130 (+/- 6,550) (higher for non-survivors--US$ 19,060, median 10,590--than for survivors US$ 12,370, median 5,780). The incremental cost-effectiveness ratio was US$ 1,150 per life-year saved and the incremental cost-utility ratio was US$ 4,100 per quality-adjusted life-year (QALY) saved, without discounting. These results compare favourably with other health-care options. However substantial variations were observed according to age, severity, diagnosis, number of organ failures and discount rate. Intoxication had the lowest ratio (US$ 620/QALY) and acute renal insufficiency the highest (US$ 30,625/QALY). CONCLUSIONS: This work provides medical and economic information on ICU stays in teaching hospitals and enables comparisons with other health-care options.
Adult↗
Internet pharmaco-economic studies in metastatic colorectal cancer.
An interactive Web site has been developed: http://smbh7.smbh.univ-paris13.fr, which uses a Markov model to calculate the management costs for metastatic colorectal cancer. This site allows drug usage costs, daily tariff costs per site, local ISA point values and the cost to the society of the chemotherapies prescribed to be recorded by cycle in a de-centralised manner. The overall cost of treatment may be calculated by one of these four units from the time when the first chemotherapy was administered until the patient has escaped from first or second line treatment. The median time to progression and the median survival time are key parameters used to calculate costs as they determine the number of patients who remain on treatment, course by course. Effectiveness results have been measured in terms of progression free survival or of global survival. Eight treatment strategies have been examined. It is possible to add new treatment regimens or new compounds into the existing pre-formatted tables. This software enables budgets to be planned depending on the regimen used and the number of patients treated. It also allows the different treatment options to be classified with respect to their incremental cost effectiveness ratio, which is defined by the additional cost of one treatment option compared to another divided by the corresponding increase in effectiveness.
Clinical Protocols↗
[The European Evaluation of Vertigo (EEV) scale: a clinical validation study].
Up until now, the questionnaires used to evaluate vertigo have been self-administered questionnaires that rate either symptoms and/or their consequences. In contrast, the European Evaluation of Vertigo scale (EEV) is a physician-administered questionnaire that only assesses symptoms of the vestibular syndrome: illusion of movement, duration of illusion, motion intolerance, neurovegetative signs, and instability. Twenty-six ear, nose, and throat (ENT) specialists participated in this validation study conducted among 123 patients suffering from different types of vertigo. The reliability, responsiveness and construct, convergent and discriminant validity of the EEV scale were assessed. Construct, convergent and discriminant validity was determined by comparing the scores on the EEV scale with those obtained using the following validated scales: patient diary and conventional scale designed by the DPHM, functional scale of the AAO-HNS, and SF-36 scale, a generic quality of life scale. With the exception of the "neurovegetative signs" item, the reliability of the EEV scale is good, particularly in terms of interrater reliability (r = 0.93 for the global score), and responsiveness is high (p < 0.01). EEV scale has good correlations with the items of patient diary, DPHM scale and "physical" dimensions of SF-36, from the first evaluation, whereas this scale has poor correlation at Day 0, with the items of AAO scale and the "psychological" dimensions of SF-36. These results confirm that EEV scale is exclusively a symptomatic scale and does not interfere with the psychism. The EEV scale is therefore a validated physician-administered questionnaire capable of monitoring the course of vertigo and of assessing the efficacy of anti-vertigo treatments.
Adolescent↗
Evaluation of ibuprofen versus aspirin and paracetamol on efficacy and comfort in children with fever.
OBJECTIVE: We compared efficacy and impact on the comfort of ibuprofen (7.5 mg/kg per dose), aspirin (10 mg/kg/dose) and paracetamol (10 mg/kg per dose) on children with fever aged 6-24 months in an open, randomised study with three parallel groups. METHODS: The main criterion for efficacy was area under the curve (AUC) of percentage temperature reduction. Comfort was assessed on scores depending on general behaviour and degree of relief. General behaviour was assessed on a verbal scale and on a visual analogue scale (VAS) and the degree of relief was assessed in relation to baseline on a verbal scale. RESULTS: The efficacy of ibuprofen was better than that of aspirin or paracetamol. In spite of more adverse events, the comfort scores were significantly in favour of ibuprofen 6 h after the first dose of treatment.
Acetaminophen↗
[Quality of life].
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Attitude of Health Personnel↗
Construction and validation of a quality of life questionnaire in chronic lower limb venous insufficiency (CIVIQ).
Quality of life may be considerably reduced in patients who are suffering from chronic lower limb venous insufficiency, although existing generic quality of life instruments (NHP, SF-36 or SIP) cannot completely identify their specific complaints. The Chronic Venous Insufficiency Questionnaire (CIVIQ) has been developed by iterative process. First, a pilot group of 20 patients was used to identify a number of important features of quality of life affected by venous insufficiency, other than physical symptoms of discomfort. A second study involving 2,001 subjects was used to reduce the number of items. Subjects were asked to score both the severity of their problems and the importance they attributed to each problem on a 5-point Likert scale. The importance items found in patients with venous insufficiency were subjected to factorial analyses (PCA, PAF). The final version is a 20-item self-administered questionnaire which explores four dimensions: psychological, physical and social functioning and pain. Internal consistency of the questionnaire was validated for each dimension (Cronbach's alpha > 0.820 for three out of four factors). Reproducibility was confirmed in a 60 patient test-retest study. Pearson's correlation coefficients for both the four dimension subscales and for the global score at 2-week intervals were greater than 0.940. Finally, the questionnaire was tested in a randomized clinical trial of 934 patients in order to assess responsiveness and the convergent validity of the instrument, together with the patient's own quality of life. This study demonstrated that convergence was valid: Pearson's correlation coefficients between clinical score differences and quality of life score differences were small (from 0.199-0.564) but were statistically different from 0 (p < 0.001). Standardized response mean (SRM) and effect size (ES) were calculated to assess sensitivity to change. SRM and ES both demonstrated considerable responsiveness to change (> 0.80). Reliability, face, content, construct validity and responsiveness were also determined for this specific quality of life questionnaire relating to venous insufficiency. Results suggest that this questionnaire may be used with confidence to assess quality of life in clinical trials on chronic venous insufficiency.
Factor Analysis, Statistical↗
Pooling public and private funds in the patient's interest: the case for long-term care insurance.
Although the extent of medical care in France may be thought adequate, the same does not apply to the social medicine sector. The Assurance-maladie paid 87.7% of hospital health expenditure in 1994, whereas direct funding of home assistance amounted to only 9%. In contrast, a recent Legos study (Bungener M. et al. Le bilan économique et financier du secteur médico social, Université de Paris IX, Legos, Janvier 1994) [1] estimated that home assistance costs represent 41-50% of medical-social expenditure. When people are unable to manage because of the high costs of their invalidity, the social security system comes to their assistance, although only under Draconian conditions involving compulsory "family support commitments" and the state's claim on the inheritance of the beneficiary (total costs for hospital admission and boarding and the dual limits of 1000F liabilities and 250,000F net assets for home assistance). The elderly well appreciate the severity of this problem and are deeply distressed by the thought of dependency. Many, however, live under the illusion that the social security system or, to a lesser extent, the mutual funds will come to their assistance, although the problems involved lie partly outside their remits. We therefore need to design new systems to allow the elderly to finance their costs should they become dependant.
Aged↗
A cost-utility analysis of second-line chemotherapy in metastatic breast cancer. Docetaxel versus paclitaxel versus vinorelbine.
The aim of this study was to determine the incremental effectiveness, the incremental health-related quality of life (differences in quality-adjusted progression-free survival between treatments), the incremental cost and the incremental cost-effectiveness and cost-utility ratios, for docetaxel, paclitaxel and vinorelbine, when these drugs were used as second-line treatment in patients with metastatic breast cancer. In the absence of comparative direct evidence of the relative efficacy of docetaxel, paclitaxel and vinorelbine in this setting, a model was designed to determine the effects of the 3 interventions on health outcome and cost. A Markov process model, based on 53 disease states, was thus constructed to evaluate the socioeconomics of the 3 treatment regimens. The model allows assessments from the start of second-line chemotherapy until death. Costs were evaluated from the combined view of the healthcare system and the patient. Direct nonmedical and indirect costs were excluded. Consumption per episode of care was estimated by retrospective analysis of 153 medical reports from 5 different hospitals. Hospital costs were allocated values from the national accounting costs by diagnosis-related group (DRG). The content of the health states was based on the multiattribute health states classification system (MASH). Preference values were assigned by application of a standard reference lottery using 20 oncological nurses as proxies for the patients. The health-related quality-of-life score was used as a quality adjustment weighting factor to calculate quality-adjusted progression-free survival associated with the 3 different regimens. Docetaxel reduces the time spent in progression, decreases the number of complications due to progressive disease and thereby provides better quality of life. It provides a benefit of 57 disease- and discomfort-free days compared with vinorelbine and 22 days compared with paclitaxel. Docetaxel may be thought of as self-financing as a result of savings in hospital admissions, providing net savings of 6800 French francs (FF; 1993 values) compared with expenditure associated with vinorelbine treatment and FF700 compared with the equivalent figures for paclitaxel.
Antineoplastic Agents↗
Chemonucleolysis versus surgical discectomy for sciatica secondary to lumbar disc herniation. A cost and quality-of-life evaluation.
The objective of this study was to evaluate and compare the cost and effects on quality of life [using quality-adjusted life years (QALYs)] of 2 treatments for sciatica secondary to lumbar disc herniation: chemonucleolysis and surgical discectomy. The design involved a combination of decision analysis and Rosser index, with assessment of probabilities from long term clinical series. Utility was based on patients' subjective assessment using a simplified self-administered Health Measurement Questionnaire (HMQ). 146 patients from 7 hospitals were enrolled, 2 to 3 months after chemonucleolysis or surgery. The end-points used were cost and QALYs for each intervention, every year for years 1 to 7. At the time of analysis (1990), the total cost of surgical discectomy was FF15,400, compared with FF8000 for chemonucleolysis. After 1 year, and including the costs of reoperation for failure and relapse and long term medical costs for the non-reoperated unsatisfactory results, discectomy costs were almost 40% higher than those of chemonucleolysis. Ratios remain unchanged after 7 years. QALY results reveal an additional benefit of 52 days of good health associated with chemonucleolysis.
Cost-Benefit Analysis↗
At the crossroads of venous insufficiency and hemorrhoidal disease: Daflon 500 mg--repercussions of venous insufficiency on everyday life.
A research program has been developed to define an evaluation tool capable of assessing the impact of venous insufficiency and its treatments on the patient's everyday life. The methodology is described in the first part of this paper, followed by the results of the first phase of the research program, based on two surveys: a "qualitative" survey in a population of severely affected patients and a "quantitative" survey in a population of 150 patients.
Activities of Daily Living↗
[Integration of patients' preferences in individual and collective health choices].
The objectives of contemporary medicine are basically to attenuate the consequences of chronic diseases and to improve the quality of life of the patient. All medical disciplines tend now to elicit therapeutic protocols directly from the general appreciation of the patients. The community is trying to obtain a transnosographic indicator which would allow the effects of its strategic choices between different areas of the health care system to be measured, taking into account the implications on the quality of life of the population. Individual preferences are now at the center of the decision-making process. Different experimental methods are being used to reveal them. Psychometricians use direct observation of a subject's reactions in a particular pathological situation: patients are asked to arrange the intensity of the impacts on bipolar numeric scales, but an actual metrical measure is not yet available. Traditionally, economists believe that in a market, only the consumer's choices enable us to estimate his level of satisfaction. In the health care field, where market mechanisms are not fully operational, they tend to extract the patients preferences through forced choices between hypothetical health states. A real metrical measure is thus obtained. The objective of this article is to exhibit these two methods: psychometric and economic, and to show how they have been implemented in French field research to obtain quality adjusted life years indicators: QALY's.
Attitude to Health↗
Cost-effectiveness analysis of strategies for screening prostatic cancer.
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Adult↗
[Value of utility measures: recurrent respiratory infections].
Medical decisions have to integrate not only the clinical dimension of a disorder, but also all the repercussions of the therapeutic strategy on the patient's life. Various techniques may be used to identify the preferences of a subject, by estimating the relative utility associated with different states of health. One of these techniques, the "standard gamble", enabled us to determine the utility that patients with recurrent respiratory infections associate with the results of various therapies. The findings show that this utility is not a linear function of therapeutic results. They also show that when the number of years of lost life is calculated, the loss due to alteration of the quality of life linked to the frequency of acute episodes is not obstructive pulmonary disease.
Adult↗