Explore the vast range of titles available.

Background Recent cost studies related to infertility treatment have focused on assisted reproductive technologies. None has examined lower-intensity infertility treatments or analyzed the distribution of infertility treatment expenditures over time. The Purpose of the study was to analyse the size and distribution of infertility treatment expenditures over time, and estimate the economic burden of infertility treatment per 10,000 women aged 18 − 50 in France from a societal perspective. Methods We used French National individual medico-administrative database to conduct a self-controlled before-after analytic cohort analysis with 556 incidental women treated for infertility in 2014 matched with 9,903 controls using the exact matching method. Infertility-associated expenditures per woman and per 10,000 women over the 3.5-year follow-up period derived as a difference-in-differences. Results The average infertility related expenditure per woman is estimated at 6,996 (95% CI: 5,755–8,237) euros, the economic burden for 10,000 women at 70.0 million (IC95%: 57.6–82.4) euros. The infertility related expenditures increased from 235 (IC95%: 98–373) euros in semester 0, i.e. before treatment, to 1,509 (IC95%: 1,277–1,741) euros in semester 1, mainly due to ovulation stimulation treatment (47% of expenditure), to reach a plateau in semesters 2 (1,416 (IC95%: 1,161–1,670)) and 3 (1,319 (IC95%: 943–1,694)), where the share of expenses is mainly related to hospitalizations for assisted reproductive technologies (44% of expenditure), and then decrease until semester 6 (577 (IC95%: 316–839) euros). Conclusion This study informs public policy about the economic burden of infertility estimated at 70.0 million (IC95%: 57.6–82.4) euros for 10,000 women aged between 18 and 50. It also highlights the importance of the share of drugs in infertility treatment expenditures. If nothing is done, the increasing use of infertility treatment will lead to increased expenditure. Prevention campaigns against the preventable causes of infertility should be promoted to limit the use of infertility treatments and related costs.

Background Compared with conventional hospitalization, admission to an acute geriatric care unit (AGU) is associated with better outcomes in elderly patients. In 2012, 50% of the hospitalizations of elderly patients were preceded by an emergency department (ED) visit. Hospital occupancy, access blocks and overcrowding experienced by patients during ED visits are associated with increased morbidity. Objective Our aim was to evaluate the effect of direct admission (DA) to an AGU on both the hospital length of stay and morbidity of elderly patients. Design This study was a retrospective cohort study conducted using electronic medical records and administrative claims data from the Greater Paris University Hospitals (APHP) health data warehouse involving 19 different AGUs. Participants We included all patients ≥ 75 years old who were admitted to an AGU for more than 24 h between January 1, 2013, and December 31, 2018. Intervention Direct admission to the AGU compared to admission after an ED visit. Main measures The main outcome was hospital length of stay. Two outcomes were used to analyse morbidity: postacute care and rehabilitation ward transfer at the end of the index hospitalization and ED return visit within 30 days after the index hospitalization (for those who survived to hospitalization). We used an inverse probability of treatment weighting (IPTW) approach to balance the differences in patient baseline variables between the two groups. Univariate linear and logistic regression models were built to estimate the effect of DA on hospital length of stay and the likelihood of postacute care transfer and ED return visit. Key results Among the 6583 patients included in the study, DA was associated with a lower hospital length of stay (estimate = -1.28; 95% CI = -1.76–0.80), and a lower likelihood of postacute care transfer (OR = 0.87; 95% CI = 0.77–0.97). It was not significantly associated with a lower risk of ED return visits (OR = 0.81; 95% CI = 0.60–1.08) in the following month. Conclusion DA should be prioritized, and reorganization of the geriatric pathway around DA should be encouraged due to the frailty of elderly individuals.

To identify potential risk factors for theneed for an additional cold or heated humidifier in nasal continuouspositive airway pressure (nCPAP) circuitry. Aprospective cohort study. University hospitalsleep-disorders center. Eighty-twoconsecutive patients with obstructive sleep apnea syndrome werefollowed up for a median of 347 days (range, 3 to 530 days) after theinitiation of n, CPAP therapy. In 46 patients (56%), the occurrence of upper-airway symptoms led tothe addition of a cold humidifier after a median time of 39 days(range, 2 to 94 days). In 23 of the 46 patients, the persistence of thesymptoms indicated the secondary use of a heated humidifier after amedian time of 28 days (range, 5 to 70 days). n, CPAP use(mean ± SD) was not influenced by cold humidification(4.58 ± 2.05 h/d vs 4.7 ± 2.48 h/d; p = 0.75), but it increasedsignificantly with heated humidification (5.38 ± 2.26 h/d vs3.51 ± 2.53 h/d; p < 0.01). Anthropometric characteristics, drying medications, clinical findings such as deformity of the nasalseptum, symptoms of a chronic mucosa disease (CMD), a previousuvulopalatopharyngoplasty (UPPP), and polysomnographic parameters hadno significant effect on the need for a cold humidifier. Age > 60years (odds ratio [OR], 5.58; 95% confidence interval [CI], 1.69to 18.43), drying medications (OR, 6.59; 95% CI, 1.29 to 33.51),presence of CMD (OR, 4.11; 95% CI, 1.24 to 13.58), and previous UPPP(OR, 4.56; 95% CI, 1.18 to 17.6) were found as significant riskfactors for the addition of a heated humidifier. Our results demonstrate that heatedhumidification significantly improves the n, CPAP daily rate of use andthat its need may be predicted.

Background The final outcome of any resource allocation decision in healthcare cannot be determined in advance. Thus, decision makers, in deciding which new program to implement (or not), need to accommodate the uncertainty of different potential outcomes (i.e., change in both health and costs) that can occur, the size and nature (i.e., ‘bad’ or ‘good’) of these outcomes, and how they are being valued. Using the decision-making plane, which explicitly incorporates opportunity costs and relaxes the assumptions of perfect divisibility and constant returns to scale of the cost-effectiveness plane, all the potential outcomes of each resource allocation decision can be described. Objective In this study, we describe the development and testing of an instrument, using a discrete choice experiment methodology, allowing the measurement of public preferences for potential outcomes falling in different quadrants of the decision-making plane. Method In a sample of 200 participants providing 4200 observations, we compared four versions of the preference-elicitation instrument using a range of indicators. Results We identified one version that was well accepted by the participants and with good measurement properties. Conclusion This validated instrument can now be used in a larger representative sample to study the preferences of the public for potential outcomes stemming from re-allocation of healthcare resources.

To compare home unattended polysomnography (H-PSG) with polysomnography performed in a local hospital and telemonitored by a sleep laboratory (T-PSG) in the diagnosis of obstructive sleep apnea syndrome (OSAS). Randomized crossover trial. Ninety-nine patients with suspected OSAS who underwent H-PSG and T-PSG on 2 consecutive nights, according to a randomized order. H-PSG and T-PSG were compared in terms of (1) effectiveness, only recordings providing interpretable signals from at least one EEG, the electro-oculograph, the electromyograph, air flow, thoracic or abdominal movements, and arterial oxygen saturation for 180 min of sleep were considered to be effective; (2) patient preference assessed by a questionnaire; and (3) polysomnographic indexes and final interpretative results in patients for whom both recordings were legible. Recordings were considered to be ineffective in 11.2% of T-PSG (95% confidence interval [CI], 4.9 to 17.4%) and in 23.4% of H-PSG (95% CI, 19.12 to 27.68%). Thermistor problems were the main cause of failure of H-PSG. Forty-one percent of patients preferred H-PSG, and 55% preferred T-PSG. H-PSG and T-PSG did not differ in terms of sleep and respiratory indexes in the 65 patients in whom both recordings were legible. H-PSG and T-PSG were concordant in 58 of 65 patients using a 10-event-per-hour apnea-hypopnea index cutoff value for the diagnosis of OSAS. T-PSG is clearly superior to H-PSG from a technical point of view and tends to be preferred by patients. The site of recording (home vs hospital) has no influence on polysomnographic indexes.

Rationale Despite its high level of effectiveness, initial acceptance of continuous positive airway pressure (CPAP) and regular use in patients with obstructive sleep apneoa syndrome (OSAS) are still an issue. Alternatively, oral appliances (OAs) can be recommended. To improve patient engagement in their treatment, physicians are advised to take into account patient preferences and to share the therapeutic decision. We aimed to determine patients’ preferences for OSAS treatment-related attributes, and to predict patients’ demand for both CPAP and OAs. Methods A discrete choice experiment (DCE) was performed in 121 newly diagnosed patients consecutively recruited in a sleep unit. Results Regression parameters were the highest for impact on daily life and effectiveness ahead of side effects. In the French context, the demanding probabilities for CPAP and OAs were 60.2% and 36.2%, respectively. They were sensitive to the variation in the amount of out-of-pocket expenses for both CPAP and OAs. Conclusions This first DCE in OSAS emphasises the importance to communicate with patients before the implementation of treatment.

From one country to another, the pay-for-performance mechanisms differ on one significant point: the identification of target populations, that is, populations which serve as a basis for calculating the indicators. The aim of this study was to compare clinical versus medication-based identification of populations of patients with diabetes and hypertension over the age of 50 (for men) or 60 (for women), and any consequences this may have on the calculation of P4P indicators. A comparative, retrospective, observational study was carried out with clinical and prescription data from a panel of general practitioners (GPs), the Observatory of General Medicine (OMG) for the year 2007. Two indicators regarding the prescription for statins and aspirin in these populations were calculated. We analyzed data from 21.690 patients collected by 61 GPs via electronic medical files. Following the clinical-based approach, 2.278 patients were diabetic, 8,271 had hypertension and 1.539 had both against respectively 1.730, 8.511 and 1.304 following the medication-based approach (% agreement = 96%, kappa = 0.69). The main reasons for these differences were: forgetting to code the morbidities in the clinical approach, not taking into account the population of patients who were given life style and diet rules only or taking into account patients for whom morbidities other than hypertension could justify the use of antihypertensive drugs in the medication-based approach. The mean (confidence interval) per doctor was 33.7% (31.5-35.9) for statin indicator and 38.4% (35.4-41.4) for aspirin indicator when the target populations were identified on the basis of clinical criteria whereas they were 37.9% (36.3-39.4) and 43.8% (41.4-46.3) on the basis of treatment criteria. The two approaches yield very \"similar\" scores but these scores cover different realities and offer food for thought on the possible usage of these indicators in the framework of P4P programmes.

Oral appliances (OAs) have been used for the treatment of obstructive sleep apnea syndrome (OSAS), with different degrees of effectiveness having been shown in previous studies. But, in the absence of a consensual recommendation, the method of the determination of effective mandibular advancement varies from one study to another. We prospectively evaluated an OA titration protocol based on a combined analysis of symptomatic benefit and oximetric recording to guide the progressive mandibular advancement. University hospital sleep disorders center. Forty patients with OSAS (mean [+/-SD] apnea-hypopnea index [AHI], 46 +/- 21 events per hour) found on baseline polysomnography, who were intolerant of nasal continuous positive airway pressure, completed all aspects of the study. Two acrylic appliances connected by Herbst attachments were constructed. The mandible was advanced 1 mm every week until there was a resolution of the symptoms and a reduction in the oxygen desaturation index (ie, the number of desaturations yielding a > 3% fall in pulse oximetric saturation per hour of recording) [ODI] of <10 events per hour of recording or a maximum comfortable limit of advancement was obtained. The final response to OA was evaluated by full polysomnography recording. A complete response (ie, mean AHI, 5 +/- 3 events per hour; mean snoring reduction [SR], 91 +/- 13%; mean Epworth sleepiness scale [ESS] score, 5 +/- 3) was obtained in 63.6% of patients, and a limited response (ie, mean AHI, 21 +/- 11 events per hour; mean SR, 88 +/- 15%; mean ESS, 6 +/- 3) was obtained in 18.2% of patients. Twenty-five percent of mandibular advancements were motivated by an abnormal ODI (ie, 21 +/- 10 events per hour) despite resolution of the symptoms, while 20% were motivated by persistent symptoms with a normal ODI (ie, 6 +/- 2 events per hour). After a mean duration of 17 +/- 4 months, 34 patients declared that they had used the OA 5 +/- 2 days a week for 89 +/- 19% of their sleep time. A combination of the patient's subjective evaluation and oximetric score improves the effectiveness of the OA titration procedure.

This contribution focuses on the medical applications of new information and communication technologies (NICTs). We discuss the paradoxical nature of the spread of these technologies, related to the discrepancy between the promises held out by their use in a healthcare system searching for new mechanisms of coordination and their actual implementation, involving a series of experiments that to date have been short-lived. We then argue that solving this paradox requires understanding the complexity of the interaction process between NICTs and organisational changes. Thus while NICTs can facilitate the restructuring of provider networks, one of the principal challenges facing healthcare systems, they also reveal the tensions engendered by some new formal coordination mechanisms.