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Ischemic stroke care for patients affiliated to the French agricultural health insurance scheme: A national study
No full textInternational audienceBackground: Health disparities along the rural-urban spectrum are a growing concern. The objective of this study was to determine whether in France, clinical profile, care and outcome after ischemic stroke differed between patients affiliated to the statutory health insurance system dedicated to the agricultural economic sector (i.e., Mutualité Sociale Agricole [MSA]) and all other patients.Methods: Data on all patients aged ≥ 20 years hospitalized for ischemic stroke in mainland France in 2018 were extracted from the French National Health Insurance Data System. Age-standardized percentages were used to compare the care accessed by MSA versus other stroke patients. Associations between health insurance scheme and case fatality were assessed using Poisson regression.Results: Of 87,864 stroke cases 7928 (9%) were MSA patients. MSA patients were more often rural dwellers (75.4 versus 32%) and older (median age: 84 versus 76 years). In the 12 months prior to the stroke, access to general practitioner (GP) was similar, but MSA patients were less likely to have an appointment with a cardiologist. Pre-stroke drug prescriptions suggested a better cardiovascular profile in male MSA patients (e.g., antidiabetics: 18.1 versus 21.5%). A part from a lower access to stroke unit (e.g., women: 55.3 versus 59%) other acute care indicators, including reperfusion therapy, were comparable. The crude 7-day case fatality was higher for MSA patients (Relative Risk [RR]: 1.44, 95% CI [1.32–1.57]), but this disadvantage reduced to non-significant level after adjustment for age, comorbidities and stroke management (adjusted RR: 1.07 95% CI [0.98–1.18])Conclusions: For the mostly farming, rural, MSA population, pre-stroke, acute and post-stroke care did not differ markedly from that provided to other patients. The lower density of GP in rural areas and the remoteness from specialized center did not result in less access to preventive and acute stroke care for MSA patients in 2018
Association between return-to-work trajectories and depressive symptoms in long-term breast cancer survivors: results from the French CONSTANCES cohort
No full textInternational audiencePurpose: Depressive symptoms (DS) are common in patients with breast cancer (BC). Our aim was to assess the association between return-to-work (RTW) trajectories and DS in long-term BC survivors (BCS) (≥ 5 years after diagnosis) in France.Methods: The French population-based CONSTANCES cohort was linked to the national retirement insurance (CNAV) and national health insurance system (SNDS) databases. RTW trajectories were identified and categorized using the sequence analysis method and clustering. DS were assessed with the 20-item Center for Epidemiological Studies-Depression (CES-D) scale. The association between RTW trajectories and DS was analyzed with adjusted logistic regressions and statistical analyses were stratified according to the time from BC diagnosis to CES-D completion (i.e. < 5 or ≥ 5 years after BC diagnosis).Results: DS (CES-D score > 20) was observed in 22.7% in the < 5 years CES-D group and 20.2% in the ≥ 5 years CES-D group. Three RTW trajectory patterns were identified: sustainable RTW (n = 203), unemployment and work transitions (n = 138), and disability worker status (n = 83). Compared with the sustainable RTW group, DS risk was higher in the disability worker status group (< 5 years post-diagnosis: OR [95% CI]: 3.22 [1.46;7.17] and ≥ 5 years post-diagnosis: 3.88 [1.13; 14.1]) and in the unemployment and work transitions group (< 5 years post-diagnosis: OR [95% CI]: 1.68 [0.81; 3.49], not significant). In this group, risk decreased after 5 years (OR [95% CI]: 0.19 [0.03; 0.88]).Conclusion: Returning to work or pursuing new professional opportunities after BC may reduce the risk of long-term DS.Implications for cancer survivors: DS may persist for an extended period after BC diagnosis. Engaging in sustainable RTW and exploring new professional opportunities contribute to supporting long-term psychological well-being and reduce the risk of persistent depressive symptoms in BCS
Élaboration d’un indicateur de qualité écologique des territoires. Apprentissages croisés de deux expérimentations
No full textNational audienceWith the territorialization of public action, there is a growing need for new local indicators. If a growing body of research emphasizes that economic aspects alone can no longer be used to assess the performance of territories, and that it is important to take social and environmental dimensions into account when assessing development, few studies examine the extent to which these information systems give meaning to “the ecological quality of territories.” The aim of the experiments we conducted in les Hauts de France and in Normandy (France), was to shed light on territorial dynamics from the perspective of their ecological quality, for the purposes of diagnosis, steering, advocacy, but also to support new forms of green territorial planning. This project is designed as a tool that can be used in several areas: territorial dialogue, monitoring of public policies, review of planning documents (PCAET, etc.). However, the research reported in this article reflects the methodological and epistemic specificities of these experiments: taking seriously one of the central themes of ecological economics, namely the concept of ecological “deliberative value,” and opening up a debate on ecological values rather than selecting or fixing them according to expert opinion.Avec la territorialisation de l’action publique, un besoin croissant de nouveaux indicateurs locaux est exprimé. Si des travaux de plus en plus nombreux soulignent que les aspects économiques ne peuvent plus, à eux seuls, énoncer les performances des territoires, et qu’il est important de tenir compte des dimensions sociale et environnementale pour rendre compte du développement, peu de travaux étudient dans quelle mesure ces systèmes d’information donnent sens à « la qualité écologique des territoires ». L’objectif des expérimentations que nous avons menées était d’éclairer les dynamiques territoriales sous l’angle de leur qualité écologique, à des fins de diagnostic, de pilotage, de plaidoyer, mais aussi d’appui à des formes renouvelées de planification territoriale écologisée. Ce projet est conçu comme un outil mobilisable dans plusieurs arènes : dialogue territorial, suivi des politiques publiques, relecture des documents de planification (PCAET, etc.). Mais les recherches dont nous rendons compte dans cet article assument les spécificités méthodologiques et épistémiques de ces expérimentations : en prenant au sérieux l’un des axes centraux de l’économie écologique avec la notion de « valeur délibérative » écologique, de mettre en débat les valeurs écologiques plutôt que de les sélectionner ou de les fixer à dire d’experts
Urbanizing the mountains: urban governance and tourism growth in Kohima
No full textEditors: Rémi de Bercegol, Nicolas Bautès, Balasubramanian Dhandapani, Anthony Goreau-Ponceaud, Ratoola Kundu & Diya MehraInternational audienc
Remaining gaps and obstacles in the outpatient setting for peripheral artery disease endovascular revascularization: Lessons learned from the French experience
No full textInternational audienceIntroduction: The transition to an outpatient setting for endovascular treatment of lower-limb peripheral artery disease (PAD) remains slow, and obstacles persist. The aim of this study was to identify the obstacles to its development, according to vascular interventionalists. Methods: Between September 2022 and October 2023, all French vascular interventionalists, who were members of the participating societies, were asked to answer an online questionnaire on their outpatient setting practice for PAD endovascular treatment. The questionnaire explored patient selection criteria (medical and social), treatments, follow up, and potential obstacles. Results: Of the 279 respondents (43%), 228 (82%) were currently performing endovascular treatment of PAD on an outpatient basis. Most interventionalists ( n = 179, 79%) declared that an outpatient setting practice did not alter their technical approach. Age, obesity, chronic limb-threatening ischemia (CLTI), and chronic renal failure were not considered exclusion criteria for an outpatient setting by more than half of the respondents. Long iliac and femoropopliteal thrombosis were considered exclusion criteria by 48 (21%) and 75 (33%) of them, respectively. Interventionalists estimated the rate of potentially eligible patients at 58.3 ± 22.5%. Social isolation (lack of comprehension, communication means, or company) was considered the main exclusion criterion for more than 90% of the respondents. Medico-legal risks were identified as the main obstacle for 39% of interventionalists not practicing outpatient care. Conclusion: This prospective study identifies, from the perspective of vascular interventionalists, medico-legal risks, social isolation, and the complexity of lesions as the main obstacles to the transition to an outpatient setting for endovascular treatment of lower-limb PAD
The 2025 Los Angeles Wildfires and Outpatient Acute Health Care Utilization
No full textInternational audienceImportance January 2025 brought devastating wildfires to Los Angeles (LA) County, California, causing poor air quality, destroying homes and businesses, and displacing thousands of people. Objective To promptly determine if the January 2025 LA fires increased outpatient acute health care utilization. Design, Setting, and Participants This cohort study assessed electronic health care records of 3.7 million members of Kaiser Permanente Southern California (KPSC) who met enrollment criteria. Of those, 305 258 were highly exposed and 1.4 million were moderately exposed. KPSC serves 4.7 million people across 10 counties. Analyses were conducted January-June 2025. Exposures Highly exposed members were those who resided in a census tract within 20 km of burn zones, and moderately exposed members were those who resided in tracts that were 20 km or more miles from the burn zones but within LA County. The maximum wildfire burn zone reached by an LA or Ventura county wildfire by January 17, 2025 was used. Main Outcomes and Measures Daily outpatient and virtual acute care visits in 5 categories: all-cause (or any medical reason), cardiovascular, injury, neuropsychiatric, and respiratory were identified and analyzed by a 2-stage interrupted time-series model using machine-learning algorithms to determine if and by how much the January 2025 LA fires increased outpatient acute health care utilization. Results Across the week following the January 7 LA fires’ ignition, there were excess visits from the 3.7 million study population (1.94 million women [52.2%], 1.77 million men [47.7%]; median age, 42 years [IQR, 21-62]; 11.5% Asian, 7.8% Black, 43.8% Hispanic, and 29% White). Virtual respiratory visits were 42% (95% empirical CI, 23%-60%) higher than expected in highly exposed groups and 36% (95% empirical CI, 19%-54%) higher than expected in moderately exposed groups. Similarly, the highly exposed and moderately exposed groups had 44% and 40% more than expected virtual cardiovascular visits, respectively, and 27% and 31% more than expected outpatient respiratory visits, respectively (n=2866 and n=5166 total excess visits). All-cause virtual care visits were also elevated in the moderately exposed group, potentially representing displaced in-person care. Among highly exposed members, outpatient and virtual injury visits and outpatient neuropsychiatric visits were 18% higher than expected on January 7. Extrapolating to all insured LA County residents, an excess of 15 792 cardiovascular and 18 489 respiratory virtual care visits and 27 903 respiratory outpatient visits was estimated during the week following ignition. Conclusions and Relevance This cohort study observed substantial increases in acute health care utilization, especially virtual care-seeking following the LA fires. As disruptive climate events increase, such data are essential to inform health care preparedness and response
La gouvernance sur une ligne de crête, entre formes réticulaire et institutionnelle
No full textNational audienced'une quarantaine de mémoires en Masters 1 (séminaire politiques européennes et action locale) et Master</div
The cost of hospital healthcare workers’ poor health
No full textThe theme for EHMA 2025 : Taking action to improve health for all.International audienceAbsenteeism among healthcare professionals represents a significant challenge, particularly in public hospitals, with the hospital sector in France reporting an average absenteeism rate of 8%, one of the highest across industries. Equally concerning is presenteeism due to health issues, often overlooked despite its impact. Demanding working conditions, elevated occupational risks, and complex relational environments contribute to health and productivity losses, further aggravated by burnout. Addressing caregivers' health requires ambitious public health initiatives to improve working conditions, especially when the costs of inaction outweigh investments in prevention.This study aims to estimate the indirect costs of health-related productivity losses across various hospital professions and healthcare facility types. These costs, including lost wages and friction costs, are often underestimated but amount to approximately €4.5 billion in France. According to human capital theory, health directly influences the return on human capital. Thus, absenteeism and presenteeism lead to productivity losses, imposing significant financial burdens on hospitals. The study uses simple multiplier coefficients to monetize the effects of absenteeism and presenteeism.The survey is based on a questionnaire adapted from Strömberg et al. (2017), tailored to the French hospital context. Addressed to team leaders in healthcare facilities, the survey collects insights from managers (e.g., hospital directors, healthcare executives, and medical managers) on the impact of health issues among healthcare professionals on activity and care quality. Managers were chosen for their critical role in implementing preventive programs and their comprehensive understanding of team dynamics, particularly during staff absences or reduced productivity periods. An ordered Probit model is employed to assess the effects of healthcare professionals' health issues on activity levels and care quality.The results confirm that absenteeism leads to substantial costs and significantly impacts hospital activity and care quality. Additionally, the findings highlight that presenteeism, though less frequently addressed, also incurs notable productivity losses and compromises care quality. As presenteeism often precedes or follows absenteeism, it is likely underreported and underestimated. This study underscores the need to recognize presenteeism as a costly issue for hospitals, affecting both productivity and the quality of care provided
The role of deans in implementing smoke-free campus policies: the case of medical schools in France
No full textInternational audienceBackground: Smoke-free campus (SFC) policies prohibit smoking and vaping on all university grounds and for all users. The literature on SFC shows that these policies reduce exposure to secondhand smoke and increase smoking cessation. Engagement from high-level leaders has been proven to be a key determinant in the SFC implementation process, but their attitudes toward SFC has rarely been investigated, and only in the USA. The aim of this research is to analyze deans' perceptions of SFC in medical schools in France, where smoking prevalence remains high despite broad awareness of the harms of tobacco.Methods: We used semi-structured interviews to explore medical school deans' perceptions of SFC implementation in France. Between October 2022 and January 2024, we interviewed 31 deans and two associate-deans, representing 31 out of the 35 medical schools in mainland France. Interviews were transcribed and the results were thematically analyzed using Nvivo 14, mobilizing the "individuals domain" from the updated Consolidated Framework for Implementation Research.Results: One school had a SFC policy, 6 were in the SFC implementation process, 23 had no SFC policy, and 1 had abandoned it. A majority of deans were unaware that a SFC goes beyond a smoking ban. However, 28 deans held a net-positive perception of SFC, arguing that it is a coherent multi-modal intervention and is effective in reducing smoking. However, SFC were also perceived as stigmatizing smokers and displacing the problem rather than solving it. Perceived barriers to SFC implementation were competing priorities, lack of funding, and opposition from smokers. Perceived facilitators of SFC implementation were access to existing resources, support from medical students, and natural legitimacy of medical schools. Deans felt they had a leadership role to play in initiating, promoting, and enforcing the SFC policy.Conclusions: SFC are poorly developed in medical schools in France, mostly because medical school deans prioritize other issues over smoking prevention and are under-aware of the benefits of SFC policy. However, they hold a net-positive opinion on SFC policy and express a willingness to implement it. We provide a set of practical strategies to help remove the main barriers to SFC implementation
Impact of a 10-year shift in ambient air quality on mortality in Canada: a causal analysis of multiple pollutants
No full textInternational audienceBackground: The impact of past air quality improvements on health and equity at low pollution levels near the revised WHO air quality guidelines remains largely unknown. Less is known about the influence of simultaneous reductions in multiple major pollutants. Leveraging real-world improvements in air quality across Canada, we sought to directly evaluate their health benefits by quantifying the impact of a joint shift in three criteria pollutants on mortality in a national cohort.Methods: In this population-based cohort study, we assembled a cohort of 2·7 million adults living in Canada in 2007 who were followed up through 2016. Annual mean concentrations of fine particulate matter (PM2·5), nitrogen dioxide (NO2), and ozone (O3) were assigned to participants’ residential locations. For each pollutant individually and combined, we conducted a causal analysis of the impact of the decadal shift in annual exposure from the pre-baseline level (2004–06) on the risk of non-accidental mortality using the parametric g-formula, a structural causal model. To check the robustness of our results, we conducted multiple sensitivity analyses, including exploring alternative exposure scenarios. We also evaluated differential benefits across regions and socio-demographic subgroups.Findings: Between 2007 and 2016, annual mean exposures to PM2·5 and NO2 decreased (from 7·1 μg/m3 [SD 2·3] to 5·5 μg/m3 [1·9] for PM2·5 and from 11·1 ppb [SD 6·6] to 8·0 ppb [4·9] for NO2), whereas O3 declined initially and then rebounded (from 38·6 [SD 8·3] ppb to 36·0 [6·0] ppb and then 38·1 [5·4] ppb). Compared to pre-baseline (2004–06) levels, the joint change in the pollution exposures beginning in 2007 resulted in, per million population, 70 (95% CI 29–111) fewer deaths by 2009, 416 (283–549) fewer deaths by 2012, and 609 (276–941) fewer deaths by 2016, corresponding to a –0·7% change in mortality risk over the decade. Stratified analyses showed greater beneficial impacts in men, adults aged 50 years and older, low income-earners, and residents in regions undergoing substantial air quality improvements. Had all regions experienced pollution reductions similar to the most improved region, approximately three times as many deaths would have been averted (2191 fewer deaths per million). Conversely, if the observed air quality improvements had been delayed in all regions by 3 years, there would have been 429 more deaths per million by 2016.Interpretation: In Canada, substantial health gains were associated with air quality improvements at levels near the revised WHO guidelines between 2007 and 2016, with notable heterogeneity observed across socio-demographic subgroups and regions. These findings indicate that modest declines in air pollution can considerably improve health and equity, even in low-exposure environments