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Financial Reform of Public Policy on Ageing in France and the Persistent Invisibilization of Caregivers
No full textInternational audienceIn diesem Artikel wird die Finanzierung staatlicher Maßnahmen für ältere Menschen in Frankreich aus einer Geschlechterperspektive untersucht. Unsere Untersuchung stützt sich auf eine Analyse der Preisgestaltung in Heimen für pflegebedürftige ältere Menschen (établissement hébergement pour personnes âgées dépendantes - EHPADs), das zuletzt im Jahr 2015 durch das Gesetz zur Anpassung der Gesellschaft an die Alterung der Bevölkerung reformiert wurde. In diesem Beitrag hinterfragen wir die Rollen, die für Frauen als Angestellte des Wohlfahrtsstaates, als pflegende Angehörige und als Bürgerinnen durch das Preisgestaltungssystem vorgesehen sind. Unsere Arbeit stützt sich hauptsächlich auf eine Befragung, die im Jahr 2023 in vier Pflegeheimen in der Bretagne durchgeführt wurde. Die Studie zeigt, dass die Invisibilisierung von Frauen auf verschiedene Weise erfolgt. Erstens ist das auf Pflegeheime angewandte Preisgestaltungssystem grundlegend für ein familialistisches Konzept dieser Politik, die sich hauptsächlich auf die unentgeltliche Leistung der pflegenden Angehörigen stützt. Zweitens ist dieses Instrument so konstruiert, dass die von den Pflegefachkräften geleistete Arbeit, vor allem die Beziehungsaspekte von Care-Arbeit, unterbewertet wird. Und schließlich zeigt unsere Untersuchung, dass das System die Rendite sozialer und politischer Investitionen unterschätzt, die eine Einrichtung stationärer Pflege auf lokaler Ebene repräsentiert.This article aims to examine the financing of public policy on ageing in France with a focus on gender. Our research draws from an analysis of the pricing system applied to nursing homes for dependent elderly people (établissement hébergement pour personnes âgées dépendantes – EHPADs), last reformed in 2015 by the Adaptation of Society to Ageing Act. In this paper, we question the roles reserved to women as employees of the welfare state, caregivers, and citizens, in light of the representations driven by the pricing system. Our work draws mainly from a survey conducted in 2023 in four care homes in Brittany, France. The study highlights that the invisibilization of women takes place in various ways. Firstly, the pricing system applied to nursing homes drives a familialist conception of this policy, which relies mainly on the free contribution of carers. Secondly, this tool tends to misrepresent the work carried out by care professionals by undervaluing relational care. Finally, our survey shows that the system underestimates the return on social and policy investment that this institution represents at the local level
Integrating environmental sustainability into healthcare decision making: Case study of a "health-economic-climate" model for depression care
No full textInternational audienceObjective: To evaluate the feasibility and utility of integrating environmental sustainability into healthcare decision-making through a novel "health-economic-climate" model, using depression care in France as a case study. Design: A cost-utility analysis incorporating clinical, economic, and carbon footprint data. A semi-Markovian state-transition model with a five-year time horizon was developed to assess three primary depression treatment strategies: antidepressants (AD), psychotherapy (PT), and combined therapy (COMB). Carbon emissions were monetized using the social cost of carbon. Setting: The French healthcare system, with direct medical costs and environmental impacts analyzed from a system-level perspective. Participants: A virtual cohort of patients experiencing a first episode of depression, transitioning between health states over time based on treatment modality. Interventions: Three treatment strategies for depression were compared: AD, PT, and COMB. Main Outcome Measures: Incremental cost-effectiveness ratios (ICER) in € per quality-adjusted life year (QALY) gained, alongside carbon footprints expressed as kg of carbon dioxide equivalent emissions per patient per year. 1 Results: PT was the least costly strategy over five years, with AD showing no additional benefit despite higher costs. COMB demonstrated superior clinical outcomes but at a higher cost, with an ICER of €35,422/QALY. Carbon emissions contributed little to overall costs across strategies, accounting for approximately 4% of total expenses. Sensitivity analyses showed that reducing the duration of antidepressant use significantly improved COMB's cost-effectiveness. The integration of carbon emissions into decision modeling provided an additional perspective without altering the overall conclusions. Conclusions: This study demonstrates the feasibility of integrating environmental sustainability into healthcare decision models. By combining clinical, economic, and carbon impact data, the proposed framework offers practical insights for decision-makers and healthcare practitioners. These findings provide an opportunity to align healthcare priorities with environmental goals, emphasizing sustainability as a core component of quality care
#2587 Survival and access to renal transplantation of patients with type 1 diabetes: a study from the REIN registry
No full textInternational audienceBackground and Aims: One of the most severe complication of type 1 diabetes (D1) is renal injury which can lead to end stage renal disease. Even though improvement have been made to slow the progression of the renal disease, some of D1 patients still reach dialysis. Those patients seem to have more comorbidities and poor prognosis compare to patients without diabetes (D0) starting dialysis or patients with type 2 (D2) diabetes. Method: The French Renal Epidemiology and Information Network (REIN) registry collects information on all patients starting dialysis in France. We used this cohort to explore survival and access to renal transplantation of D1 on dialysis patients compare to D0 and D2 patients, using Cox proportional hazard models and graphical representation of the variables to explore the pathway from type 1 diabetes to the outcomes of interest. We performed sensitivity analysis on the imputed base obtain by MICE (in order to reduce the influence of missing data) to compare HR. Results: From January 1, 2010 to December 31,2016, 1596 D1 patients were compared to 39540 D0 patients and 28170 D2 patients. Excess in all-cause mortality rate were 1.26 [1.14-1.40] (p < 0.001) for D1 versus D0 and rises to 1.45 [1.32-1.59] (p < 0.001) when considering diabetes-related comorbidities on the pathway from diabetes to death. D1 had a poorer access to kidney transplantation (0.74 [0.66-0.82] p < 0.001) adjusting for non-diabetes-related comorbidities. Using the survival model to compare D1 and D2 on the imputed bases, we obtained an HR: 1.11; 95% CI: 1.01-1.21 p = 0.027, in favor of a worse survival of D1 patients in dialysis compare to D2 patients Conclusion: These results confirm that D1 patients starting dialysis are severely ill and particular care need to be given to detect and so reduce diabetes-related comorbidities and increase access to kidney transplantation
Le risque du cancer dans la SEP : une étude de cohorte nationale (2012–2021)
No full textNational audienceObjectifs :Comparer le risque de cancer entre les pSEP et la population générale entre 2012 et 2021 à partir du Système national des données en santé (SNDS ; 99 % population française)
Characterization of organic contaminants in hair for biomonitoring purposes
No full textInternational audienceBiological monitoring is one way to assess human exposure to contaminants. Blood and urine are often used as biological matrices, but hair is an innovative and effective tool for quantifying more biomarkers over a wider exposure window. In order to improve the use of hair in exposure assessment, this article identifies relevant compounds in the literature to investigate hair contamination. Statistical analysis was performed to correlate the physical-chemical properties of the relevant compounds and their concentration levels in hair. Phthalates, pyrethroids and organophosphate flame retardants were chosen for further study of the interpretation of hair measurements for exposure assessment. No significant correlation was found between the average concentration levels in the literature and the physical-chemical properties of the selected compounds. This work also explores the properties of hair and the analytical process that may impact the quantification of organic contaminants in hair. The sample preparation method (sampling, storage, washing) were also studied and adaptations were suggested to improve the existing methods
Avis de l'Anses relatif à la priorisation des lieux fréquentés par les cas importés d’arbovirose pour la réalisation des prospections entomologiques et des actions de lutte anti-vectorielle
No full textCitation suggérée : Anses. (2023). Priorisation des lieux fréquentés par les cas importés d’arbovirose pour la réalisation des prospections entomologiques et des actions de lutte anti-vectorielle. (saisine n°2022-AST-0103). Maisons-Alfort : Anses, 39 p.Présents sur tous les continents, les moustiques du genre Aedes (Aedes aegypti et Aedes albopictus notamment) sont responsables de la transmission d’agents pathogènes affectant l’être humain et responsables d’arboviroses* telles que la dengue, le chikungunya, le Zika ou encore la fièvre jaune. Ces maladies sévissent principalement dans les régions tropicales mais sont désormais parfois observées en régions tempérées comme en Europe, notamment en raison de l’expansion géographique d'Ae. albopictus en lien avec le développement des activités humaines (transports de biens et de personnes, aménagements du territoire, etc.) (Paupy et al. 2009; Akhoundi 2018). Au cours des dernières décennies, l’incidence de la dengue a augmenté de manière significative au niveau mondial et des épidémies dechikungunya et de Zika ont émergé en dehors de leur aire de distribution d’origine. Dans tous les territoires concernés, la lutte contre ces arboviroses est une priorité de santé publique (Diagne et al. 2021; Mayer et al. 2007).Dans l’attente de vaccins opérationnels (à l’exception de celui de la fièvre jaune) et en l’absence de traitement curatif spécifique, le principal moyen de réduire les risques sanitaires résultant de la transmission vectorielle de ces arboviroses reste la lutte anti-vectorielle (LAV). Celle-ci doit viser la diminution des populations de vecteurs* à un niveau en-dessous des seuils de densités permettant une transmission virale active et/ou la réduction du contact être humain - vecteur pour empêcher la transmission de l’agent pathogène. Pour y parvenir, les moyens de lutte sont variés : lutte mécanique, aménagements de l’environnement, lutte biologique, génétique ou chimique (insecticides et répulsifs) pouvant être utilisés de manière alternée ou combinée. La LAV repose en effet sur l’utilisation d’outils et le recours à des techniques différentes, selon le couple vecteur/agent pathogène ciblé, mais aussi selon les objectifs poursuivis.Pour que la LAV soit efficace, les responsables doivent élaborer une stratégie intégrée tenant compte du contexte local et en particulier de la situation entomo-épidémiologique. La stratégie de LAV, cadrée par la réglementation, doit reposer sur une combinaison optimale d’outils et de techniques adaptés au contexte du territoire et aux ressources.En France, le décret n° 2019-258 du 29 mars 2019 relatif à la prévention des maladies vectorielles a confié aux Agences Régionales de Santé (ARS) les missions de surveillance entomologique et d’intervention autour des nouvelles implantations de moustiques vecteurs, ainsi qu’autour des cas humains d’arboviroses. Ainsi, depuis le 1er janvier 2020, les ARS sont responsables de la LAV et peuvent désigner des opérateurs de démoustication (OpD) chargés de réaliser les interventions autour du domicile et des lieux fréquentés par les cas confirmés* de dengue et autres arboviroses (chikungunya et Zika) transmises par les moustiques du genre Aedes, et plus particulièrement, Ae. albopictus. Ces interventions comprennent notamment la sensibilisation des populations à la prévention des maladies vectorielles et aux moyens pour s’en protéger, la suppression ou la vidange des gîtes larvaires, le traitement larvicide, ainsi que le traitement adulticide contre les vecteurs visant à diminuer la longévité et la densité de femelles potentiellement infectées et susceptibles de transmettre à de nouvellespersonnes le virus considéré dont elles sont porteuses. Ces interventions doivent être réalisées conformément aux dispositions de l’arrêté du 23 juillet 2019
Real-world evaluation of mortality in patients with heart failure treated with Sacubitril-Valsartan in France
No full textInternational audienceIntroduction: Sacubitril-Valsartan was approved in Europe in 2015, for treatment of adults with symptomatic chronic heart fail ure (HF) with reduced left ventricular ejection fraction (HFrEF). In France, Sacubitril-Valsartan had firstly benefited from an early access program (2015–2018), and then became available in community pharmacy since October 2018.Objective: This study aims to describe characteristics of patients who received Sacubitril-Valsartan in France and to assess real-life all-cause mortality in this population.Method: This non-interventional retrospective study was based on existing claims data from the French National Healthcare Data System (SNDS) allowing long-term follow-up of patients who benefited from at least one reimbursement of Sacubitril-Valsartan. Data were collected between April 2012 to December 2020. Characteristics of patients were assessed at first reimbursement of Sacubitril-Valsartan and all-cause mortality was estimated using Kaplan-Meier method.Results:Between 2015 and 2020, 104,910 patients initiated Sacubitril-Valsartan treatment and were followed for an average of 20 months after initiation. Mean (SD) age of patients was 70.9 (12.9) years (with 42.6% 75 years), 72.1% were male, 31.9% had diabetes, ≥ and 93.4% had hypertension. 38.4% of patients were hospitalizedfor HF in the year prior to Sacubitril-Valsartan initiation, 20.5% did not receive angiotensin-converting–enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) in the 6 months prior to Sacubitril-Valsartan initiation, 73.4% had beta-blockers, 38.3% had mineralocorticoid - receptor antagonists (MRAs), and 71.5% hadloop diuretics. In this study population, all-cause mortality was 6.0% [5.9–6.2%] at 6 months, 10.6% [10.4–10.8%] at 12 months, and 18.8% [18.5–19.1%] at 24 months.Conclusion: This study provides exhaustive nationwide data on Sacubitril-Valsartan real-world utilization and mortality in France over a 6-year period
Characterization of multiple pesticide exposure in pregnant women in Brittany, France
No full textInternational audienceBACKGROUND: France is one of the biggest users of pesticides in Europe and exposure to pesticides is a current concern, especially when it occurs early in life. OBJECTIVE: The aim of this study was to assess the exposure of pregnant women in Brittany (western France) with high pesticide use. METHODS: The pesticides were selected according to agricultural practices. Forty pesticides or metabolites were measured in urine samples collected in 2004 from 296 pregnant women in Brittany. The samples were analyzed by ultra-high performance liquid chromatography (UHPLC) coupled to high resolution mass spectrometry (HRMS) after a solid phase extraction (SPE) step. RESULTS: Twenty seven pesticides were detected: the most frequently detected were the metabolites of organophosphate and pyrethroid insecticides (>89%) and several herbicides (phenoxypropionic acid derivatives and fluazifop >60%). Organophosphate and pyrethroid metabolites were also quantified in highest levels with maximum values of 590 μg/l for dimethylphosphate and 5.4 μg/l for 3- phenoxybenzoic acid. For the other parent compounds, such as prochloraz, bromoxynil and procymidone, they were also detected in 10-29% of the samples. SIGNIFICANCE: Our results are consistent with pesticide use at the time of collection. The median concentrations of organophosphorus and pyrethroids were of the same order of magnitude as those reported in other countries. Herbicides and fungicides (fluazifop-p-butyl, bromoxynil, and prochloraz) were measured for the first time in this biomonitoring study, showing the usefulness of measuring widely used pesticides locally to improve knowledge of exposure. IMPACT: The objective of this study is to assess the exposure of pregnant women in a region of Europe with high pesticide use
Le déploiement des CPTS suite à la crise du Covid-19 : entre soutien à des dynamiques locales et structuration par le haut d’une organisation territoriale
No full textST32International audienc
Etude de l’accès à la greffe rénale des femmes en France par une approche méthodologique mixte
No full textEnd-stage kidney disease is the final stage of chronic kidney disease, a condition that progresses slowly and silently. At this stage, replacement treatment is required to improve patient survival. In France, dialysis and kidney transplantation are the two kidney replacement therapy available. However, kidney transplantation is the best renal replacement therapy for eligible patients. Studies in certain regions of France and in other countries have shown that there are non-medical determinants (sex/gender, etc.) of access to the waiting list and access to kidney transplantation. The overall aim of this thesis is to study women's access to kidney transplantation in France using a mixed method approach. The quantitative study will describe this gender gap and the qualitative study will suggest possible explanations for this gap. We found that women aged over 60 had less access to kidney transplantation in France, and that this was due to their less access to the waiting list. This disparity was present in several France regions. The qualitative study allowed us to understand that this disparity could be linked to differences in patients'perceptions of kidney transplantation, which could be due to factors such as previous experience of dialysis or the patient-healthcare professional relationship. The study showed that some women trend to refuse a transplant from a living donor. An in-depth study of kidney transplant refusal showed that women were more likely to refuse a kidney transplantation than men. Reasons for refusal included advanced age, fear of uncertainty, good adaptation to dialysis and the presence of comorbidities. Taken together, these findings have led to recommendations and the identification of new possibilities of research to improve understanding of disparities in access to kidney transplantation.L’insuffisance rénale chronique terminale est le dernier stade de la maladie rénale chronique, une affection d’évolution lente et silencieuse. À ce stade, un traitement de suppléance est nécessaire pour une meilleure survie du patient. En France, la dialyse et la greffe rénale constituent les deux moyens de suppléance rénale disponible. La greffe rénale représente cependant le meilleur traitement de suppléance pour les patients éligibles. Les études dans certaines régions en France et dans d’autres pays ont montré qu’il existe des déterminants non médicaux (sexe/genre…) de l’accès à la liste d’attente et de l’accès à la greffe rénale. L’objectif général de cette thèse est d’étudier l’accès à la greffe rénale des femmes en France par une approche méthodologique mixte. L’étude quantitative va décrire cette disparité de genre et l’étude qualitative apportera des pistes d’explications de ces disparités. Nous avons observé que les femmes de plus de 60 ans avaient un moindre accès à la greffe rénale en France et que cela était dû à leur faible accès à la liste d’attente. Cette disparité était présente dans plusieurs régions de France. L’étude qualitative a permis de comprendre que cette disparité pouvait être en lien avec les différences de perceptions de la greffe rénale par les patients, lesquelles sont issues de certains facteurs comme l’expérience passée en dialyse ou la relation soignant-soigné. Cette étude a montré des signaux comme la propension des femmes à refuser la greffe issue de donneurs vivants. L’exploration approfondie du refus de greffe a montré que les femmes refusent plus la greffe que les hommes. Les motifs étaient entre autres: l’âge avancé, la crainte de l’incertitude, la bonne adaptation en dialyse et l’existence de comorbidités. L’ensemble de ces résultats a permis de faire des recommandations et d’identifier de nouvelles pistes de recherche pour une meilleure compréhension des disparités dans l’accès à la greffe rénale