Caisse Nationale Research Articles

Technical efficiency measurement in insurance companies by using the slacks-based measure (SBM-DEA) with undesirable outputs: analysis case study

PurposeThe purpose of this study is to measure the technical efficiency of 20 Algerian insurance companies from 2016 to 2020, by using slacks-based measure (slacks-based measure [SBM] data envelopment analysis [DEA]) model. This research aims to provide a comprehensive assessment of this companies' efficiency, taking into account both the desirable and undesirable outputs.Design/methodology/approachThe study uses a nonoriented, SBM model with the assumption of constant returns to scale to estimate the technical efficiency of commercial insurance companies over a five-year period. The inputs used are labor expense, agent expense and investments, while the outputs included are gross premiums and investment income as desirable outputs and gross claims as undesirable output.FindingsAmong 20 insurance companies evaluated, only 5 companies consistently achieved technical efficiency during the study period (Caisse Nationale de Mutualité Agricole [CNMA], MACIR, CARDIF, MUTUALISTE and AGLIC); so they represent the best practices in the Algerian insurance sector, with overall average of the technical efficiency is 81%. However, the reference sets analysis showed that CNMA and AGLIC had high robustness. Also, the results demonstrate the impact of ignoring the undesirable outputs on the accuracy of the assessment.Research limitations/implicationsThe sample of the study consists of the active insurance companies in Algeria, based on the Annual Insurance Reports of Algeria; there are 20 companies as shown in the table. The data are taken from the annual reports of insurance companies during the 2020 period, issued by the Algerian Ministry of Finance.Practical implicationsThe challenge for insurance company is how to find a balance between reducing claims paid and simultaneously improving the quality of insurance services. In fact, it is observed that studies evaluating their efficiency ignore claims in the analysis process. Therefore, the study highlights the importance of considering undesirable outputs within the DEA framework; this allows for a more accurate assessment of the company's performance and helps in improvement. Furthermore, although the insurance sector plays a crucial role, it has not received enough research attention compared to other financial sectors, especially in Arab and developing countries.Originality/valueThe literature on efficiency assessment in the insurance companies shows a lack of addressing undesirable outputs (such as claims) within the DEA framework; so this study aims at bridging this research gap. Also, the study provides an overview of the efficiency of Algerian insurance companies.

6.M. Workshop: Private equity investment in Europe’s primary care sector

Abstract This workshop explores the growing role of private equity funds in Europe's primary care sector. Based on a rapid response report of the European Observatory on Health Systems to the French National Health Insurance Fund (Caisse nationale de l’assurance maladie, CNAM), it offers a platform for sharing examples from across Europe, facilitating cross-country learning through country presentations and audience participation. Private equity investments in Europe’ health sector have increased exponentially in recent years, including in primary care, but this trend has so far received very little attention. This is surprising, as this development has the potential to change the healthcare landscape in Europe dramatically. The short investment and resale horizon of private equity funds and the emergence of practice chains and monopolistic structures are of particular concern. Ultimately, the growing private equity involvement in Europe's primary care sector could undermine equitable access to health care, reduce physicians’ autonomy, affect local or regional cooperation, erode data protection and raise health care costs. However, private equity investments may also be associated with benefits, such as providing needed capital or enabling employment for young physicians who want to work part-time or do not want to run a practice as entrepreneur. So far, there is little transparent information on ownership structures and very little research on the impact of private equity investments on outcomes, such as equity, access and quality of care. This workshop aims to provide a snapshot of trends in Europe and to inform current debates on how regulators should best respond. It provides an overview of the situation in four European countries (Germany, the Netherlands, Ireland and Sweden) and of policy responses so far. The workshop will provide opportunity for the audience to comment on and discuss the country presentations, share experience in their own countries, and consider policy options in Europe to improve transparency on ownership structures and ensure the interests of patients, the public, and health workers are protected. The workshop will be of interest to researchers, practitioners and policy-makers working on primary care in Europe. Key messages • The workshop provides a forum for discussing the growing role of private equity investment in Europe's primary care sector. • It explores regulatory options to safeguard the interests of patients, health workers and the public.

CHECGAIT: A Functional Electrical Stimulation Clinical Pathway to Reduce Foot Drop during Walking in Adult Patients with Upper Motor Neuron Lesions.

Foot drop during the swing phase of gait and at initial foot contact is a current kinematic abnormality that can occur following an upper motor neuron (UMN) lesion. Functional electrical stimulation (FES) of the common peroneal nerve through an assistive device is often used in neuro-rehabilitation to help patients regain mobility. Although there are FES-specific guideline recommendations, it remains a challenge for clinicians to appropriately select patients eligible for the daily use of FES devices, as very few health insurance systems cover its cost in Europe. In Luxembourg, since 2018, successfully completing an FES clinical pathway called CHECGAIT is a prerequisite to receiving financial coverage for FES devices from the national health fund (Caisse Nationale de Santé-CNS). This study describes the structure and steps of CHECGAIT and reports our experience with a cohort of 100 patients enrolled over a three-year period. The clinical and gait outcomes of all patients were retrospectively quantified, and a specific analysis was performed to highlight differences between patients with and without an FES device prescription at the end of a CHECGAIT. Several significant gait differences were found between these groups. These results and CHECGAIT may help clinicians to better select patients who can most benefit from this technology in their daily lives. In addition, CHECGAIT could provide significant savings to public health systems by avoiding unnecessary deliveries of FES devices.

Le programme PRADO–IC, programme d'aide au retour à domicile des patients insuffisants cardiaques : description, évaluation, perspectives

IntroductionReturn to home after discharge for congestive heart failure (CHF) is associated with prolonged and recurrent hospitalizations, the prognosis remains poor. Since 2013, the Caisse Nationale d'Assurance Maladie (CNAM) with the Société Française de Cardiologie (SFC) has set up a support program PRADO-IC (support program for returning home after hospitalization for heart failure). The aim of this studywas to describe the program, to present epidemiologic data, and the evaluations by the CNAM, and by clinical studies, then to expose strengths limits and perspectives. ResultsAfter the inclusion a CPAM advisor organize the outcome, the care of the outpatient is based on his general practitioner (GP) and a private nurse trained in CHF care during a three-months program. Between 2017 and 2019, 20 264 patients per year were hospitalized in Ile de France, 8.8% were included in PRADO-IC. The retrospective CNAM evaluations were positive: follow up criteria were improved and mortality rate at 6 months was lower (10.3% vs. 14.1%). However, clinical retrospective study of Troyes hospital (n = 89), and Paris Saint Joseph Hospital (n = 633), did not confirm these results: rate mortality and/or re-hospitalization were not different between patients and control. Several prospective studies are underway; results will be soon available.Limits of PRADO-IC are discussed like the lack of inclusion criteria, lack of geriatric evaluation, or the pivotal role based on GP, and the short term of duration. Strengths are its existence, national reach, multi-disciplinary approach, educational contents. Clinical studies showed that the PRADO-IC program concerned to the most severe patients. Despite this, the one-year mortality and the HF readmission rate are the same than out-program patients. ConclusionPRADO-IC is the one and the only national transition of care program for IC patients. First evaluations are positive but prospective evaluation studies are needed in order to limit methodologic bias.

Impact de l’alignement stratégique et de la culture digitale sur la réussite de la transformation digitale au sein de l’organisation publique Marocaine

Digital transformation is currently a hot topic and a strategic issue for all public and private organizations, regardless of their size. Having entered the "digital era", organizations are facing unprecedented transformations that disrupt their operations and management systems. However, the concept is new and it is not yet clear what factors influence or boost digital transformation. While previous theoretical and empirical work has allowed us to identify the impacts on the success of Digital transformation of the strategic alignment between the digital technologies implemented and the strategy of the public or private organization. Also, we have revealed that the digital culture is the guarantee of strategic coherence and success of the organization's digital transformation. The aim of this research project is to study the extent to which digital technology deployment projects are strategically aligned with the organization's overall strategy, and the degree to which digital culture impacts digital transformation within the organization. We mobilized a quantitative method by means of a questionnaire. A total of 52 respondents from the central entities of the Caisse Nationale de Sécurité Sociale (CNSS) completed the questionnaire. These were managers and executives involved in digital transformation initiatives. The theoretical model was tested using structural equation modeling. Analysis of the data collected using SMART PLS V4 highlights the crucial role of the CNSS establishment's strategy in value creation and the success of digital transformation. The results also indicate that to fully seize the opportunities and potential of this transformation, it is essential to embed a digital-focused organizational culture. In fine, the two hypotheses mobilized at the outset of the positive impact of strategic alignment and digital culture on the success of digital transformation are validated.

ECJ 8 December 2022, case C-731/21, (Caisse nationale d’assurance pension), Social Insurance

ECJ 8 December 2022, case C-731/21, (Caisse nationale d’assurance pension), Social Insurance

Association between Outdoor Air Pollution Exposure and Handgrip Strength: Findings from the French CONSTANCES Study.

Association between Outdoor Air Pollution Exposure and Handgrip Strength: Findings from the French CONSTANCES Study.

Outdoor air pollution exposure and cognitive performance: findings from the enrolment phase of the CONSTANCES cohort

Air pollution exposure is one of the modifiable risk factors of cognitive decline. We aimed to test the association between exposure to several outdoor air pollutants and domain-specific cognitive performance. In this cross-sectional study, we used data from the enrolment phase of the French CONSTANCES cohort. From the 220 000 people (aged 18-69 years) randomly recruited in the French CONSTANCES cohort, participants aged 45 years old or older (104 733 people) underwent a comprehensive cognitive assessment (verbal episodic memory, language skills, and executive functions). After exclusion of those who were not suitable for our analysis, 61 462 participants with available data were included in the analyses. We used annual mean concentrations at residential addresses, derived from land-use regression models, to assign exposure to particulate matter with aerodynamic diameters less than 2·5 μm (PM2·5), nitrogen dioxide (NO2), and black carbon. We used multiple linear regression models with different covariate adjustments to test the associations between each pollutant and cognitive outcomes. We did several sensitivity analyses, including multilevel modelling, meta-analysis by centre of recruitment, and exclusion of specific population groups. We found significantly poorer cognitive function, especially on semantic fluency and domains of executive functions, with an increase in exposure to black carbon and NO2. Exposure to PM2·5 was mainly significant for the semantic fluency test. We found that decrease in cognitive performance with an increase of one interquartile range of exposure ranged from 1% to nearly 5%. The largest effect size (percentage decrease) for both PM2.5 and NO2 was found for the semantic fluency test (PM2.5 4·6%, 95% CI 2·1-6·9 and NO2 3·8%, 1·9-5·7), whereas for black carbon, the largest effect size was found for the digit symbol substitution test of the domains of executive functions (4·5%, 2·7-6·3). Monotonic and linear exposure-response associations were found between air pollution exposure and cognitive performance, starting from a low level of exposures. Significantly poorer cognitive performance was associated with exposure to outdoor air pollution even at low levels of exposure. This highlights the importance of further efforts to reduce exposure to air pollution. The Caisse Nationale d'Assurance Maladie, and partly funded by Merck Sharp & Dohme and L'Oréal, the French National Research Agency, and Fondation de France. For the French translation of the abstract see Supplementary Materials section.

Blood inflammatory phenotypes were associated with distinct clinical expressions of asthma in adults from a large population-based cohort.

SummaryBackgroundAsthma is an inflammatory heterogeneous disease. Asthma inflammatory phenotypes based on blood eosinophil and neutrophil counts have never been identified and characterized in population-based studies.MethodsAdults with current asthma and available blood eosinophil and neutrophil counts from the French population-based CONSTANCES cohort were included. Current asthma was defined by reports of asthma attacks, symptoms or treatments in the last 12 months. Inflammatory phenotypes were based on low (L) and high (H) blood (B) eosinophil (E) (LBE/HBE: </⩾0·25 × 109/L, respectively) and neutrophil (N) (LBN/HBN: </⩾5 × 109/L, respectively) cut-offs. Associations between inflammatory phenotypes and the clinical expressions of asthma were studied using logistic models adjusted for age, sex, smoking status, body mass index, education level, French deprivation index and treatment. Other cut-offs were applied. Stratified analyses according to age or sex were performed.FindingsAmong 15,019 adults with asthma (56% women, 59%≥40 years), the LBE/LBN (reference), LBE/HBN, HBE/LBN and HBE/HBN phenotypes accounted for 57%, 6%, 33% and 4% respectively. The LBE/HBN phenotype was associated with being awaken by an attack of coughing, chronic bronchitis, and dyspnoea (adjusted(a)OR ranging from 1·21 to 1·42). The HBE/LBN and HBE/HBN phenotypes were associated with asthma attacks (aOR=1·31[1·20-1·42], 1·25[1·02-1·53]) and asthma symptom score (p for trend<0·0001, p for trend=0·001, respectively). The HBE/LBN phenotype was also associated with being awaken with chest tightness (aOR=1·30[1·20-1·40]). Results were unchanged whatever the cut-offs used. No statistically significant heterogeneity was observed according to age or sex.InterpretationDifferences in the clinical expressions of asthma were found between the phenotypes, reproducible whatever the cut-offs used, and similar to those observed in case-control and clinical studies. Such phenotypes are of interest to improve asthma management and study its environmental risk factors.FundingThe CONSTANCES cohort receives grants from ANR (ANR-11-INBS-0002), the Caisse nationale d'assurance maladie-CNAM and the Ministry of research. CONSTANCES also receives funding from MSD, AstraZeneca, Lundbeck and L'Oréal, managed by INSERM-Transfert. T.Tsiavia is supported by a PhD grant from the Fondation pour le Recherche Médicale (ECO202006011654).

L’expertise collective de l’Inserm sur le trouble développemental de la coordination ou dyspraxie : état des principaux travaux et recommandations

This current article presents the main work of the experts gathered by INSERM within the framework of the collective expertise procedure attached to the Institute of Public Health to respond to the request of the Caisse nationale de solidarité pour l’autonomie (French National Solidarity Fund for Autonomy) concerning the support and care of people with a developmental coordination disorder (DCD) or dyspraxia. This report (synthesis, analyses and recommendations) was published in December 2019. The work of the experts has made it possible to review the scientific knowledges on developmental coordination disorder at both national and international levels based on the available scientific literature. In this synthesis, we will attempt to present the essential points of the analyses and recommendations resulting from the work of the experts group concerning terminology, typology, epidemiology, brain imaging, genetics, sensory-motor and cognitive deficits, writing disorders, impact on activities of daily living, identification and diagnosis. International studies on DCD show recurrent methodological bias and DCD is a generic term poorly defined by the DSM-5, for which the diagnosis includes a necessary but insufficient standardized assessment of motor coordination. Developmental tests assessing the maturation of neuromotor development underlying motor function should complement the assertion of the diagnosis, as well as other multidimensional investigations of cognitive, sensorial and motor function in order to make a differential diagnosis and report a typology. In addition, the individual impact of the disability on activities, participation and quality of life must be evaluated, not only in childhood but also as adults.

Incidence of Dacryocystorhinostomy (DCR) in France: A Nationwide Study over the 2010-2019 Period

ABSTRACT Background To assess the annual incidence, surgical technique preferred (i.e. external versus endonasal) and the characteristics of patients undergoing a Dacryocystorhinostomy (DCR) in France over a 10-year-period. Methods A national observational cohort study was conducted in France between January 2010 and December 2019. Data were collected from the national PMSI (Programme de Médicalisation des Sytèmes d’Information) database provided by the CNAM (Caisse Nationale de l’Assurance Maladie). All patients undergoing a DCR were included. Results Twenty-one thousand one hundred ninety-nine patients, with a mean age of 70.4 years, were included. A female predominance (78%) was noted. The mean annual number of DCRs was 2481 (2366–2633), corresponding to a mean incidence of 3.8 per 100,000 person-years. This number remained stable over the study period (p = .966). Of the 24,808 DCRs, external DCRs were more prevalent compared to endonasal procedures (70.8% vs. 29.2%, p = .0001). Six hundred and fifteen (2.5%) associated acts were performed intraoperatively, mainly during endonasal DCR (96.3%). A total of 10,857 (43.8%) silicone stents were placed intraoperatively. Bicanalicular silicone stenting was preferred over the monocanalicular stenting. All the regions performed more likely external DCR except the Île-de-France area where endonasal DCR was performed in 75.6% of procedures. DCRs were mainly performed by an ophthalmologist (80%). Conclusion The mean annual incidence of external and endonasal DCRs remained stable over the study period. Endonasal DCR was more likely performed by the otorhinolaryngologists, emphasizing the need to develop personalized endonasal training in the ophthalmology residency program.

Incidence of Orbital Exenteration: A Nationwide Study in France over the 2006-2017 Period

ABSTRACT Purpose Orbital exenteration is a radical and disfiguring surgery mainly performed for treating orbital malignancies. Recently, several studies found favorable results in terms of overall survival with eye-sparing surgeries combined with targeted therapies and/or radiotherapy. The aim of this study was to assess the incidence of orbital exenteration and its evolution in France between 2006 and 2017. Methods A national observational cohort study was conducted in France between January 2006 and December 2017. Data were collected from the national PMSI (Programme de Médicalisation des Systèmes d’Information) database provided by the CNAM (Caisse Nationale de l’Assurance Maladie). All patients undergoing orbital exenteration over the study period in France were included. Results One thousand and fifty-seven patients were included. The mean annual number of orbital exenterations was 88.1 (63–117), corresponding to a mean incidence of 0.1/100,000 inhabitants/year. A male predominance was noted (n = 626, 59.2%). Exenteration was mainly performed between 75 and 79 years. The underlying etiology was available for 821 patients (77.7%): malignancies were the most common (n = 755; 92.0%) followed by infectious diseases (n = 16; 1.9%). Over the study period, no statistical difference in the mean incidence of orbital exenteration was found (p = .132). Conclusion The mean annual incidence of orbital exenteration was 0.1/100,000 inhabitants in France and was not significantly modified during the study period.

Is the incidence of motor neuron disease higher in French military personnel?

Objective: Previous studies, mostly from the United States, showed an increased risk of motor neuron disease (MND) in military personnel. We compared MND incidence rates in French military personnel to that in the general population. Methods: Among persons covered between 2010 and 2016 by the Caisse Nationale Militaire de Sécurité Sociale (CNMSS, military personnel) and the Caisse Nationale d’Assurance Maladie des Travailleurs Salariés (CNAMTS, general population) aged ≥50 years, we identified incident MND cases and estimated populations at risk using national health insurance databases. We estimated relative risks (RRs) and 95% confidence intervals (CIs) separately for men and women using age-adjusted Poisson regression. Analyses were also stratified by 10-year age groups. We used the E-value approach and probabilistic bias analysis to assess robustness of the results regarding unmeasured confounding by smoking. Results: On average, 25 cases/year were newly diagnosed with MND among military personnel aged ≥50 years. The incidence rate was higher for male military personnel compared to the general population (RR = 1.16; 95% CI = 1.05–1.29) but was similar for women (RR = 1.02; 95% CI = 0.79–1.31). Although there were no significant interactions with age and sex, the association was mainly explained by men aged 70–79 years. The prevalence of ever-smoking should be at least 1.1-fold higher in male CNMSS compared to male CNAMTS members to make the association in male military personnel not significant. Conclusion: MND incidence was 16% higher in French male military personnel, in agreement with studies from other countries. Smoking may contribute to this finding. Further studies are needed to identify exposures that drive this association.

Causes of nonfatal occupational injury in the private sector in Tunisia

The absence of studies that investigate the causes and risk factors of nonfatal occupational injury in Tunisia inhibits the development of effective preventive strategies. The objective of this study was to identify the causes and risk factors of nonfatal occupational injury in the private sector in Tunisia. We used retrospective data derived from the occupational injury reporting forms submitted to the Caisse Nationale d'Assurance Maladie. A sample of 42,293 workers in the private sector for 2014 contains information on sociodemographic variables. Multivariable Poisson regression was used to investigate the association of cause-specific injury with demographic variables. The leading causes of nonfatal occupational injury were "falls" (employee fall and falling objects; 36%) and "struck by objects" (23%). Male employees were at higher risk of "exposure to extreme temperatures" (PR = 12 [7-45]), "asphyxia and poisoning" (PR = 4 [2.4-12]), "transport and handling" (PR = 2.4 [1.9-5]), "falling objects" (PR = 2.3 [1.4-3.7]), and "employee fall" (PR = 1.2 [1.1-1.5]). Although, rural areas were at higher risk to "asphyxia and poisoning" (PR = 3.6 [1.1-11.4]), "transport and handling" (PR = 2.5 [1.3-5.4]), and "burns" (PR = 1.3 [1.1-3]). It is important that effective interventions be developed to minimize the impact of falls and "struck by objects." The most vulnerable categories to occupational injury are less educated men, rural residents aged between 15 years and 24 years, and elderly employees (55 years and over). Thus, our findings can contribute to the planning of prevention intervention programs that should expand to the most vulnerable categories.

Impact of the obstructive sleep hypopnea-apnea syndrom treated on employment for military employment

The diurnal hypersomnia associated with obstructive sleep apnea (OSA) affects soldier employment and deployability. In this study, we examined the impact of OSA on the employment of soldiers on continuous positive airways pressure (CPAP) therapy by measuring several items: work absenteeism using the Work Productivity and Activity Impairment (WPAI) questionnaire, diurnal hypersomnia, and career advancement. A questionnaire was sent by regular mail to 940 soldiers with OSA on CPAP therapy who are insured by the French Military Healthcare Fund (Caisse Nationale Militaire de Sécurité Sociale). Questionnaires were returned by 439 soldiers: mean age 47 years; mean body mass index 29.8kg/m2. Absenteeism reached 0.45%, and work productivity impairment 8.7%. Hypersomnia was reported by 15.4% and was severe for 9.7%. The average daily working time was 6.5hours. Quality of life was improved for 91.1%. The military practitioner had diagnosed OSA in 19.6% of these soldiers and had prescribed treatment in 14.9%. Residual OSA in these soldiers on CPAP therapy had little impact on work productivity impairment that was less than observed in populations with chronic diseases. In our study population, hypersomnia was less common than observed in the general population. An impact on career advancement could not be clearly demonstrated. Close medical follow-up is warranted in certain populations due to the persistence of severe somnolence in a significant number of patients.

Military and risk of motor neurone disease: A French nationwide case-control study

Introduction There is evidence of an increased risk of motor neuron disease (MND) in military that is mainly based on studies performed in the US. We used health insurance databases to conduct a French nationwide case-control study in order to study the association between being military and MND. Methods We identified incident MND cases between 2010 and 2015 in France using a previously developed algorithm that is based on drug claims (Riluzole), hospitalization records (ICD-10 code G122), and benefits for long-term chronic diseases. Each case was randomly matched on age, sex, and residency area (departement) to 10 controls selected among all persons who were reimbursed any health care during the year of incidence of the matched case. We defined military personnel as persons affiliated to the “Caisse Nationale Militaire de Securite Sociale” (CNMSS) or the general scheme of the social security with a military status. We examined the association between military and MND using conditional logistic regression in order to compute odds ratios (ORs) and 95% confidence intervals (95% CI). All analyses were performed separately in men and women. We also performed analyses restricted to retired military (specific code for retired CNMSS affiliates). Results Of all the MND cases identified in France during the study period (n = 13,082), 12,729 (97%) had correct data for the matching variables and information on type of social security; they were matched to 127,283 controls. Among cases, mean age at incidence year was 67 years in men and 70 years in women, and 55% were men. The proportion of military was of 1.8% and 1.6% among male cases and controls, and of 0.7% and 0.8% among female cases and controls. There was no association between military and MND in women (OR = 0.89; 95% CI: 0.65–1.23). In men, there was a trend towards a small increased risk of MND both for military overall (OR = 1.13; 95% CI: 0.94–1.36) and retired military (OR = 1.16; 95% CI: 0.95–1.43) that was not statistically significant. Conclusion This French nationwide study did not show a statistically increased risk of MND among military personnel between 2010 and 2015, although there was a trend towards a small increased risk in men. The broad definition of military in our study that includes workers with different occupations and professional exposures is a limitation of our study. We plan to pursue these analyses by adjusting for additional covariates and extending the study period.

Out-of-pocket health spending and equity implications in Tunisia

Using data from 2000, 2005 and 2010 national household budget and consumption surveys, this paper examines the scope of catastrophic out-of-pocket (OOP) health expenditures in Tunisia and their distribution. It analyses their evolution since 2000 in relation to policy reforms in Tunisia especially since a new national health insurance fund (Caisse Nationale d’Assurance Maladie (CNAM)) became effective in 2007. The paper assesses the catastrophic dimension of OOP payments by calculating their incidence and their intensity at several thresholds and by analyzing their distribution throughout concentration indices. Estimating a probit model, the paper explores the determinants of catastrophic payments and identifies the characteristics of households coping with higher risk of catastrophic health expenditures. Finally, questioning whether the catastrophic payments have impoverishing effects on households, the paper estimates the percentage of households who move below the poverty line when accounting for OOP health payments. The paper concludes that the lasting importance of health OOP expenditures in Tunisia, their catastrophic dimension and their impoverishing effect make it necessary to look for a better allocation of the existing resources through more efficient financing mechanisms and better institutional arrangements.

Epidemiology of multiple sclerosis

Multiple sclerosis (MS) is the most frequently seen demyelinating disease, with a prevalence that varies considerably, from high levels in North America and Europe (>100/100,000 inhabitants) to low rates in Eastern Asia and sub-Saharan Africa (2/100,000 population). Knowledge of the geographical distribution of the disease and its survival data, and a better understanding of the natural history of the disease, have improved our understanding of the respective roles of endogenous and exogenous causes of MS. Concerning mortality, in a large French cohort of 27,603 patients, there was no difference between MS patients and controls in the first 20 years of the disease, although life expectancy was reduced by 6–7 years in MS patients. In 2004, the prevalence of MS in France was 94.7/100,000 population, according to data from the French National Health Insurance Agency for Salaried Workers (Caisse nationale d’assurance maladie des travailleurs Salariés [CNAM-TS]), which insures 87% of the French population. This prevalence was higher in the North and East of France. In several countries, including France, the gender ratio for MS incidence (women/men) went from 2/1 to 3/1 from the 1950s to the 2000s, but only for the relapsing–remitting form. As for risk factors of MS, the most pertinent environmental factors are infection with Epstein-Barr virus (EBV), especially if it arises after childhood and is symptomatic. The role of smoking in MS risk has been confirmed, but is modest. In contrast, vaccines, stress, traumatic events and allergies have not been identified as risk factors, while the involvement of vitamin D has yet to be confirmed. From a genetic point of view, the association between HLA-DRB1*15:01 and a high risk of MS has been known for decades. More recently, immunogenetic markers have been identified (IL2RA, IL7RA) and, in particular thanks to studies of genome-wide associations, more than 100 genetic variants have been reported. Most of these are involved in the immune response and often associated with other autoimmune diseases. Studies of the natural history of MS suggest it is a two-phase disease: in the first phase, inflammation is focal with flares; and in the second phase, disability progresses independently of focal inflammation. This has clear implications for therapy. Age may also be a key factor in the phenotype of the disease. In conclusion, France is a high-risk country for MS, but it only slightly reduces life expectancy. MS is a multifactorial disease and the implications of immunogenetics are major. Preventative approaches might be derived from knowledge of the risk factors and natural history of the disease (smoking, vitamin D).

What type of support for children with disorders of motor skills?

The difficulties of defining the concepts of praxies and coordination during the development of the child are linked with recent debates and consensus-building regarding the diagnostic criteria for the developmental coordination disorder (DCD), dyspraxia, disorders of motor skills. The relevance of the proposed therapeutic approach logically depends on the clarity of the identification of disorders; in the current state of knowledge, support for children “DD” or “DCD” is still not consolidated. We report the recommendations established by certain organizations or scientific societies (Economic and Social Research Council Leeds 2006, INSERM 2007, European Academy for Childhood Disability 2012, Réseau Régional de Rééducation et Réadaptation Pédiatrique 2012, Caisse Nationale de Solidarité pour l’Autonomie 2014) as well as the therapeutic proposals published by the clinicians and researchers particularly invested in this area (Albaret, Gerard, Mazeau…). Our service at the Hôpitaux de Saint-Maurice has developed experience in the diagnostic and therapeutic support for children with developmental dyspraxia and children with praxic disorders associated with early brain damage. This leads us today, in the light of the recent work on the difficult passage of the assessment to the rehabilitation. Which place to give to approaches oriented on the deficit or functional performance? Is it possible to codify criteria of indication of adaptations (including computer) and their learning? What therapeutic strategy in the event of co-morbidity?

Infectious risk of biological drugs versus conventional systemic treatments in moderate to severe psoriasis

INfeCTIouS rISk of bIologICal drugS VerSuS CoNVeNTIoNal SySTemIC TreaTmeNTS IN moderaTe To SeVere pSorIaSIS S. Couderc; R. Bourrel; C. Paul; J.L. Montastruc; M. Lapeyre-Mestre; and A. Sommet UMR 1027, Inserm, Universite Toulouse III, Toulouse, France; Caisse Nationale d’Assurance Maladie Midi-Pyrenees, Toulouse, France; Service de Dermatologie, Centre Hospitalier Universitaire, Toulouse, France; and Pharmacologie Medicale et Clinique, Centre Hospitalier Universitaire, Toulouse, France Introduction: Moderate to severe psoriasis affects about 0.5% of the population. Its management is based on conventional systemic treatments (TSC: phototherapy, acitretin, methotrexate, and cyclosporine) and biological second-line drugs (etanercept, infliximab, ustekinumab, adalimumab, golimumab). Results of studies comparing the infectious risk of TSC and biological drugs are divergent. Objective: To compare the infectious risk associated with biological drugs versus TSC for moderate to severe psoriasis. Material and Methods: We conducted a retrospective cohort in the French Health Insurance Database for the Midi-Pyrenees region from 01/01/2010 to 31/12/2013, with patients treated incidentally for moderate to severe psoriasis. After a 6-month observation period with all patients exposed to TSC, we compared patients exposed to biological drugs (“exposed”) versus TSC (“unexposed”). We performed a Cox model on the first infectious event, for up to 6 months after the last dispensation of psoriasis drug. An infectious event was defined as delivery of any anti-infectious systemic drug or a hospital diagnosis of infection. Results: The 101 “exposed: patients and 788 “unexposed” patients were comparable in terms of socio-demographic data and comorbidities. Considering the first infectious event over a period of 2 years, no significant difference was found between “exposed” and “unexposed” (HR = 0.94; 95% CI, 0.71–1.22; P = 0.62). Being a woman (HR = 1.23), benefit from the Universal Health Coverage (HR = 1.44), suffering from chronic hepatitis B or C (HR = 2.74), history of neoplasia (HR = 1.70), a previous infectious event during the observation period (HR = 1.74), and the number of drugs consumed during the observation period (HR = 1.03) significantly increased the risk of infection. Conclusions: We did not reveal any difference in infection risk between the TSC and biological drugs in the management of moderate to severe psoriasis. This risk appears constant the first 2 years of use.