French Health System Research Articles

Cross-cultural adaptation of the Quebecois Patient-Centered Coordination by a Care Team Questionnaire for use in France

BackgroundThe prevalence of chronic disease and multimorbidity is increasing and the associated disease and treatment burden is particularly heavy. Coordinated multidisciplinary, patient-centered care is particularly important for people living with chronic disease or multimorbidity. There was no valid tool to measure the quality of coordinated patient-centered care from the patient’s perspective until the Patient-Centered Coordination by a Care Team (PCCCT) questionnaire was recently developed in Canada (Quebec/Ontario). The Quebecois version has been validated but is not directly transferable to France due to linguistic, cultural and health system differences between the two countries. To perform a cross-cultural adaptation of the Quebecois PCCCT questionnaire is therefore necessary to obtain a questionnaire’s new version adapted for use in France, ensuring item and semantic equivalence.MethodsThe adaptation process consisted of two stages, both of which were supervised by a scientific committee made up of five healthcare professionals. The first stage was a Delphi consensus involving a multidisciplinary healthcare professional panel to evaluate and harmonize the clarity and appropriateness of the questionnaire for patients in the French health system. During the second stage, adult patients with one or more chronic diseases, from various age, sex, socio-occupational categories, assessed the comprehensibility and conformity of the adapted version of the questionnaire resulting from stage 1 and improved it if necessary. This was achieved using cognitive interviews.ResultsDuring Stage 1, two rounds were undertaken with 10 professional experts resulting in consensual reformulation of 10 out of the 14 items. These newly formulated items and the 4 remaining items were submitted to patients in Stage 2. Cognitive interviews were undertaken with 14 patients, testing 3 successively adapted versions of the questionnaire, until three consecutive patients did not find any ambiguity or misunderstanding. The final version resulting from the cross-cultural adaptation process aimed at being used in France, has item and semantic equivalence to the original Quebecois version.ConclusionsMeasurement equivalence will be addressed in a future study. This French version is intended to be a useful resource for the health system reforms aimed at promoting more integrated and patient-centered care pathways.

Incidence, In-Hospital and Long-Term Mortality, and Sequelae of Epidermal Necrolysis in Adults

The incidence of epidermal necrolysis (EN), including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), varies across studies. While in-hospital mortality rates range from 15% to 20%, contributors to long-term mortality have been rarely evaluated and remain unknown. To assess the incidence of and compare factors associated with in-hospital mortality and postdischarge mortality and sequelae among patients with EN. This cohort study used French Health System data from January 1, 2013, to December 31, 2022, and included all adult patients (aged ≥18 years) with EN identified using International Statistical Classification of Diseases, Tenth Revision codes combined with a validated algorithm. Epidermal necrolysis. Incidence, in-hospital mortality, postdischarge mortality, and sequelae were assessed as main outcomes. Factors associated with mortality were assessed using a multivariable Cox proportional hazards model. A total of 1221 adult patients with EN (median [IQR] age, 66 [49-79] years; 688 females [56.3%]) were included. Incidence was 2.6 (95% CI, 2.5-2.7) cases per million person-years. The in-hospital mortality rate was 19% (95% CI, 17%-21%) and postdischarge mortality rate, 15% (95% CI, 13%-17%) for an overall mortality of 34% (95% CI, 31%-36%). In multivariable analysis, factors associated with in-hospital mortality were age (adjusted hazard ratio [AHR], 1.03 per year of age; 95% CI, 1.02-1.04 per year of age), history of cancer (AHR, 2.04; 95% CI, 1.53-2.72), dementia (AHR, 1.85; 95% CI, 1.12-3.07), liver disease (AHR, 1.81; 95% CI, 1.24-2.64), and EN severity (TEN vs SJS: AHR, 2.14; 95% CI, 1.49-3.07). Cancer, liver disease, and dementia remained associated with postdischarge mortality (AHR, 3.26 [95% CI, 2.35-4.53], 1.86 [95% CI, 1.11-3.13], and 1.95 [95% CI, 1.11-3.43], respectively). Conversely, EN initial severity was not associated with mortality after hospital discharge (TEN vs SJS: AHR, 0.95; 95% CI, 0.60-1.47), but acute complications remained associated (AHR, 2.14 [95% CI, 1.26-3.63] and 2.44 [95% CI, 1.42-4.18] for acute kidney injury and sepsis, respectively). The main sequelae were ophthalmologic and mood disorders. The findings of this cohort study suggest that although EN is a rare condition, it is associated with high rates of in-hospital and postdischarge mortality among patients who are older and have comorbid conditions. However, in contrast with in-hospital mortality, postdischarge mortality is not associated with EN initial severity but with acute in-hospital complications (eg, acute kidney injury and sepsis). Future studies are needed to construct models to estimate long-term outcomes and sequelae in patients with EN.

CAP, comprendre, agir et partager : une boite à outils made in Nouvelle Aquitaine pour accompagner les établissements dans leur transformation écologique

In the face of climate change, Health is mobilizing to find solutions and reduce its environmental impact. The CAP (Understand, Act and Share) sustainable hospital toolbox cited in the roadmap for the Ecological Planning of the French Health System offers 3 original, operational and complementary tools to (1) acculturate professionals in the sector (Plan Health Faire®), (2) build the establishment strategy (2030 Agenda), and (3) take action with healthcare professionals (The Sustainable Units program).

Comparison of incidence, causes and prognosis of adultand paediatric epidermal necrolysis: a French population-based study.

Epidermal necrolysis (EN), comprising Stevens-Johnson syndrome and toxic EN, is a rare and severe blistering reaction, mainly induced by drugs. Differences between paediatric and adult patients regarding incidence, causes and outcomes have been discussed but are based on a limited number of patients from small case series. To directly compare the incidence, cause and prognosis of adult and paediatric EN. We used data from the French Health System Database (1 January 2013-31 December 2022). We identified adult and paediatric patients hospitalized for EN using the International Classification of Diseases, 10th Revision codes combined with validated algorithms. Outcomes were the incidence of EN; the presence of a suspected drug before EN onset (defined as a new drug dispensation from 5 to 56 days prehospitalization); and in-hospital mortality. To estimate the association between paediatric EN and the presence of a suspect drug, we computed a multivariable logistic regression with odd ratios (ORs). To estimate the association with mortality, we computed a multivariable Cox proportional hazard ratio (HR) model. A total of 1440 patients [799 (55.5%) female] with EN were included, comprising 219 children and 1221 adults. Among children, the incidence of EN was 1.5 cases [95% confidence interval (CI) 1.3-1.7] per 1 million person-years vs. 2.6 cases (95% CI 2.5-2.7) in adults. Moreover, children had less chance of being given a culprit drug before the onset of EN [n = 93/219 (42.5%) vs. n = 829/1221 (67.9%)], with an adjusted OR of 0.43 (95% CI 0.32-0.59; P < 0.001), together with a better prognosis: the mortality rate in paediatric patients was 1.4% (95% CI 0.4-3.7) vs. 19.4% (95% CI 17.3-21.7) in adults. The adjusted HR for in-hospital mortality in children was 0.12 (95% CI 0.04-0.38; P < 0.001). Paediatric EN appears to be rarer, with less chance of being caused by drugs and has a better prognosis than adult EN. These results suggest the existence of different underlying pathophysiological mechanisms and clinical particularities between adult and paediatric patients with EN.

Determining the cost-effectiveness of follitropin alfa biosimilar compared to follitropin alfa originator in women undergoing fertility treatment in France

ObjectiveThe study assessed cost-effectiveness of follitropin alfa biosimilar versus the originator in terms of cost per cumulative live-birth (CLB) for the French healthcare system based on real-world evidence. Follitropin alfa biosimilars have been shown to have comparable clinical outcomes to the originator, in both clinical studies and real-world settings, in terms of oocyte retrieval and cumulative live-birth rate (CLBR). Previous health economic studies comparing the cost-effectiveness of follitropin alfa biosimilars against the originator utilised clinical trial data, leaving ambiguity over cost-effectiveness in real-world settings. Additionally, previous cost-effectiveness analysis has been performed for live-births following only fresh embryo transfers, whereas, fresh and frozen transfers are common in clinical practice. This study investigates the cost per CLB, which more closely models clinical practice. Study designA decision-tree cost-effectiveness model was developed based on the total costs and CLBR per ovarian stimulation (OS) for a follitropin alfa biosimilar (Bemfola®, Gedeon Richter Plc, Budapest, Hungary) and the originator (Gonal-f®, Merck KGaA, Darmstadt, Germany). A time horizon of one year from oocyte retrieval to embryo transfer was used but costs from resulting transfers were also included. Clinical inputs were taken from the REOLA real-world study or clinician insights, while acquisition costs were taken from French public databases. The output was cost per CLB following one OS. One-way sensitivity analysis was performed to determine the largest model drivers. ResultsCost per CLB was €18,147 with follitropin alfa biosimilar and €18,834 with the originator, saving €687 per CLB following OS with the biosimilar. When wastage estimates were considered the biosimilar cost saving is estimated to be between €796 and €1,155 per CLB further increasing cost savings. Irrespective of wastage, if used ubiquitously throughout France for ART, the biosimilar could save the French health system €13,994,190 or lead to 771 more births when compared to its higher-cost originator. Sensitivity analysis showed that the originator’s relative CLBR had the greatest impact on the model. ConclusionThis analysis demonstrates that the follitropin alfa biosimilar, Bemfola®, is a more cost-effective option for OS compared with the originator from a French healthcare payer perspective, in terms of cost per CLB.

Use of qualitative methods to optimize collaborative practices by highlighting differences in perceptions between professionals: an example of patient education

ABSTRACT Interprofessional working must be approached within health promotion interventions using systematic methods to identify areas of suboptimal collaboration. We designed a qualitative study with a purposive sample of seven French therapeutic patient education programs. Semi-structured individual interviews were conducted with 14 healthcare providers and seven clinician leaders (coordinators) involved in patient education. We used the same interview guide and thematic grid regardless of the professional’s profile to compare their perceptions on elements affecting outcome, participation and sustainability of programs. Healthcare providers and coordinators addressed non-convergent issues at both ends of a continuum from a micro-level nested in the program delivery to a macro-level corresponding to the structured implementation and sustainability of the program. Meso-level issues featured convergent perspectives. Our methodology could be used at the level of health services in a health system to provide a complete recovery of stakeholders’ perspectives (without “blind spots” from one stakeholder or another). In our study, we focused on patient education in the French health system and pointed out possible considerations to optimize the functioning of programs. Such considerations include specific training plan development, encouraging reflection on the content and use of initial assessment, leading sessions in pairs to save on work time, and communication on the ins and outs of organizational imperatives that require healthcare providers’ contributions.

The deployment of advanced practice nurses in the French health system: From clinics to professional networks.

The aim of this study is to contribute to an understanding of the role deployment of advanced practice nurses (APNs) in French healthcare settings. The introduction of APNs was formalised in France by the decrees issued on 18 July 2018, which described the areas, activities and training of APNs. A qualitative study on the role implementation of APNs was conducted between July 2021 and May 2022 following a call for projects launched by the Île-de-France Regional Health Agency to evaluate the deployment of APNs in the area. Data were collected through field observations and semi-structured interviews in order to explore both the APNs deployment processes in nine healthcare structures and the roles played by APN networks and associations with regard to the deployment of APN activities in their working environments. The projects proved to be evolutionary, and their development was marked by various forms of APN isolation and multiple obstacles that were specific to their professional practice settings. Some APNs relied on a variety of forms of mutual assistance and advocacy deployed throughout APN networks and associations. The deployment of APNs' role was impacted by diverse configurations of professional power relations and the nature of the obstacles that were structural for APNs in primary care. Their experience of isolation derived from the novelty of their role, the challenge they posed to the cohesion of the nursing profession and a lack of supportive policies for their deployment. Their participation in APN networks and associations enabled them to access advocacy and manage the uncertainties and unknowns related to the deployment of their activities. The results suggest that the formalisation of schemes for mutual assistance among APNs and advocacy should be integrated into the guidelines for the implementation of their role. APN policy should strengthen a bottom-up approach, relying in particular on the development of different forms of collaboration and communication between APN networks and associations on the one hand and the public authorities on the other.

New Public Management, Austerity, and the Alienation of the Medical Profession in France.

In the last twenty years, France has gone through health policy changes that are perceived as paradigm shifts. After briefly describing the reforms driven by the new public management and the subsequent re-centralization of the French health system for budgetary purposes, it appears that those reforms had outcomes below expectations. The regrouping of policy decisions within the Regional Health Agencies and the rise of a French Welfare elite weakened the medical profession. Blame-shifting strategy, political dilution, and spatial inequality linger. The COVID-19 epidemic highlights those limitations. The negative societal and political impact of failed public reforms is increasingly evident.

Agencification, policy reversal and the reforms of the French health care system

PurposeOften linked to the New Public Management (NPM) doctrines, agencification has been on the priority list of policy makers for over two decades. This article proposes an analysis of the role of agencies in the French health system and the impact of government agency reform on physicians and the public.Design/methodology/approachThe research analyzes the perceived implementation of a re-concentration of decision-making powers within public agencies as the declared goal of agencification at the French health care system, specifically primary care providers and hospitals. The assessment relies on secondary sources from ministerial bodies such as the Ministry of Health and Social Affairs, the Ministry of Labor, the Social Security and the General Accounting Office, and specialized French technical agencies.FindingsDecentralization in France and the subsequent rise of public health care agencies had outcomes below expectations. Hence, a re-concentration of decision-making powers within the larger Regional Health Agencies; a streamlining of the public administration; and a re-appropriation of decision-making powers by the Ministry of Health are needed. The monitoring of health providers allows central health authorities to govern at a distance.Originality/valueThe analysis of health care agencies in France and of their use of efficiency-enhancing techniques may trigger a change of values within the medical profession.

Prevention of Rhesus-D Alloimmunization in the First Trimester of Pregnancy: Economic Analysis of Three Management Strategies

Anti-D alloimmunization in the first trimester of pregnancy has long been the subject of prevention with anti-D immunoglobulins during events at risk of fetomaternal hemorrhage. Although the efficacy of preventing anti-D alloimmunization by an injection of immunoglobulin at 28 weeks of gestation (WG) is obvious, the literature provides little evidence of the effectiveness before 12+6 WG and several countries have modified their recommendations. In the presumed absence of a difference in alloimmunization risk between early and late prevention, our objective was to evaluate and compare the cost of treatment for 3 alloimmunization prevention strategies in France, the United Kingdom, and the Netherlands. This was a single-center retrospective study. Our target population included all women who received anti-D immunoglobulins (Rhophylac) in the first trimester of pregnancy before 12+6 WG at Nantes University Hospital in 2018 (N = 356). Within the target population, 2 other populations were constituted based on British (N = 145) and Dutch (N = 142) clinical practice guidelines (CPG). These 3 populations were analyzed for the comparative cost of treatment for prevention from a health system perspective. The average cost of Rhophylac alloimmunization prevention for 1 episode was €117.8 from a health system perspective. The total cost attributed to prevention in 2018 at Nantes University Hospital (N = 356) was €41,931.4 according to this perspective. If the UK CPG or Dutch CPG had been applied to the Nantes target population, a saving of around 60% would have been achieved. At the national level, the cost according to the health system perspective specifically attributable to induced abortion (N estimated = 26,916) could represent a total cost of €3,170,704. This study highlighted the high cost of the French prevention strategy in the first trimester of pregnancy compared with British or Dutch strategies. The modification of our practices would allow substantial financial savings to the French health system but would also avoid the nonrecommended exposure to a blood product at this term, would allow a faster medical management and a relief of the care system.

Nursing boundaries and work identity construction among nurses exercising an advanced role: A qualitative study

Research on the deployment of advanced practice nurses (APNs) in healthcare settings highlights significant challenges for APNs transitioning to a broader, less well-defined nursing role in negotiating professional boundaries and a new work identity with other health workers. However, theories of boundary-work and professional identity have been rarely applied to APNs relationships with general nurses and colleagues in lower professional position such as nursing-assistants. APNs relationships with these colleagues remain poorly understood. This article aims to contribute to addressing this gap. It is based on qualitative research on a pilot-project prefiguring the introduction of APN (pre-APN) in the French Health system entitled the Prefiguration of Clinical Nurse Specialists (PrefICS). Data were collected through field observations and interviews with pre-APNs, general nurses, nursing-assistants, doctors and nursing hierarchy, to assess the implementation of PrefICS project in four hospitals, one health centre and one cancer control centre. The analysis shows that facing the risk of their role being limited to collaborations with doctors, pre-APNs engaged in different forms of boundary-work with general nurses and nursing-assistants, to negotiate new professional relationships with these colleagues. Some pre-APNs presented themselves as resource persons and led activities aimed at developing and sharing nursing knowledges and competencies with general nurses and nursing-assistants. Other pre-APNs shaped their work identity around a reformist role in terms of both the nursing profession and work environments. Pre-APNs boundary work with general nurses and nursing-assistants produced work spaces in which pre-APNs interwove their work identity with these colleagues by negotiating new professional ties and brokering knowledges between different professional worlds. Changes in levels of pre-APN self-categorization reflected different views of the nursing and nursing-assistant professions, from which pre-APNs started building new alliances for a shared reflective work on their practice and about caring.

P-457 A biosimilar FSH is a cost-effective option for women undergoing IVF/ICSI treatment in France

Abstract Study question Is Bemfola® a cost-effective treatment option compared to Gonal-f® for women undergoing IVF/ICSI treatment in France based on real-world evidence? Summary answer Bemfola® is a cost-effective treatment option, based on real-world evidence, demonstrating lower gonadotropin costs per live-birth following one ovarian stimulation cycle compared to Gonal-f®. What is known already Since Bemfola®’s first launch in 2015, real-world data has been collected in France, comparing it with the originator Gonal-f®, in the REOLA study (Barriere P, et al., J Gynecol Obstet Hum Reprod. 2023;52:102510). This study demonstrated comparable clinical outcomes according to follicle stimulating hormones (FSH) starting dose between the two FSH, in terms of oocytes retrieved, cumulative live-birth rate (CLBR), and total FSH dose per cycle. Previous health economic studies comparing the cost-effectiveness of Bemfola® against Gonal-f® utilise clinical trial data and therefore leave ambiguity over the cost-effectiveness as the results may not reflect what happens in clinical practice. Study design, size, duration We developed a decision-tree cost-effectiveness model with a one-year time horizon based on the gonadotropin costs and CLBR per ovarian stimulation for Bemfola® and Gonal-f®. The output was gonadotropin cost per live-birth following one ovarian stimulation cycle. CLBR per ovarian stimulation data were taken from the REOLA real-world study while acquisition costs were taken from publicly available databases in France. Model structure and methodology were based on previous publications and validated by clinical experts. Participants/materials, setting, methods The model used clinical data from REOLA, a non-interventional, retrospective, real-world study conducted in 17 French Assisted Reproductive Technology (ART) centres including data from 2,319 Bemfola® and 4,287 Gonal-f® ovarian stimulation cycles for IVF/ICSI grouped according to starting dose. Data was collected for ovarian stimulations between the dates of 01/01/16 and 28/02/17 and CLBR included a follow-up to live-birth of all pregnancies following both fresh and frozen embryo transfer within 12 months of oocyte retrieval. Main results and the role of chance The REOLA study data utilised within the model comparing Bemfola® vs Gonal-f® grouped according to FSH starting dose (&amp;lt; 150 IU, 150 - 224 IU, 225 −299 IU and ≥ 300 IU) are the median total FSH used - 1100 IU, 1500 IU, 2250 IU and 3300 IU vs 1008 IU, 1500 IU, 2250 IU and 3300 IU, and the CLBR - 30.5%, 25.4%, 21.4% and 12.3% vs 27.0%, 27.3%, 19.6% and 12.0%, respectively. The gonadotropin cost per live-birth for Bemfola® was €2,302.12 compared to €2,856.26 per live-birth for Gonal-f®, saving €554.15 per live-birth. The main reasons for this cost saving was the lower acquisition costs of Bemfola® of €489.01 compared with Gonal-f® costs of €597.36 on average per ovarian stimulation. As this analysis is based on real world data as opposed to results from clinical studies it can be used to estimate potential gonadotrophin cost savings in clinical practice in France. With 27,861 babies born annually in France using ART it can be estimated that if all had been born following Gonal-f® usage then a change to all being born following Bemfola® usage could result in savings sufficient to fund gonadotrophins for an additional 31,572 ovarian stimulation cycles. Limitations, reasons for caution The model assumed equal distribution of Bemfola® and Gonal-f® across the starting dose categories and have assumed that the number of fresh and frozen cycles required following ovarian stimulation would be equivalent irrespective of the gonadotropin used. Wider implications of the findings Bemfola® is cost-effective compared to Gonal-f® for IVF/ICSI treatment which would potentially enable more women to be treated with the same healthcare budget for the French health system. This might apply for other countries where Bemfola® is available and benefit from lower acquisition costs than Gonal-f®. Trial registration number not applicable

The profile of French osteopaths: A cross-sectional survey

BackgroundOsteopathy is not a health profession in France but it was regulated in 2007. However, the profession is very popular, and the number of osteopaths is the largest in Europe. Since there is limited published data on the profile and characteristics of osteopaths practising in France, this study aimed to survey the current situation of osteopathic practitioners in France. MethodsA voluntary online-based survey was distributed to French osteopaths between March and July 2022. This survey consisted of 52 questions adapted from the original French version of the validated Benelux Osteosurvey. ResultsA total of 1461 osteopaths responded to the study, of which 785 (53.73%) were female. The majority of respondents were aged between 30 and 39 years (50.65%), had full-time training (89.73%), during 5 years (67.15%), were self-employed (99.59%), advertised themselves exclusively as osteopaths (90.35%) and showed a solid professional identity. The median number of consultations per week was 21–25, and nearly one-third of respondents (31.42%) reported having other professional activities outside their clinical practice as an osteopath. Osteopaths in France manage acute and chronic complaints in all body areas but mainly in the spine. ConclusionsThis study provides a first overview of the current profile of osteopathic practitioners in France since 2012. At present, it constitutes a new informative report of their characteristics and provides several perspectives on the profession's development in terms of status and training. Implications for practice●The majority of respondents were aged between 30 and 39 years, had undergone a full-time five-year training, advertised themselves exclusively as osteopaths and manifested a strong osteopathic identity.●Most reported being self-employed, and managing acute and chronic complaints located in all body areas, but mainly the spine.●Respondents expressed a strong desire for a greater integration of osteopathy into the French health system, especially through better collaboration with other healthcare professionals.

Impact of Covid-19 on breast cancer stage at discovery, and time to treatment in Cote d’Or, France

Due to the COVID-19 pandemic, and ensuing overcrowding in the French health system, management of patients with COVID-19 was given priority over that of patients with other pathologies, including chronic diseases. The aim of this study was to study the impact of COVID-19 on the stage of discovery of cancers diagnosed in the context of an organized breast cancer screening programme, as well as the impact on time to treatment. All women diagnosed with cancer in the Côte d'Or via organized breast cancer screening (first or second reading) from January 1, 2019 to December 31, 2020 were included in this study. Using data from pathological laboratories, clinical centers, and the breast and gynecological cancer registry of the Côte d'Or, France, we collected socio-demographic, clinical and treatment data on all patients. We compared data from the year 2019 (before-Covid) with the year 2020 (Covid). We did not observe a significant difference in the stage of breast cancer at discovery, or in time to treatment. However, the number of invasive cancers and the clinical size of in situ cancers both increased in 2020. Although these results are reassuring, continued monitoring is needed to determine the downstream effects of the pandemic.

Abstract P6-03-03: Persistence and compliance of the French metastatic breast cancer population

Abstract Keywords Metastatic breast cancer, Endocrine therapy, Targeted therapy, Oral chemotherapy, French population Context Oral anti-cancer treatments have been shown to be effective when followed carefully. Tamoxifen, for example, reduces the risk of relapse by half within 10 years of the diagnosis [1]. However, these treatments are frequently poorly adhered to. To determine the categories of patients at risk and the appropriate moment to contact them, we developed predictive models trained on anonymised reimbursement data extracted from the French Health Insurance database. Objective The primary objective is to model a metastatic breast cancer patient’s persistence and compliance to the treatment. We aim at detecting unwanted episodes (non persistence and non compliance) six months before they happen. The oncologist may then follow the patient more closely. Methods Patients data is extracted from the SNDS database, one of the largest structured databases of health data in the world. It contains reimbursement data of the French Health System, covering 98% of the French population (66 million persons). Useful data are, for example, hospitalisations, drug purchases or the patient’s age and city of residence. From this database, patients were selected on the basis of a diagnosis of metastatic breast cancer (if hospital stay) or on the basis of specific treatments for metastatic breast cancer. Men and patients under 18 are excluded from the study. We consider that a patient has a non persistent event if she has no treatment stock for 2 months (during a phase of targeted therapy or oral chemotherapy) or 3 months (during a phase of endocrine therapy) and if no change in treatment, palliative care entry or death is observed. The compliance is labelled through the MPR (Medical Possession Ratio): a patient is considered non-compliant if the MPR of her 3 nexts purchases is below 80%. The proposed models are trained to detect non-persistence and non-compliance events in the next 180 days. We created several groups of features describing the patient and her healthcare pathway. Results 250 000 patients were spotted with a breast cancer in the SNDS database. Amongst these, around 40 000 were spotted for a metastatic breast cancer between 2013 and 2018. 14% of the patients had at least one non persistence episode and 46% had at least one non compliance episode. For the persistence study, we used a logistic regression with a feature selection. This model has a Gini coefficient of 0.35. For the compliance study, we used a deep learning model based on a GRU model. This model has a Gini coefficient of 0.37. A multivariate analysis shows that the following features had a significative impact on both predicted risks (persistence and compliance) : age, previous compliance, type of oral treatment(s) currently followed (endocrine therapy, targeted therapy, or oral chemoterapy), number of different oral treatments followed in the past year. In both models, if the patient’s age is between 50 and 70 years it does not correlate with an increased risk. On the other hand, the more they deviate from this interval, the more likely they are to be non-compliant. Conclusion Both studies have models with quite the same interpretation. Patients younger than 50 or older than 70 are more likely to be non-persistent and non-prevalent. The past compliance is highly correlated to the future events. The consumption of oral chemotherapy in comparison to oral endocrine and targeted therapy is linked to an increased risk in both studies. Bibliographie [1]: E. Ekinci, S. Nathoo, T. Korattyil et al. (2018) Interventions to improve endocrine therapy adherence in breast cancer survivors: what is the evidence? J Cancer Surviv 12:348-356 Citation Format: Pierre Rinder, Théo Marcille, Paul Sinel–Boucher, Pierre Hornus, Pierre E. Heudel, Chantal Bernard-Marty, Christelle Levy, Luis Teixeira, Dorra Kanoun. Persistence and compliance of the French metastatic breast cancer population [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-03-03.

Reliability of Self-Screening for Intrinsic Capacity Impairments Using the ICOPE Monitor App.

To verify the inter-rater agreement of the Integrated Care for Older People (ICOPE) STEP 1 screening tool using the ICOPE Monitor app, comparing self-assessment to a screening performed by a health professional. We compared the results of the ICOPE Step 1 obtained by self-screening with those obtained by a professional screening using Gwet's agreement coefficient in two studies. Study 1 tested inter-rater reliability in participants to the INSPIRE-T cohort who agreed to undergo the self-and the professional screening on the same day. Study 2 used data from the INSPIRE-ICOPE care cohort. We included real-life users of the French health system whose first ICOPE Step 1 was a self-assessment followed by a professional Step 1within 130 days (mean=76 days, SD=60). Study 1 included 79 participants (45 aged less than 60, 34 aged 60 and over, 60% female, mean (SD) age of 54.5 (18.5) years). Of the 207 participants in Study 2, 49 were less than 60, and 158 were 60 and over (54% female, mean (SD) age 67 (16.1) years). Agreement coefficients in Study 1 ranged from 0.49 (CI95% 0.24; 0.66) in the cognition domain - moderate agreement) to 0.99 (CI95% 0.96;1.00) in the nutrition domain - very good agreement); and in Study 2 from 0.36 (CI95% 0.23;0.49) in the cognition domain to 0.97 (95% 0.95;1.00) in the nutrition domain. The agreement coefficients for the cognition and hearing domains were higher for the participants aged <60 than those aged 60 and over. The time orientation items (cognition) showed high reliability. Our study supports using ICOPE Step 1 as a self-assessment screening tool. High reliability was found for intrinsic capacity's nutrition, psychological, and locomotion domains, regardless of age. We discuss aspects of the self-assessment of cognition, vision, and hearing domains when using the ICOPE monitor app in older adults.

Factors for Consideration When Setting Prices for Private Healthcare Providers Operating in Public Systems: A Comparison of France and Japan.

Most publicly-funded health systems purchase healthcare from private providers, but the optimal purchasing arrangements between public purchasers and private healthcare providers are yet to be determined. This study compares the healthcare purchasing arrangements made with private providers in 2 social health insurance (SHI)-based systems to identify factors that influence the prices paid for private healthcare service provision. France and Japan use different approaches to determine the payment arrangements with public and private providers. The presence of for-profit healthcare providers in the French health system explains the different payment rates for public and private healthcare providers in that country. In both France and Japan, in addition to payment rates, several policy tools are used to assure the provision of public good services and the availability of necessary healthcare for all, which public providers are required to deliver but private providers can choose to deliver. This study highlights the importance of considering the profit-making status of the private healthcare providers operating in the healthcare market, and clarity in the roles and responsibilities of the public, for-profit and not-for-profit providers when determining healthcare purchasing arrangements. Regulatory policy instruments, used alongside payment rates, are essential to influence efficiency, equity, and quality in mixed (public-private) health systems.

Orthopaedic and trauma surgery in the time of COVID-19 in France: A nationwide survey

IntroductionThe year 2020 was marked by the COVID-19 pandemic. The entire French health system was mobilized. Surgical services were asked to reschedule all elective procedures. We wondered about the impact of this pandemic on French orthopaedic surgeons. The main objective of this survey was to assess the impact of COVID-19 on emergency and non-emergency orthopaedic surgical activities. The secondary objectives were: to report how orthopaedic surgeons had mobilized and reorganized, and to assess the physical and psychological consequences on their state of health. HypothesisThe COVID-19 epidemic has led to the suspension of all elective orthopaedic surgeries and has also led to changes in the management of urgent surgeries and traumatology. Material and methodsThis descriptive epidemiological study was conducted in France. A 40-question survey was sent to all French orthopaedic surgeons (senior surgeons and residents) via the mailing lists of the French Society of Orthopaedic and Traumatological Surgery (SoFCOT), the French Society of Pediatric Orthopaedics (SoFOP) and the College of Young Orthopedists (CJO). ResultsOver a period of one month, 1098 surgeons; 852 senior surgeons and 246 residents, answered the questionnaire. The complete cessation of all elective interventions was effective in 80% of cases. Urgent and semi-urgent interventions were maintained. Three hundred and twenty-six surgeons (30%) modified their trauma management, among them 55% came from the regions most affected by the pandemic. Sixty percent of surgeons did not receive training to take care of COVID+ patients and 40% took care of these patients. Among the orthopaedic surgeons surveyed, 28% were redeployed to medical services. Teleconsultation was used by 41% of surgeons. Twenty-six (2%) surgeons tested positive for COVID-19 and 54% showed at least one sign of psychological suffering. ConclusionFrench orthopaedic surgeons reorganized and changed their practices quickly and efficiently to deal with the pandemic. However, progress remains to be seen with training of orthopaedic surgeons in the care of COVID+patients, as well as to democratize the use of telemedicine. Level of evidenceIV.

P07-03 The characteristics of the medical prescription for adapted physical activity among the French Health System, experience of the Grand Est region

Issue/problemThe law of modernization of the French health system promoted in 2016 have authorized any attending physician to prescribe a program of physical activity suitable for patients with a chronic disease. The health benefits of active living habits are now well known but too few physicians have seized this prescription of Adapted Physical Activity (APA).Description of the problemAPA teachers have come to complement the health professions to deliver APA, and sports clubs have improved their organization to welcome patients who have adequate physical condition. Regional systems have been deployed to receive patients, using such resources. The ‘Médicosport Santé’ guide provides relevant guidance for patients according to physical and/or sporting activities (PSA) and diseases. The medical prescription for APA must therefore become a practical reality for chronic disease patients, guaranteeing a lasting change in lifestyle through more active behavior.Experience from the Grand Est countryThe commitment of certain French Regional Health Agencies, has led certain regions to offer regional systems, as the “Prescri'mouv” plan in the Grand Est country, allowing a step forward to best support the patient from the medical prescription to regular and lasting practice. After medical prescription, patients are directed to an APA professional or physiotherapist, for an initial evaluation and orientation towards one of the three types of care: autonomous practice, labeled structure, specific support.LessonsThe main objective of APA is to fight against a sedentary lifestyle. With an adequate physical condition, physical activities and sports are to be considered in order to help patients with chronic disease, sources of pleasure and lasting health benefits. New actors have come to strengthen health professionals, and through ‘Sport Santé’ concept, sports clubs have organized themselves to welcome patients.Main messagesAdapted physical activity is the keystone in the fight against sedentary lifestyle.New players have come to strengthen health professionals, sports clubs have organized themselves to welcome of and best support patients with chronic disease.The challenge is for physicians to take hold of this medical prescription for APA, by directing patients towards more active lifestyle habits.

P09-03 Costing the economic burden of sedentary behaviors in France

BackgroundThere is strong evidence showing that sedentary behaviour (SB) increase the risk to develop several chronic diseases and to premature death (Chau et al., 2015). A dose response relation is observed with a more marked risk when people spend more than 7 hours/day in sitting position (Ekelund et al., 2019). The study INCA 3 on the lifestyle habits of French population indicated that 40% of people between 18 and 79 years had a high risk for health conditions with more than 7 hours of daily SB (ANSES, 2017). The economic consequences of this risk have never been evaluated. The aim of this study was to estimate the economic burden of SB-related diseases in France.MethodsFrom meta-analysis or large cohorts based on individual SB time, we identified relative risk (RR) to develop cardiovascular disease (CVD), colon cancer, breast cancer and all-causes premature death after co-variables adjustments including physical activity. From RR and prevalence of SB time in France, a population attributable fraction approach was used to estimate the yearly number of cases for each disease. Data from the national health insurance were used to calculate the annual average costs per case for each disease. Then, disease-specific and total health-care costs attributable to prolonged SB time were calculated. Indirect costs for private sector and households were calculated in a second stage.ResultsIn France, 66 528 premature deaths/year appear related to a daily SB time ≥ 8,6 hours Each year prolonged SB cost 559 millions € for the national health insurance, including 359 millions € for CVD (≥ 10 hours of daily SB), 170 millions € for breast cancer (≥ 6 hours of daily SB), and 31 millions € for colon cancer (≥ 5 hours of TV/day).ConclusionsThese preliminary results showed that many deaths could be avoided by reducing prolonged SB prevalence in France. Moreover, direct health-care costs attributable to SB related diseases represent a high economic burden for the French health system. To address this issue, strong responses should be implemented to tackle SB, complementary to physical activity promotion.