Regional Health Agency Research Articles

Territorial mobile team: A response element to ambulatory shift? Lyon's experience

At the time of “ambulatory shift”, new modes of care are developing: this is the case of the mobile teams of physical and rehabilitation medicine (PRM) [LJ1] who participate in diversification of health care facilities. They concern disability (whatever its origin) and actions for short or medium stay, links between private and hospital practice, medico-social, care pathway and the absence of breach for this complex patient. The objective is to encourage out of hospital care, as far as possible, in all actions waged. Our mobile team “EMT3R 69” (territorial mobile team of rehabilitation, reintegration) is multidisciplinary (Physician PRM, occupational therapist, physiotherapist, social worker) and was created in January 2017. It is funded by the regional health agency “ARS” for a period of 3 years. Application for Team's intervention must contain specific objectives. A rapid response is provided in order to found the most appropriate response. After 1 year experience, 121 persons (58% of men) were included corresponding to 682 interventions, among which 193 in the living place. Other interventions comprised follow-up to the recommendations, coordination with the partners,…). Patients were heavily dependent (RANKIN 4), mainly neurologically disabled (92%), living at home (66.8%) or in a medico-social institution (27.4%). Sixty-eight percent benefited from information/recommendations on technical assistance of all types, 33% were helped/oriented in administrative procedures related to disability and 29% were redirected to medical professionals or other adapted structures. The creation of this team (and 6 other ones in Rhône-Alpes) allows responding to several priorities of public health: “facilitate access to an adapted and efficient healthcare offer”, “make care pathway more fluid”. After more than a year of experience, improvement will be set up particularly in supporting caregivers and then in terms of territorial coverage and network development.

Factors associated with a prolonged Norovirus outbreak in a nursing home, Normandy, France, 2016

Introduction On September 26, 2016, the Normandy regional health agency was reported about an outbreak of acute gastroenteritis among 20 residents and 4 staff members in a nursing home. Onset of symptoms occurred between September 25 and 26, 2016. A foodborne outbreak was initially suspected to be the source of contamination of the cases as the initial environmental investigation found a sample of “mixed porc” meal served on September 24, 2016 positive for Norovirus type II. In total, the outbreak lasted 3 weeks. During the 3rd week of the outbreak, further epidemiological and environmental investigations were launched in order to identify factors associated with a prolonged transmission of Norovirus. Methods A case of gastroenteritis was defined as a resident or a staff member with symptoms of diarrhea and/or vomiting that occurred between October 17, 2016 and October 12, 2016. A retrospective cohort study was conducted among staff and residents in order to identify risk factors associated with a prolonged transmission of norovirus. A standardized questionnaire collected information on risk factors of norovirus infection during the outbreak period including sociodemographic characteristics, type of diet and place of lunch, score of dependency, type of accommodation, type of employment (staff) and type of symptoms. Risk factors of gastroenteritis were searched using a logistic regression (P Results In total, 49/89 (55%) “resident” cases and 9/85 (11%) “staff” cases were identified between September 17, 2016 and October 22, 2016. The occurrence of a peak of cases on September 25 and 26 with a 20% attack rate motivated the reporting of the outbreak to the health agency. However, the retrospective epidemiological investigations showed the occurrence of previous unreported cases, including an index case in a staff with onset of symptoms on September 17, 2016. No further food sample other the “mixed pork” served on September 24, 2016 came back positive for Norovirus. The analyses of the supplier's batch however, tested negative for Norovirus. Three stool samples from residents were positive for Norovirus type II over the outbreak period. In multivariate analysis, the only risk factor for contamination was a high dependence score (GIR Conclusion Norovirus outbreak are common in nursing home during the autumn–winter season. The introduction of the virus in the premises probably occurred through a sick staff who was not reported. The lack of reporting of index cases, in addition to a poor application of barrier measures, explains the persistence of gastroenteritis cases via cross-transmission, favored by the large dependency of residents. The training of professionals in timely recognition and reporting of gastroenteritis cases and proper application of control measures remains challenging in such setting.

Alternative to supply of health services in physical medicine and rehabilitation: From mobile team to home hospitalization

In France, the notion of care pathway is enshrined in the circular of March, 2012 relative to the organization of care for patients’ victim of stroke. The rehabilitation-reinsertion mobile team of the pole Saint-Helier (EM2R) was created in 2012 in this context, with support from the Regional Health Agency of Brittany. The main mission of this newly created team is to implement the necessary devices to facilitate the home returning of people hospitalized after a neurological event or maintain home people with neurological disorders (more than 200 coverage a year). The neurodegenerative diseases plan of 2014–2019 points, especially in its 15th measure, that we shall remove all things slowing down the hospital care access at home for people with neurodegenerative diseases and this no matter where they live. And this is done mainly through mobile teams and home medical care (HAD in France) activities. In coherence with the activities recently developed “outside the walls” by the pole Saint Helier (EM2R and telemedicine), the establishment of a HAD-SSR (home medical care of rehabilitation care), further consolidated the healthcare pathway for people with disabilities.This activity has been developing since September, 2017 in relation with the HAD 35 and two rehabilitation centers which provide reeducation professionals’. 15 patients have already been cared, mostly persons with stroke. The aim is to ensure a global, coordinated and specialized care by bringing to patients’ home a variety of expertise in the field of rehabilitation: doctors of physical medicine and rehabilitation, physiotherapists, occupational therapists, speech therapists, neuropsychologists… and to propose an additional alternative to hospitalization in rehabilitation care when the situation permits it in the healthcare pathway of people with disabilities.

Early heat wave and heat stroke during distance running, April 2017, France

Introduction A 10 K run was organized in southwestern France in early April 2017. Several dozens of runners had discomforts, some of them very serious faint. Early health care was provided by first aid workers on site. Fire and emergency Service and the local hospital activated their emergency response plan. The Regional Health Agency called on the local Poison Control Center (PCC) and the Regional office of the French National Agency for Public Health to investigate the outbreak. The purpose of the survey was to describe the event and to determine the causes of these discomforts, and the risk factors of their occurrence. Methods An exploratory survey was set up to describe the event. Telephone interviews were conducted with the race organizer, the first aid station director, paramedics and the local hospital. People transported to the hospital were asked about their consumption (water, food, doping substances, medication, etc.) before and during the race, their risk factors for hyperthermia, as well as their symptoms through an individual questionnaire. A telephone survey was conducted by an epidemiologist. Emergency and hospitalization reports as well as the results of biological and toxicological analyses were evaluated by a toxicologist from the regional PCC. Results The running event gathered 4280 participants, including 70 dropouts. The event started at 6:30 PM. First participants arrived on site at 4:30 PM, which implied a 2-hour-wait under unusual heat for the season (27 °C at 6 PM). The first aid station took care of 31 people during and after the event for severe dehydration and hypoglycemia, especially after the 7th and the 8th km A total of 17 people (2 women and 15 men, between 23 and 52 years old) were transported to the hospital, 15 of them for a medical consultation and 2 were hospitalized in intensive care. They all recovered; no deaths were reported. Individual risk factors could be investigated for 7 men who were transported to hospital, including the 2 admitted to intensive care. Of these, 2 were overweight, 1 reported chronic pathology (asthma). None had used alcohol or other psychoactive substances within 24 hours of the race. It was the first participation to such an event for only one man. However, this man practiced running on a regular basis. Four runners spontaneously reported a lack of water or difficulties to access to the water, particularly at the 7th km. Eight hospitalization reports were sent to regional PCC. The clinical and biological analyses of these patients were consistent with heat stroke. Toxicology tests did not indicate any presence of toxic substances. For one of the patients, the consumption of a prescribed medication (corticoid) may have contributed to the occurrence of the heat stroke. Discussion The investigation was consistent with heat stroke. Relatively hot conditions, prolonged exposure to heat before the race, limited access to water stations and some unclear waypoints may have been aggravating factors. A delay in preventive health care (rehydration–cooling) was also reported. These elements were taken into account by the organizers for the organization of the next races. The organization of a sport's events during a heat wave requires specific precautions to be taken by the organizers and by participants. Prompt medical assistance during the race is needed.

Accessibilité de la remédiation cognitive en Île-de-France, en psychiatrie adulte et infanto-juvénile, et dispositifs de réhabilitation

Cognitive remediation (CR) aims to decrease cognitive deficits and provide palliative strategies for reintegration of patients with psychic disability. It is part of a personalized care program and requires multidisciplinary assessment and management, including eventually other psychosocial therapies. This study, carried out in 2016, aims to establish an inventory of accessibility and practice of the CR in Île-de-France, to promote broad access and systematize the integration of CR in a global and coherent course. The CR is proposed by nearly 58 % of the structures that answered the survey, but its implementation could be improved: it stands for 58 % in a specific project and the multidisciplinary evaluation before/after is carried out at 51 % in Adult Psychiatry and 20 % in Child and Teen Psychiatry (CTP), perhaps due to a lack of qualified staff (neuropsychologists). The programs used in CTP are nonspecific. The accommodation capacity should be increased by group programs. Despite a lack of knowledge to fill, there is an important interest for the CR with a will expressed by 12 structures to be trained. Other psychosocial therapies, although better known, would benefit from being more often proposed and labeled by the Regional Health Agency. Our results confirm a scarcity of psychiatric care's supply in 77, 91 and 93. Four rehabilitation units in the 77 and 3 in the 91 are being trained. Three structures in the 77 and 2 in the 91 are willing to get trained. Supporting them is all the more important as the good practice of CR has a direct effect on social costs’ benefits. Since then, in the entire region, 8 structures have proposed for a CR and rehabilitation platform.

Outbreak of ED visits related to the use of synthetic cannabinoids, Mayotte Island

ObjectiveTo confirm and to characterize the increase in emergency department (ED) visits related to the use of synthetic cannabinoids (SC)IntroductionOn October 2016, the Indian Ocean Regional Health Agency was alerted about an increase in ED visits related to adverse reactions associated with use of SC on Mayotte Island. In this context, an investigation based on a syndromic surveillance system was implemented by the regional unit of the French national public health agency.MethodsAn extraction of anonymized records routinely collected by the syndromic surveillance system (1) was carried out from January 1st, 2012 to October 30, 2016. ED visits related to the consumption of SC were identified from ICD-10 codes of the principal diagnostic according to two levels of confidence:- a probable case was defined as ED visit coded X69 (Intentional self-poisoning by and exposure to other and unspecified chemicals and noxious substances). This code has been implemented specifically by ED physicians since august 2015;- a suspect case was defined as ED visit coded: F11 (Mental and behavioral disorders due to use of opioids), F12 (Mental and behavioral disorders due to use of cannabinoids), F16 (Mental and behavioral disorders due to use of hallucinogens), F18 (Mental and behavioral disorders due to use of volatile solvents), F19 (Mental and behavioral disorders due to multiple drug use and use of other psychoactive substances).Based on these data, an epidemic curve and a descriptive analysis of ED visits were carried out.ResultsIn total, 146 ED visits related to adverse events associated with use of SC were registered from January 1st, 2012 to October 30, 2016. The epidemic curve shows two waves between 2015 and 2016 with a particularly high peak in August 2015 (Figure 1). In total, 49% (n=72/146) of these ED visits were probably related to adverse reactions associated to use SC and 51% (n=74/146) meet to the suspect case definition. On the surveillance period, men represented 84% of the patients (n=122) and median age (min – max) was 23 (8-62) years old. When the severity score variable was filled (n = 138), a vital emergency was reported for 4% (n = 5) of patients and 19% of patients were hospitalized.ConclusionsData from syndromic surveillance system allowed to confirm an increase in ED visits related to adverse reactions associated with use of SC in Mayotte Island. To our knowledge, it’s the first time that an outbreak related to use SC is described in the Ocean Indian areaThis phenomenon was particularly marked in 2015 with a peak of ED visits on August 2016.After this outbreak, the regional unit of the French national public health agency recommended the pursuit of the coding X69 in principal diagnosis with the following case definition: any patient with an adverse reaction attributed to synthetic cannabinoid use whether suspected by the medical team or declared by the patient himself or if the patient is in possession of the substance; and to raise awareness ED physicians to the notification of these poisonings to the Regional Addictive Surveillance Center.In conclusion, the young population, weakened by a precarious socio-economic situation, is a target for new synthetic drugs and a threat to public health. This emerging risk in Mayotte must be taken into account and must be actively monitored. In this context, collaborative work with the emergency services must continue in parallel with targeted prevention measures.

Thrombosis and cancer: Awareness of private practitioners and patients in Poitou-Charentes, a French region

The purpose of this study was to enhance awareness among healthcare professionals about the application of guidelines relating to the management of venous thromboembolism (VTE) in cancer patients. This collective approach involved: the Regional Health Agency (ARS), the Unions of Representatives of Healthcare Professionals (URPS), the Observatory of Drugs, the Medical Devices and Therapeutic Innovation agency (OMEDIT), the regional Oncology Network and specialist physicians. Performance indicators were defined to evaluate the actions performed. Multidisciplinary information meetings were organized. A standardized patient's folder was proposed in all healthcare institutions dealing with cancer, as a link between healthcare professionals and patients. Information brochures were prepared for healthcare professionals and patients. Web-based surveys were taken among healthcare professionals to evaluate changes in their knowledge and practices before and after the first actions taken. This collective approach improved the awareness of health professionals about care practices for VTE in cancer patients.

Therapeutic Patient Education (TPE) and health education in spa centers in France

Therapeutic Patient Education (TPE) aims to help patients manage their lives better with chronic illness Spa centers are good places for the TPE for many reasons: groups of homogeneous and motivated patients, sufficient duration of the stay and presence of competent health professionals to ensure therapeutic education In France TPE programs are governed by an opposable regulation and an obligation of evaluation. The stakeholders must have a specific training of at least 40 hours. Programs are licensed for 4 years by regional health agencies (RHA). A TPE program consists of: 1°) an individual session of elaboration of the educational diagnosis or its updating to identify the needs and expectations of the patient, formulate with him the skills to be acquired and the learning priorities, and define a personalized action program, 2°) collective or individual therapeutic or alternating therapeutic education sessions for the acquisition of self-care skills and the mobilization or acquisition of adaptive skills and their maintenance, 3°) an individual assessment session of skills acquired, changes implemented by the patient in his daily life and the progress of the individualized program, 4°) a coordination of health professionals involved in the management of chronic disease around and with the patient TPE programs in French spa centers are proposed in addition to the classic spa treatment In 2018 in France TPE programs have been authorized by the RHA for several spa centers for the following twelve indications: fibromyalgia, lower limb osteoarthritis, rheumatoid arthritis, overweight and metabolic syndrome, post-bariatric surgery, type 2 diabetes, venous insufficiency, lymphoedema, psoriasis, eczema, asthma and post breast cancer Some of these TPE programs have been the subject of evaluation studies by AFRETH (Association Francaise pour la Recherche Thermale) One of the main problems of TPE programs is its cost, which is entirely the patient's responsibility because it is not reimbursed by the health system Beside the labeled “TPE programs” authorized by RHA, many other simpler health education programs, not labeled TPE and not requiring authorization from RHA, are organized in French spa centers: stopping smoking, benzodiazepine withdrawal, chronic low back pain education, prevention of falls, Parkinson‘disease, support for patients with Alzheimer's disease and their caregivers, etc. In conclusion more and more TPE programs and health education are developing in French spa centers. The value of these programs must continue to be evaluated.

Vaccination coverage among school children aged 14–15 years in the French department of Sarthe

ObjectivesVaccinations are the main pillar of primary prevention for infectious diseases. To guide and prioritize public health interventions, the Regional Health Agency has asked the Prevention, Vaccination, and Screening Center of the Sarthe department to assess vaccination coverage (VC) at the sub-departmental level. The main objective was to measure the VC among school children aged 14–15 years in Sarthe at the sub-departmental level. Patients and methodsWe conducted a VC evaluation survey at the administrative district level among school children aged 14–15 years in the Sarthe department during the first quarter of the 2015–2016 school year. ResultsAmong 2384 randomly selected school children, 1171 were included in the study. At the departmental level, 85% of children were up to date for DTP, 72% for pertussis, 45% for hepatitis B, 31% for meningococcus C, 93% for measles, and 18% of girls had received at least one dose of the HPV vaccine. Vaccination coverage varied by administrative districts. ConclusionAt the departmental level, all VC were below national goals. Territorial disparities could be explained by sociodemographic differences or differences in medical practices. This survey allowed us to identify areas and population groups where the CV rate justified public health actions.

Telepsychiatry for Children and Adolescents: A Review of the PROMETTED Project.

Telemedicine for children and adolescents is a public health topic, and since 2009 in France, the legal framework defines practical modalities. Some children with Attention Deficit with or without Hyperactivity Disorder, social anxiety, or Autism Spectrum Disorder (ASD) can be easily engaged within a teleconsultation model. Literature suggests new opportunities to facilitate the care process for the ASD person and his family: diagnosis with the use of validated instruments and parental accompaniment. Since 2015, a pilot project called PROMETTED was supported by the Regional Health Agency of Ile de France. It was developed and managed by the team of the Center for Diagnosis and Evaluation for Autism (CDEA) of Sainte-Anne Hospital and associated PEDIATED, the CDEA of Versailles. Five medico-social structures for children and adolescents with ASD and the two CDEAs co-elaborated a scheme of intervention with telemedicine. The remote evaluation is a four-step process structured around the medical history and the observation of the young subject; the Autism Diagnostic Interview; the use of the Childhood Autism Rating Scale and the Vineland Adaptive Behavior Scales; and feedback to parents. Medico-economic and satisfaction evaluations are in progress.

Lessons learned from co-constructing a guide on healthy urban planning and on integrating health issues into environmental impact assessments conducted on French urban development projects

Recent regulatory evolutions gave the opportunity to professionals and academics from the health, urban planning and environment sectors – within a working group – to conduct in-depth research at a national level on health challenges in the field of EIA procedure and urban planning. This work resulted in the publication of a guide aimed at all actors involved in the urban planning decision process, which has now become a national reference document. Among the key findings of this project, three main concrete outputs caught our attention: a reference framework for Healthy Urban Planning (HUP); an all-encompassing tool for analysing urban planning projects ‘with a health lens’; an operational tool aimed at French regional health agencies (ARS) to help them formulate their health statements within the framework of the EIA regulatory procedure applied to urban development projects. This paper reviews the process of co-constructing the guide with special attention paid to the ARS tool, present the key findings and outputs and discuss the potential of the EIA process in promoting HUP in the current French context.

A new hot spot for tick-borne encephalitis (TBE): A marked increase of TBE cases in France in 2016

ObjectivesTick-borne encephalitis virus (TBEV) is a zoonotic agent causing severe encephalitis. In 2016, in Northeastern France, we faced a TBEV infection increase, leading to a warning from the Regional Health Agency. Here, we report the confirmed TBE cases diagnosed between January 2013 and December 2016, with particular emphasis on the year 2016. MethodsA total of 1643 blood and cerebrospinal fluid (CSF) samples from everywhere in France, corresponding to 1460 patients, were prospectively tested for anti-TBEV-specific IgM and IgG antibodies by ELISA. Additional 39 blood and CSF samples from patients with suspected Lyme neuroborreliosis were retrospectively investigated. ResultsThe TBEV seropositivity rate was estimated to 5.89% and 54 patients were diagnosed as TBE-confirmed cases. A significant increase in TBE cases was observed during the year 2016 with 29 confirmed cases, instead of a mean of eight cases during the three previous years (p=0.0006). Six imported cases and 48 autochthonous cases, located in the Alsace region (n=43) and in the Alpine region (n=5) were reported. Forty-six patients experienced neurological impairment. Nine patients showed an incomplete recovery at last follow-up (from 15days to eight months post-infection). TBE diagnosis was performed earlier for patients taken in charge in the Alsace region than those hospitalized elsewhere in France (p=0.0087). Among the 39 patients with suspected Lyme neuroborreliosis retrospectively investigated, one showed a TBEV recent infection. ConclusionThe TBE increase that occurred in France in 2016 highlights the need to improve our knowledge about the true burden of TBEV infection and subsequent long-term outcomes.

Les acteurs de la loi HPST confrontés à la recentralisation du secteur médicosocial

Hypothesis: The 2009 Hospital, Patients, Health and Territories Act crystallises a central government attempt to regain control over the social and long term care sector, which involves the utilisation of policy instruments borrowed from the hospital sector: capped budgets, agreements on targets and resources, competitive tendering or quasi-market mechanisms involving hospitals and services, etc. This paper is therefore based on the hypothesis of a recentralisation and healthicization of the social and long term care sector, with a key role for the regional health authorities. Method and data: 27 semi-structured interviews were conducted with actors operating within and outside the regional health agencies and thereafter analysed using Alceste. The aim was to describe and to analyse the positioning of the RHAs in relation to key actors of the social and long-term care sector in 2 regions in 2011. Results: Key issues for public organisations include the style of planning and knowhow transfer, while the professionals were chiefly concerned with the intensity of the ambulatory turn and needs analysis methodology. The compromises forged were related to types of democratic legitimacy, namely representative or participatory democracy. Conclusion: There is little evidence to support the initial hypothesis, namely the existence of a link between the creation of RHAs and a recentralisation of health policy between 2009 and 2013. One may rather suggest that a reconfiguration of the activities and resources of the actors operating at the centre (RHAs and conseils départementaux) and at the periphery (territorial units of the RHAs and third sector umbrella organisations) has occurred.

Behind Smoke and Mirrors: A Political Approach to Decoupling

In this paper, we examine neglected dimensions of decoupling - i.e., its power and political aspects. We draw on an empirical study of the reaction of two hospital subunits and an external agency (the Regional Health Agency) to a policy implementation, to contribute to the recent renewed interest in decoupling. We first reconsider the distinction between internal and external actors by investigating how they interact in their responses to the new policy implementation. While observing different forms of decoupling, we show how power and politics allow us to understand how these forms are articulated and related. Furthermore, we highlight that contexts characterized by institutional complexity are particularly propitious for decoupling. Finally, we outline that how actors use logics to justify their claims might differ significantly from how they enact those logics. More broadly, this paper contributes by bringing back power and politics into the analysis of institutional processes.

Social inequalities in health, missions of a regional healthcare agency

The presence of social inequalities in health requires a multi-faceted intervention, focusing on the social determinants as well as the provision of care and prevention strategies. Regional health agencies have important levers at their disposal, as illustrated by the example of the Île-de-France region.

Evaluation of a knowledge transfer scheme to improve policy making and practices in health promotion and disease prevention setting in French regions: a realist study protocol

BackgroundEvidence-based decision-making and practice are pivotal in public health. However, barriers do persist and they relate to evidence properties, organisations and contexts. To address these major knowledge transfer (KT) issues, we need to rethink how knowledge is produced and used, to enhance our understanding of decision-making processes, logics and mechanisms and to examine the ability of public health services to integrate research findings into their decisions and operations. This article presents a realist evaluation protocol to assess a KT scheme in prevention policy and practice at local level in France.Methods/designThis study is a comparative multiple case study, using a realist approach, to assess a KT scheme in regional health agencies (ARS) and regional non-profit organisations for health education and promotion (IREPS), by analysing the configurations contexts/mechanisms/outcomes of it. The KT scheme assessed is designed for the use of six reviews of systematic reviews concerning the following themes: nutrition, alcohol, tobacco smoking, physical activity, emotional and sexual life and psychosocial skills. It combines the following activities: supporting the access to and the adaptation of scientific and usable evidences; strengthening professionals’ skills to analyse, adopt and use the evidences in the course of their practices and their decision-making process; facilitating the use of evidence in the organisations and processes. RAMESE II reporting standards for realist evaluations was used.DiscussionThe aims of this study are to experiment and characterise the factors related to the scheme’s ability to enable public health stakeholders to address the challenges of KT and to integrate scientific knowledge into policy and practice. We will use the realist approach in order to document the parameters of successful KT strategies in the specific contexts of preventive health services in France, while seeking to determine the transferability of such strategies.

Quels sont les facteurs prioritaires à mettre en œuvre pour développer une démarche éducative en médecine générale ?

General practitioners (GP) are in a special position to conduct educational strategies for their patients with chronic disease. Despite the GP’s desire to be involved in patient education, this approach remains underdeveloped.Objective: To determine the factors required support the development of educational strategies in general practice from the GPs’ perspective.Methods: Qualitative study based on a “modified nominal group technique” carried out among 21 GPs (not specifically trained in patient education) participating as investigators in an interventional study testing a structured educational strategy. The interventional study based on processes and tools specifically developed to suit general practice was held during their usual consultations. Thirty one patients with COPD were followed for 9 months.Results: GPs identified 23 specific factors restructured after the clarification-reformulation step in 6 main factors required for the development of educational strategies in general practice. The consensus revealed that reinforcement of initial and continuing medical training was the most frequently cited factor and was considered to be a priority. The development of inter- and intra-professional cooperation was the second leading factor to be taken into account.Conclusion: The improvement of GP training and the promotion of areas of cooperation could help GPs to develop educational strategies during their consultations. These results may provide insight to regional health agencies concerning the deployment of patient education in primary care.

Letter: Outpatient Cervical and Lumbar Spine Surgery is Feasible and Safe: A Consecutive Single Center Series of 1449 Patients.

To the editor: We greatly appreciate the paper by O Helseth et al1 entitled “Outpatient Cervical and Lumbar Spine Surgery is Feasible and Safe: A Consecutive Single Center Series of 1449 Patients” because the authors led us to consider that innovative surgery is achievable in day surgery, concluding “in favor of outpatient spinal surgery in properly selected patients.”1 They also remind us that nonmedical criteria could represent a major challenge for developing early discharge. Indeed, “patients who had a travel distance >1.5 h by car were advised to stay overnight at a hotel adjacent to the clinic.” Thus, “1446 out of 1449 (99.8%) patients were successfully discharged either to their homes or to a hotel on the day of surgery.”1 Like the authors, in France, surgeons are faced with “limited healthcare resources and steadily increasing rates of surgery,” and they have “to be a focus on efficient and cost-effective treatment.”1 Today, ambulatory surgery has become a priority for the government, making it a national challenge. The recent implementation of an incentive pricing system by the National Health Insurance and the constant increase of the type of procedures referenced for ambulatory surgery2 increased the rate from 32.2% in 2007 to 37.7% in 2010, aiming to reach 50% in 2016.3 However, these measures still encounter some difficulties. The first of these is that, in France, the hospital stay in an ambulatory surgery unit is limited by law to no more than 12 h from the patient's admission to his discharge. In their study, the authors have fixed the limit at 6 h of postoperative observation. This could be a problem, as all the scheduled patients could not be first on the theatre list. In our multidisciplinary ambulatory surgery unit, the earlier the patients are operated, the more likely they are to return home the same day. Another difficulty concerns the patients without social home support or for whom home is far away from the hospital, regardless of their medical eligibility for day surgery. In this study, it would be very interesting to have more details on the distribution between a return home and an accommodation in a hospital hotel. The fact remains that medical literature on hospital hotel is not profuse. In France, the lack of hospital hotels is critical, too often leading to hospital conventional accommodation for patients who do not medically require it, either for the preoperative night and/or for the night following the day of surgery, leading to additional costs.4,5 A nation-wide experiment has just been voted on by the Parliament, and the experimentation should take place very soon. The problem of funding of this project has to be solved, either by the national health system of care, or by the private insurance companies. This also means modifying habits of our patients. Disclosures Pr Jean-Pierre Bethoux is the head of the Day Surgery Observatory of the Regional Health Agency of Paris and its area. Pr Henri-Jean Philippe is the head of the College of the Ambulatory Surgery of the AP–HP (Assistance Publique-Hôpitaux de Paris). The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

A cooperation protocol for the follow-up of patients after bariatric surgery

Professional cooperation protocols have recently been developed by the French national health authority and regional health agencies. They enable paramedical staff to perform procedures usually carried out by doctors. In the framework of bariatric surgery, the follow-up of patients after surgery is thereby assured by specialist nurses. They can make a diagnosis and prescribe vitamins, minerals and tests.

The structure, organisation and perioperative management of ambulatory surgery and anaesthesia in France: Methodology of the SFAR-OPERA study

The organization of health care establishments and perioperative care are essential for ensuring the quality of care and safety of patients undergoing outpatient surgery. In order to correctly inventory these organizations and practices, in 2013–2014, the French society of anaesthesia and intensive care organized an extensive practical survey in French ambulatory surgery units entitled the “OPERA” study (Organisation periopératoire de l’anesthésie en chirurgie ambulatoire). From among all of the ambulatory surgery centres listed by the Agences régionales de santé (Regional health agencies, France), 206 public and private centres were randomly selected. A structural (typology, organization) survey and a medical-practice survey (focusing on the management of postoperative pain, nausea and vomiting as well as the prevention of venous thromboembolism) were collected and managed by a prospective audit of practices occurring on two randomly selected days. The latter was further accompanied by an additional audit specifically focussing on ten representative procedures: (1) stomatology surgery (third molar removal); (2) knee arthroscopy; (3) surgery of the abdominal wall (including inguinal hernia); (4) perianal surgery; (5) varicose vein surgery; (6) digestive laparoscopy–cholecystectomy; (7) breast surgery (tumourectomy); (8) uterine surgery; (9) hallux valgus and (10) hand surgery (excluding carpal tunnel). Over the 2 days of observation, 7382 patients were included comprising 2174 patients who underwent one of the procedures from the above list. The analysis of these data will provide an overview of the organization of health establishments, the modalities thus supported and compliance with standards.