Bruno Ventelou

Is depression associated with health risk-related behaviour clusters in adults?

BACKGROUNDnDepressive disorders have been linked to health risk-related behaviours (HRBs) considered separately. Our objective was to study whether depression is associated with the co-occurrence of HRBs in adults.nnnMETHODSnA sample of 17 355 subjects aged > or =18 years, derived from the 2002-03 cross-sectional Decennial Health Survey; probable depression was assessed with the CES-D scale. A cluster analysis of various HRBs (tobacco use, alcohol use, binge drinking, physical inactivity, certain eating habits) was used to study their co-occurrence. Multiple regressions adjusted on demographic and socio-economic characteristics, Body Mass Index and chronic illnesses were performed to study associations between probable depression and the HRBs clusters obtained.nnnRESULTSnFive clusters were observed evidencing a gradient of cumulative exposure to HRBs: healthy lifestyles (Cluster 1), non-daily-consumers-fruit-and-green-vegetables (Cluster 2), regular alcohol users (Cluster 3), daily smokers (Cluster 4) and cumulate risk takers (Cluster 5). Compared with Cluster 1, positive associations were found between probable depression and Clusters 2, 4 and 5: OR 1.49 (95% CI 1.26-1.76) for Cluster 2; OR 1.81 (95% CI 1.54-2.12) for Cluster 4; OR 2.05 (95% CI 1.68-2.51) for Cluster 5. For Cluster 3, no association was found: OR 1.01 (95% CI 0.84-1.21).nnnCONCLUSIONSnHRBs tend to co-occur in the general population, more frequently in case of probable depression. Further research is necessary to disentangle the direction of the links between depression and HRB clusters. Nonetheless, these results question the classic design of education campaigns considering HRBs separately. Moreover, screening for depression should be systematic during prevention consultations and various HRBs should be monitored when treating depressive patients.

Achieving universal health coverage in France: policy reforms and the challenge of inequalities

Since 1945, the provision of health care in France has been grounded in a social conception promoting universalism and equality. The French health-care system is based on compulsory social insurance funded by social contributions, co-administered by workers and employers organisations under State control and driven by highly redistributive financial transfers. This system is described frequently as the French model. In this paper, the first in The Lancets Series on France, we challenge conventional wisdom about health care in France. First, we focus on policy and institutional transformations that have affected deeply the governance of health care over past decades. We argue that the health system rests on a diversity of institutions, policy mechanisms, and health actors, while its governance has been marked by the reinforcement of national regulation under the aegis of the State. Second, we suggest the redistributive mechanisms of the health insurance system are impeded by social inequalities in health, which remain major hindrances to achieving objectives of justice and solidarity associated with the conception of health care in France.

Socioeconomic inequalities in informal payments for health care: An assessment of the 'Robin Hood' hypothesis in 33 African countries.

In almost all African countries, informal payments are frequently made when accessing health care. Some literature suggests that the informal payment system could lead to quasi-redistribution among patients, with physicians playing a Robin Hood role, subsidizing the poor at the expense of the rich. We empirically tested this assumption with data from the rounds 3 and 5 of the Afrobarometer surveys conducted in 18 and 33 African countries respectively, from 2005 to 2006 for round 3 and from 2011 to 2013 for round 5. In these surveys, nationally representative samples of people aged 18 years or more were randomly selected in each country, with sizes varying between 1048 and 2400 for round 3 and between 1190 and 2407 for round 5. We used the normalized concentration index, the poor/rich gap and the odds ratio to assess the level of inequality in the payment of bribes to access care at the local public health facility and implemented two decomposition techniques to identify the contributors to the observed inequalities. We obtained that: i) the socioeconomic gradient in informal payments is in favor of the rich in almost all countries, indicating a rather regressive system; ii) this is mainly due to the socioeconomic disadvantage itself, to poor/rich differences in supply side factors like lack of medicines, absence of doctors and long waiting times, as well as regional disparities. Although essentially empirical, the paper highlights the need for African health systems to undergo substantial country-specific reforms in order to better protect the worse-off from financial risk when they seek care.

Cross-sectional survey: risk-averse French general practitioners are more favorable toward influenza vaccination.

OBJECTIVESnWe tested the following hypotheses: (i) risk-averse general practitioners (GPs) are more likely to be vaccinated against influenza; (ii) and risk-averse GPs recommend influenza vaccination more often to their patients. In risk-averse GPs, the perceived benefits of the vaccine and/or the perceived risks of the infectious disease might indeed outweigh the perceived risks of the vaccine.nnnPATIENTS/METHODSnIn 2010-2012, we conducted a cross-sectional survey of a nationwide French representative sample of 1136 GPs. Multivariate analyses adjusted for four stratification variables (age, gender, urban/suburban/rural practice location and annual patient consultations) and for GPs characteristics (group/solo practice, and occasional practice of alternative medicine, e.g., homeopathy) looked for associations between their risk attitudes and self-reported vaccination behavior. Individual risk attitudes were expressed as a continuous variable, from 0 (risk-tolerant) to 10 (risk-averse).nnnRESULTSnOverall, 69% of GPs reported that they were very favorable toward vaccination in general. Self-reported vaccination coverage was 78% for 2009/2010 seasonal influenza and 62% for A/H1N1 pandemic influenza. Most GPs (72%) reported recommending the pandemic influenza vaccination to at-risk young adults in 2009, but few than half (42%) to young adults not at risk. In multivariate analyses, risk-averse GPs were more often vaccinated against seasonal (marginal effect=1.3%, P=0.02) and pandemic influenza (marginal effect=1.5%, P=0.02). Risk-averse GPs recommended the pandemic influenza vaccination more often than their more risk-tolerant colleagues to patients without risk factors (marginal effect=1.7%, P=0.01), but not to their at-risk patients and were more favorable toward vaccination in general (marginal effect=1.5%, P=0.04).nnnCONCLUSIONnIndividual risk attitudes may influence GPs practices regarding influenza vaccination, both for themselves and their patients. Our results suggest that risk-averse GPs may perceive the risks of influenza to outweigh the potential risks related to the vaccine.

Factors associated with the use of rapid antigen diagnostic tests in children presenting with acute pharyngitis among French general practitioners

In this investigation, we wanted: (i) to describe the attitudes and declared practices of a representative sample of French general practitioners (GPs) regarding rapid antigen diagnostic tests (RADTs) for acute pharyngitis and (ii) to identify the GPs’ characteristics associated with the use of an RADT in the last paediatric patient with pharyngitis. We performed a cross-sectional survey conducted in 2012 among a representative sample of 1,126 self-employed GPs in France. 60.1xa0% of GPs declared that they used an RADT in their last patient aged between 3 and 16xa0years presenting with acute pharyngitis; 29.6xa0% of these tests were positive. Among the GPs who did not use an RADT, 50.2xa0% prescribed an antibiotic, compared to 30.5xa0% of prescriptions among GPs who performed an RADT, whatever its result. In a multivariate analysis, GPs’ age between 45 and 54xa0years and having attended Continuing Medical Education (CME) sessions on infectious diseases in the past year were significantly associated with an increased use of an RADT in the last patient with pharyngitis, whereas a low volume of activity, occasionally practising alternative medicine, receiving pharmaceutical representatives at the practice and declaring a consultation duration <15xa0min were factors associated with a decreased use of RADTs. The use of RADTs by GPs must be promoted; our findings could help define interventions to improve practice.

Rates of admission for ambulatory care sensitive conditions in France in 2009–2010: trends, geographic variation, costs, and an international comparison

BackgroundAdmissions for ambulatory care sensitive conditions (ACSCs) are considered preventable and indicators of poor access to primary care. We wondered whether per-capita rates of admission for ACSCs in France demonstrated geographic variation, were changing, were related to other independent variables, or were comparable to those in other countries; further, we wanted to quantify the resources such admissions consume.MethodsWe calculated per-capita rates of admission for five categories (chronic, acute, vaccination preventable, alcohol-related, and other) of ACSCs in 94 departments in mainland France in 2009 and 2010, examined measures and causes of geographic variation in those rates, computed the costs of those admissions, and compared rates of admission for ACSCs in France to those in several other countries.ResultsThe highest ACSC admission rates generally occurred in the young and the old, but rates varied across French regions. Over the 2-year period, rates of most categories of ACSCs increased; higher ACSC admission rates were associated with lower incomes and a higher supply of hospital beds. We found that the local supply of general practitioners was inversely associated with rates of chronic and total ACSC admission rates, but that this relationship disappeared if we accounted for patients’ use of general practitioners in neighboring departments. ACSC admissions cost 4.755 billion euros in 2009 and 5.066 billion euros in 2010; they consumed 7.86 and 8.74 million bed days of care, respectively. France had higher rates of ACSC admissions than most other countries examined.ConclusionsBecause admissions for ACSCs are generally considered a failure of outpatient care, cost French taxpayers substantial monetary and hospital resources, and appear to occur more frequently in France than in other countries, policymakers should prioritize targeted efforts to reduce them.

The true impact of the French pay-for-performance program on physicians’ benzodiazepines prescription behavior

ObjectivesThe French pay-for-performance (P4P) contract CAPI implemented by the national health insurance included a target-goal which aims at reducing benzodiazepines prescriptions. In this investigation, we would like to assess whether: (1) the general practitioners (GPs) having signed P4P contract obtain better results regarding the target-goal than non-signatories; (2) (part of) this progression is due to the CAPI contract itself (tentative measurement of a “causal effect”); (3) (part of) the money spent on this P4P incentive can be self-financed with the amount of pharmaceuticals saved.MethodsWe matched cross-sectional and longitudinal data including 4622 French GPs from June 2011 to December 2012. A treatment effect model using instrumental variables was performed to take into account potential self-selection issue in signing. After having identified the NET impact of the P4P, we calculate the cost of an avoided benzodiazepines treatment.ResultsIn our study, GPs who have signed the CAPI contract (36xa0% of the sample) are more numerous in achieving benzodiazepines target goal than non-signatories: 90.7 vs. 85.5xa0%. After controlling for the self-selection bias, the propensity of GPs to achieve the benzodiazepines target is only 0.31xa0% higher for signatories than for their non-signing counterparts—estimate for June 2012, which yields a statistically significant gap. Our economic analysis demonstrates that the CAPI contract does not allow savings, but presents in 2012 a NET cost of 93.6€ per avoided benzodiazepines treatment (291€ in 2011).ConclusionsThe P4P contract has a positive but modest impact on the achievement of GPs regarding benzodiazepines indicator.

The value of specialist care—infectious disease specialist referrals—why and for whom? A retrospective cohort study in a French tertiary hospital

This study evaluated the impact of infectious disease (ID) specialist referrals on outcomes in a tertiary hospital in France. This study tackled methodological constraints (selection bias, endogeneity) using instrumental variables (IV) methods in order to obtain a quasi-experimental design. In addition, we investigated whether certain characteristics of patients have a bearing on the impact of the intervention. We used the payments database and ID department files to obtain data for adults admitted with an ID diagnosis in the North Hospital, Marseille from 2012 to 2014. Comparable cohorts were obtained using coarsened exact matching and analysed using IV models. Mortality, readmissions, cost (payer perspective) and length of stay (LoS) were analysed. We recorded 15,393 (85.97%) stays, of which 2,159 (14.03%) benefited from IDP consultations. The intervention was seen to significantly lower the risk of inpatient mortality (marginal effect (M.E) = –19.06%) and cost of stay (average treatment effect (ATE) = – €5,573.39). The intervention group was seen to have a longer LoS (ATE = +4.95 days). The intervention conferred a higher reduction in mortality and cost for stays that experienced ICU care (mortality: odds ratio (OR) =0.09, M.E cost = –8,328.84 €) or had a higher severity of illness (mortality: OR=0.35, M.E cost = –1,331.92 €) and for patients aged between 50 and 65 years (mortality: OR=0.28, M.E cost = -874.78 €). This study shows that ID referrals are associated with lower risk of inpatient mortality and cost of stay, especially when targeted to certain subgroups.

Medicine and democracy: The importance of institutional quality in the relationship between health expenditure and health outcomes in the MENA region

Evidence suggests that the effect of health expenditure on health outcomes is highly context-specific and may be driven by other factors. We construct a panel dataset of 18 countries from the Middle East and North Africa region for the period 1995-2012. Panel data models are used to estimate the macro-level determinants of health outcomes. The core finding of the paper is that increasing health expenditure leads to health outcomes improvements only to the extent that the quality of institutions within a country is sufficiently high. The sensitivity of the results is assessed using various measures of health outcomes as well as institutional variables. Overall, it appears that increasing health care expenditure in the MENA region is a necessary but not sufficient condition for health outcomes improvements.

Predicting medical practices using various risk attitude measures

This paper investigates the predictive power of several risk attitude measures on a series of medical practices. We elicit risk preferences on a sample of 1500 French general practitioners (GPs) using two different classes of tools: scales, which measure GPs’ own perception of their willingness to take risks between 0 and 10; and lotteries, which require GPs to choose between a safe and a risky option in a series of hypothetical situations. In addition to a daily life risk scale that measures a general risk attitude, risk taking is measured in different domains for each tool: financial matters, GPs’ own health, and patients’ health. We take advantage of the rare opportunity to combine these multiple risk attitude measures with a series of self-reported or administratively recorded medical practices. We successively test the predictive power of our seven risk attitude measures on eleven medical practices affecting the GPs’ own health or their patients’ health. We find that domain-specific measures are far better predictors than the general risk attitude measure. Neither of the two classes of tools (scales or lotteries) seems to perform indisputably better than the other, except when we concentrate on the only non-declarative practice (prescription of biological tests), for which the classic money-lottery test works well. From a public health perspective, appropriate measures of willingness to take risks may be used to make a quick, but efficient, profiling of GPs and target them with personalized communications, or interventions, aimed at improving practices.