Sébastien Lamy

Social Determinants of Cardiovascular Diseases

Social determinants of health can be understood as the social conditions in which individuals live and work; conditions that are shaped by the distribution of power, income and resources, as much on a global and national level as on a local level. Social determinants of cardiovascular diseases are found largely outside the healthcare and preventative healthcare systems; but it is important to think in terms of chains of cause and effect, which enable us to see these determinants at work within the system of curative and preventative care, including the management of traditional risk factors. Taking a dynamic perspective on these social determinants of health, and in particular viewing them in a biological and epidemiological context, emphasizes the fact that intervention as early in life as possible is desirable in order to prevent cardiovascular diseases. It is important to act early, before childhood adversities in these critical periods are permanently or irrevocably recorded in the body. In terms of behaviour, focussing health education on adults runs counter to the fact that, with age, it is increasingly difficult to change our behaviour and to overcome biological damage already inflicted. In an area where attention has long been focussed on individual risk factors, underlining the fact that these factors act from infancy allows us to highlight the collective influences on the development of these diseases. Reflecting on health determinants in this way suggests that perhaps the population strategy proposed by Geoffrey Rose may lead to an increase in social inequalities if the modest decrease in risk factors, for example in terms of nutrition, involves the population categories initially most privileged.

Life expectancy estimates as a key factor in over-treatment: the case of prostate cancer.

OBJECTIVE To estimate the magnitude of over-diagnosis and of potential and actual over-treatment regarding prostate cancer, taking comorbidities into account. MATERIALS AND METHODS We used a sample collected by the French cancer registries of 1840 cases (T1: 583; T2: 1257) diagnosed in 2001. The proportion of over-diagnosed and over-treated patients was estimated by comparing life expectancy (LE), including or not comorbidities, with natural LE with cancer, using several assumptions from the literature. We distinguished potential and actual over-treatment according to the treatment that patients actually received. RESULTS Among patients with T1 tumors the proportion of potential over-treatment using LE adjusted for comorbidity varied from 29.5% to 53.5%, using LE adjusted on comorbidities, and varied from 9.3% to 22.2% regarding actual over-treatment. Between 7.7% and 24.4% of patients receiving a radical prostatectomy, and between 30.8% and 62.5% of those receiving radiotherapy, were over-treated. Among patients with T2 tumors, the proportions of potential and actual over-treatment were 0.9% and 2.0%. Two per cent of patients receiving a radical prostatectomy and 4.9% of those receiving radiotherapy were over-treated. Comorbidities dramatically increased these proportions to nearly 100% of patients, with more than two comorbidities being potentially over-treated and around 33% actually over-treated. CONCLUSIONS According to the French incidence, 3200-4800 French patients may be over-treated, among whom a large proportion of patients had comorbidities. The real issue is to offer the most appropriate treatment to people with low-grade tumors and comorbidities.

Psychosocial and organizational work factors and incidence of arterial hypertension among female healthcare workers: results of the Organisation des Soins et Santé des Soignants cohort

Background: Many studies have supported the role of organizational work factors (OWFs) on the risk of cardiovascular diseases (CVDs) and CVD risk factors, including arterial hypertension. However, a little information is available concerning the role of collective stressors deriving from work organization on nurses risk of hypertension. This study aimed to test the independent longitudinal relationships linking the 2-year incidence of arterial hypertension to collective stressors at the work unit level, among baseline normotensive female hospital registered nurses and nursing assistants, after adjusting for known individual predictors of CVDs and for occupational stress. Method: Arterial hypertension was defined as the intake of antihypertensive drug or as blood pressure (BP) measures higher than 140 mmHg (SBP) or 90 mmHg (DBP) at both the clinical visit and 1 month later. We analyzed the effect of OWFs at the work unit level, constraints related to the physical work environment and the individual perception of the work environment in 2006 on the risk of arterial hypertension in 2008 among 1882 initially normotensive female healthcare workers followed in the French Organisation des soins et santé des soignants (ORSOSA) cohort. Results: We showed that OWFs at the work unit level may influence the 2-year risk of arterial hypertension independently of work factors at the worker level, baseline BP, age and BMI. In this study, OWFs affected 2-year risk of arterial hypertension only through direct effects. Conclusion: Our results pointed out the possibility of a primary prevention of arterial hypertension through interventions based at the work unit level among healthcare workers.

A longitudinal study of non-medical determinants of adherence to R-CHOP therapy for diffuse large B-cell lymphoma: implication for survival

BackgroundAdherence to therapy has been established for years as a critical parameter for clinical benefit in medical oncology. This study aimed to assess, in the current practice, the influence of the socio-demographical characteristics and the place of treatment on treatment adherence and overall survival among diffuse large B-cell lymphoma patients.MethodsWe analysed data from 380 patients enrolled in a French multi-centre regional cohort, with diffuse large B-cell lymphoma receiving first-line treatment with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) or R-CHOP-like regimens. Direct examination of administrative and medical records yielded the date of death. We studied the influence of patients’ socio-demographic characteristics and place of treatment on the treatment adherence and overall survival, adjusted for baseline clinical characteristics. Treatment adherence was measured by the ratio between received and planned dose Intensity (DI), called relative DI (RDI) categorized in “lesser than 85%” and “at least 85%”.ResultsDuring the follow-up, among the final sample 70 patients had RDI lesser than 85% and 94 deceased. Multivariate models showed that advanced age, poor international prognosis index (IPI) and treatment with R-CHOP 14 favoured RDI lesser than 85%. The treatment in a public academic centre favoured RDI greater than or equal to 85%. Poor adherence to treatment was strongly associated with poor overall survival whereas being treated in private centres was linked to better overall survival, after adjusting for confounders. No socioeconomic gradient was found on both adherence to treatment and overall survival.ConclusionsThese results reinforce adherence to treatment as a critical parameter for clinical benefit among diffuse large B-cell lymphoma patients under R-CHOP. The place of treatment, but not the socioeconomic status of these patients, impacted both RDI and overall survival

The care center influences the management of lymphoma patients in a universal health care system: an observational cohort study.

BackgroundHealthcare providers-related disparities in adherence to the treatment plan among lymphoma patients are found even in a universal healthcare system, but the mechanism remains unclear. We investigated the association between the type of care center and the relative dose intensity and determined whether it persists after adjustment for patients’ recruitment differences.MethodsProspective observational cohort study of 294 patients treated with standard protocols for diffuse large B-cell lymphoma (DLBCL) in teaching or community public hospitals or in private centers in the French Midi-Pyrénées region from 2006–2013. To test our assumptions, we used multinomial and mixed-effect logistic models progressively adjusted for patients’ biomedical characteristics, socio-spatial characteristics and treatment-related toxicity events.ResultsPatients treated using standard protocols in the teaching hospital had more advanced stage and poorer initial prognosis without limitation regarding the distance from the residence to the care center. Patients’ recruitment profile across the different types of care center failed to explain the difference in relative dose intensity. Low relative dose intensity was less often observed in teaching hospital than elsewhere.ConclusionWe showed that even in a universal healthcare system, disparities in the management of DLBCL patients’ do exist according to the types of care center. A main issue may be to find and diffuse the reasons of this benefit in cancer management in the teaching hospital to the other centers.

Amélioration de la qualité de vie au travail dans les unités de soins : la démarche ORSOSA

Developper la qualite de vie au travail devient un enjeu important pour les soignants qui ont de plus en plus a faire face a des contraintes de productivite et de procedures multiples. A partir du concept des hopitaux magnetiques, l’etude ORSOSA (cohorte prospective de 4000 soignants) a permis de developper puis de valider une methodologie de diagnostic rapide des niveaux de contraintes psychologiques et organisationnelles (CPO) portant sur la perception des agents. Cette methode s’appuie sur un psychologue du travail, qui, lors de la phase de restitution du diagnostic, initie une dynamique d’appropriation des forces et faiblesses puis accompagne l’equipe a hierarchiser les preconisations emanant de ce collectif. Cet article presente la demarche et les premieres phases de son evaluation.

Is the use of emergency departments socially patterned

ObjectivesTo analyse the association between patients’ socioeconomic position (SEP) and the use of emergency departments (EDs).MethodsThis population-based study included all visits to ED in 2012 by inhabitants of the French Midi-Pyrénées region, recorded by the Regional Emergency Departments Observatory. We compared ED visit rates and the proportion of non-severe visits according to the patients’ SEP as assessed by the European Deprivation Index.ResultsWe analysed 496,388 visits. The annual ED visit rate increased with deprivation level: 165.9 [95% CI (164.8–166.9)] visits per 1000 inhabitants among the most advantaged group, compared to 321.9 [95% CI (320.3–323.5)] per 1000 among the most disadvantaged. However, the proportion of non-severe visits was about 14% of the visits, and this proportion did not differ according to SEP.ConclusionsAlthough the study shows a difference of ED visit rates, the probability of a visit being non-severe is not meaningfully different according to SEP. This supports the assumption that ED visit rate variations according to SEP are mainly explained by SEP-related differences in health states rather than SEP-related differences in health behaviours.

Physician uncertainty aversion impacts medical decision making for older patients with acute myeloid leukemia: results of a national survey

Elderly patients with acute myeloid leukemia can be treated with intensive chemotherapy, low-intensity therapy such as low-dose aracytine or hypomethylating agents, or best supportive care. The choice between these treatments is a function of many patient-related and disease-related factors. We investigated how physicians’ behavioral characteristics affect medical decision-making between intensive and non-intensive therapy in this setting. A nationwide cross-sectional online survey of hematologists collected data on medical decision-making for 6 clinical vignettes involving older acute myeloid leukemia patients that were representative of routine practice. Questionnaires elicited physicians’ demographic and occupational characteristics along with their individual behavioral characteristics according to a decision theory framework. From the pattern of responses to the vignettes, a K-means clustering algorithm was used to distinguish those who were likely to prescribe more intensive therapy and those who were likely to prescribe less intensive or no therapy. Multivariate analyses were used to identify physician’s characteristics predictive of medical decision-making. We obtained 230 assessable answers, which represented an adjusted response rate of 45.4%. A multivariate model (n=210) revealed that physicians averse to uncertainty recommend significantly more intensive chemotherapy: Odds Ratio (OR) [95% Confidence Interval (CI)]: 1.15 [1.01;1.30]; P=0.039. Male physicians who do not conform to the expected utility model (assumed as economically irrational) recommend more intensive chemotherapy [OR (95% CI) = 3.45 (1.34; 8.85); P=0.01]. Patient volume per physician also correlated with therapy intensity [OR (95% CI)=0.98 (0.96; 0.99); P=0.032]. The physicians’ medical decision-making was not affected by their age, years of experience, or hospital facility. The significant association between medical decision and individual behavioral characteristics of the physician identifies a novel non-biological factor that may affect acute myeloid leukemia patients’ outcomes and explain variations in clinical practice. It should also encourage the use of validated predictive models and the description of novel bio-markers to best select patients for intensive chemotherapy or low-intensity therapy.

État des lieux des inégalités sociales de santé en France

Health is dependent on the living conditions and the socioeconomic environment of populations. The healthcare system tends to underestimate these aspects and thereby maintain, and even aggravate, the resulting social inequalities in health. It is essential that this situation is improved by adopting a global and interdisciplinary vision of healthcare and its social determinants.

Disentangling the influence of living place and socioeconomic position on health services use among diabetes patients: A population-based study

This research investigates the influence of place of residence and diabetic patient’s socioeconomic position on their use of health services in a universal health care system. This retrospective cross-sectional population-based study is based on the joint use of the Health Insurance information systems, an ecological indicator of social deprivation and an indicator of potential spatial accessibility of healthcare provision in the Midi-Pyrénées region. Using French healthcare insurance population-based data on reimbursement of out-of-hospital care during the year 2012, we study the use of health services among patients aged 50 and over (n = 90,136).We built logistic regression models linking health services use to socioeconomic position by geographic area, adjusted for age, gender, healthcare provision, information regarding patients precariousness, and long-term condition, used as proxy for the state of health. After adjustment for healthcare provision, the lower population density in the geographical area of concern, the lower the access to specialised care, independent of the patients’ SEP. General practitioner attendance was higher among the patients with the lowest SEP without being clearly influenced by their living place. We found no clear influence of either patients’ SEP or their living place on their access to biological follow-up. This study is an attempt to account for the geographical context and to go further in studying the social determinants of health among diabetes patients.