Sophie Béjean

Cost-effectiveness analysis of fecal occult blood screening for colorectal cancer.

OBJECTIVES Clinical trials have demonstrated that fecal occult blood screening for colorectal cancer can significantly reduce mortality. However, to be deemed a priority from a public health policy perspective, any new program must prove itself to be cost-effective. The objective of this study was to assess the cost-effectiveness of screening for colorectal cancer using a fecal occult blood screening test, the Hemoccult-II, in a cohort of 100,000 asymptomatic individuals 50-74 years of age. METHODS A decision analysis model using a Markov approach simulates the trajectory of the cohort allocated either to screening or no screening over a 20-year period through several health states. Clinical and economic data used in the model came from the Burgundy trial, French population-based studies, and Registry data. RESULTS Modeling biennial screening versus the absence of screening over a 20-year period resulted in a 17.7 percent mortality reduction and a discounted incremental cost-effectiveness ratio of 3357 Euro per life-year gained among individuals 50-74 years of age. Sensitivity analyses performed on epidemiological and economic data showed the strong impact on the results of colonoscopy cost, of compliance to screening, and of specificity of the screening test. CONCLUSIONS Cost-effectiveness estimates and sensitivity analyses suggest that biennial screening for colorectal cancer with fecal occult blood test could be recommended from the age of 50 until 74. Our findings support the attempts to introduce large-scale population screening programs.

Which patients with colorectal cancer are followed up by general practitioners? A population-based study.

The aim of the study was to assess the contribution of general practitioners in the surveillance of colorectal cancer, and to examine characteristics and survival of patients with routine general practitioner follow-up. This French registry-based study included 389 patients diagnosed with first colorectal cancer in 1998 and free of disease at least 6 months after curative surgery. For each physician involved, medical records were thoroughly reviewed to collect information about the clinical examinations and follow-up tests prescribed within 3 years after surgery or until death or detection of recurrence. Five-year vital status was obtained through registry records. The proportion of routine clinical examinations performed by general practitioners increased from 35% in the first year to 65% in the third year. Patients having undergone regular general practitioner routine examinations (≥one examination every 6-month period) had significantly less advanced disease (odds ratio: 0.45; 95% confidence interval: 0.21–0.96), preoperative complications (odds ratio: 0.28; 95% confidence interval: 0.08–0.91) and routine examinations by gastroenterologists/oncologists (odds ratio: 0.37; 95% confidence interval: 0.14–0.98) compared with those without general practitioner examinations. Routine general practitioner follow-up had no influence on 3 and 5-year survival. General practitioners detected significantly more recurrences than specialists in patients over 75 and in those presenting symptoms. French general practitioners are widely involved in the surveillance of patients with early-stage colorectal cancer, without any unfavourable impact on the patients survival. Some suggestions exist that continuing education in oncology may increase the implication of general practitioners in colorectal cancer surveillance.

Prevention of occupational injuries: moral hazard and complex agency relationships

This paper exploits the results of agency theory with the aim of contributing a new viewpoint and a form for analysis of the current functioning of the occupational injury and disease section of the French Social Security system in its mission of providing incentives for prevention. After outlining the organization and specific features of insurance against occupational risks, an initial level of analysis highlights the presence of moral hazard in relations between insurer and company and between company and employee. A second level of analysis with the appeal to complex agency relationship models, multitask model and third-party model, is necessary to take into account the consequences for occupational injury prevention of wage indexing on productivity and the presence of supervisors between the legislator and the company.

Psychosocial and organizational work environment of nurse managers and self-reported depressive symptoms: cross-sectional analysis from a cohort of nurse managers

ObjectivesThe association between depressive symptoms and psycho-organisational work environment has been established in the literature. Some studies have evaluated depressive symptoms in healthcare workers, but little research has been carried out among nurse managers. The aim of the study is to evaluate the depressive symptoms prevalence among nurse managers’ population and work environment factors.Material and MethodsA descriptive correlational research design was used. Data were collected from 296 nurse managers in five hospitals in the eastern area of France between 2007 and 2008. Health outcomes were evaluated by measuring depressive symptoms (CES-D scale), the exposure data by assessing psycho-organisational work environment with effort-reward imbalance-model of Siegrist. Multiple logistic regressions were used to describe the strength of the association between depressive symptoms and effort-reward imbalance adjusted for personal and occupational characteristics of the nurse managers.ResultsAmong the nurse managers, a third had depressive symptoms, and 18% presented an effort-reward imbalance (ratio: ≥ 1). A significant association was found between depressive symptoms and effort-reward imbalance (OR = 10.81, 95% CI: 5.1–23, p < 10−3), and with esteem as a reward (OR = 3.21, 95% CI: 1.6–6.3, p < 10−2).ConclusionIn view of the hierarchical situation of nurse managers and their primary roles in hospitals, it is necessary to take prevention measures to improve their work environment and health.

Cancers des voies respiratoires attribuables aux expositions professionnelles : quels coûts pour la société française ?

OBJECTIVE To estimate the social cost of respiratory cancers attributable to occupational risk factors in France in 2010. METHODS We estimated the number of cases of respiratory cancers attributable to each identified occupational risk factor according to the attributable fractions method. We also estimated direct (costs of hospital stays, drugs, outpatient care) and indirect costs (production losses) related to morbidity (absenteeism and presenteeism) and mortality (years of lost production). Production losses for paid work and unpaid domestic activities were taken into account. RESULTS The social cost of respiratory cancers (lung, larynx, sinonasal, pleural mesothelioma) attributable to exposure to asbestos, chromium, diesel engine exhaust, polycyclic aromatic hydrocarbons, painting occupations (unidentified carcinogen), crystalline silica, wood and leather dust in France in 2010 was estimated to be between €960 and 1,866 million. The cost of lung cancer represents between €804 and 1,617 million. The three risk factors with the greatest impact are asbestos (€530 to 890 million), diesel engine exhaust (€227 to 394 million), and crystalline silica (€116 to 268 million). CONCLUSION These results provide a conservative estimate of the public health and economic burden of respiratory cancers attributable to occupational risk factors from a societal perspective.

Les incitations à la prévention peuvent-elles être efficaces en médecine libérale ?

Le mode de paiement a l’acte est adapte a une relation medecin – patient ancree sur le curatif mais est peu performant pour inciter le medecin a la prevention. Cette pratique preventive est pourtant souhaitable pour la sante publique et, en France, une consultation specifique de prevention (CSP) est actuellement mise en place. L’efficacite de ce type d’incitation n’est toutefois pas garantie. Cet article propose d’elaborer des criteres d’efficacite pour une incitation a la prevention en medecine liberale, criteres qui relevent a la fois de la forme de l’incitation (montant, indexation au resultat, temporalite) et de son contexte (pratique individuelle ou de groupe, campagne d’information, motivations). Ces criteres sont mobilises pour analyser le potentiel de la CSP.