Background and Purpose-To replace digital subtraction angiography (DSA) in carotid stenosis evaluation, noninvasive imaging techniques have to reach a high concordance rate. Our purpose is to compare the concordance rates of contrast-enhanced MR angiography (CEMRA) and CT angiography (CTA) with Doppler ultrasound (DUS) in clinical routine practice. Methods-We evaluated prospectively with DUS, CEMRA, and CTA 150 patients suspected of carotid stenosis. The overall concordance rates of the 3 techniques were calculated for symptomatic stenosis Ն50% and Ն70%, for asymptomatic stenosis Ն60%, and for occlusion. For the carotid arteries treated by surgery (nϭ97), the results of each method and combined techniques were recorded, and misclassification rates were evaluated from surgical reports. Results-The overall concordance rates of DUS-CEMRA, DUS-CTA, and CEMRA-CTA were not statistically different.However, the concordance rate of DUS-CEMRA (92.53%) was significantly higher than that for DUS-CTA (79.10%) in the surgical asymptomatic stenosis group (Pϭ0.0258). CTA considered alone would misclassify the stenosis in a significant number of cases (11 of 64) in the surgical asymptomatic group compared with CEMRA (3 of 67) and DUS (1 of 66) (Pϭ0.0186 versus MRA, Pϭ0.0020 versus DUS). Conclusions-With the techniques as utilized in our study, the overall concordance rates of combined noninvasive methods are similar for measuring carotid stenosis in clinical routine practice, but in asymptomatic carotid stenosis, the decision making for surgery is significantly altered if DUS and CTA are considered in place of DUS and CEMRA.
BackgroundOral anticancer drugs (OADs) allow treating a growing range of cancers. Despite their convenience, their acceptance by healthcare professionals and patients may be affected by medical, economical and organizational factors. The way the healthcare payment system (HPS) reimburses OADs or finances hospital activities may impact patients’ access to such drugs. We discuss how the HPS in France and USA may generate disincentives to the use of OADs in certain circumstances.DiscussionFrench public and private hospitals are financed by National Health Insurance (NHI) according to the nature and volume of medical services provided annually. Patients receiving intravenous anticancer drugs (IADs) in a hospital setting generate services, while those receiving OADs shift a part of service provision from the hospital to the community. In 2013, two million outpatient IADs sessions were performed, representing a cost of €815 million to the NHI, but positive contribution margin of €86 million to hospitals. Substitution of IADs by OADs mechanically induces a shortfall in hospital income related to hospitalizations. Such economic constraints may partially contribute to making physicians reluctant to prescribe OADs. In the US healthcare system, coverage for OADs is less favorable than coverage for injectable anticancer drugs. In 2006, a Cancer Drug Coverage Parity Act was adopted by several states in order to provide patients with better coverage for OADs. Nonetheless, the complexity of reimbursement systems and multiple reimbursement channels from private insurance represent real economic barriers which may prevent patients with low income being treated with OADs. From an organizational perspective, in both countries the use of OADs generates additional activities related to physician consultations, therapeutic education and healthcare coordination between hospitals and community settings, which are not considered in the funding of hospitals activities so far.SummaryFunding of healthcare services is a critical factor influencing in part the choice of cancer treatments and this is expected to become increasingly important as economic constraints grow. Drug reimbursement systems and hospital financing changes, coupled with other accompanying measures, should contribute to improve equal and safe patient access to appropriate anticancer drugs and improve the management and care pathway of cancer patients.
Les inégalités sociales de santé sont un thème récurrent dans la littérature en santé de ces dernières années. Le cancer colorectal touche environ 40 000 personnes par an, 17 526 en sont décédées en 2011. Son dépistage contribue significativement à la baisse de la mortalité, en favorisant une prise en charge précoce. Depuis 2001, les autorités sanitaires françaises ont organisé une incitation systématique de la population des personnes âgées de 50 à 74 ans, dépistage auquel les populations de catégories socio-économiques les moins favorisées sont moins susceptibles de bénéficier. De 2012 à 2014, nous avons participé à l’étude interventionnelle française COLONAV, reproduisant une expérience née aux États Unis appelée « navigation program ». Le dispositif de navigation est une fonction intermédiaire permettant d’accéder à une population que le système de santé lui-même n’arrive pas à atteindre. Le design de ces programmes est décrit de façon sommaire et peu explicité dans ses fondements. Il n’est jamais étudié sur le plan théorique. L’étude approfondie du recrutement des navigateurs exposé dans la littérature américaine et l’expérience COLONAV permet de révéler les éléments qui contingentent le design de ce dispositif, ainsi que les fondements qui en assurent l’efficacité. Dans ce papier, nous étudions cette organisation par le prisme du profil de recrutement de celui qui porte le dispositif de navigation. Ce travail interroge sur la place dans le design du dispositif de cet intervenant supplémentaire. Est-il destiné à servir d’intermédiaire entre un système dont les dysfonctionnements sont nombreux et des personnes peu aptes à les surmonter ? Interroge-t-il sur la capacité de ce système à esquisser un modeste, mais nouveau design du dispositif de dépistage du cancer ? Ayant travaillé selon la perspective de la théorie ancrée (Grounded Theory), nous avons travaillé par abduction à partir des résultats de nos analyses pour identifier des pistes théoriques. Nous montrons comment le dispositif de navigation s’apparente à l’approche des organisations frontières développées à partir des travaux de Peton. Cette analyse théorique permet d’esquisser des pistes de réflexion quant à la manière d’organiser un dépistage accessible aux populations les plus éloignées actuellement des préoccupations qui l’ont fondé. Le dispositif de navigation, et donc par extension les navigateurs, sont une organisation frontière permettant de faire le lien et la traduction des attentes entre les différents organismes qui le composent et la population cible. Ils servent souvent d’intermédiaires entre un système dont les dysfonctionnements sont nombreux et des personnes peu aptes à les surmonter, mais dans le cadre du dépistage, leur fonction la plus intéressante est en amont de la levée des barrières logistiques, dans leur capacité à faire le lien de sens entre des objectifs divergents.
Despite a slightly higher acquisition cost, the treatment cost of L + C remains lower than that of TBT, and it is the only approved anti-HER2 treatment for HER2-positive patients with progressing MBC. Based on this, it seems important to consider the potential savings for Health Insurance with the use of oral drug due to the reduction of outpatient hospitalizations. Such reductions may result in a subsequent budget reduction for hospitals, but may also provide those facing acute medical activity with opportunities to better manage other diseases whose treatment cannot be externalized.
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