AMU - AMSE
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Dans plusieurs pays en développement et en particulier au Moyen-Orient et en Afrique du Nord, l’informalité est regardée comme une fatalité et laisse une proportion importante de la population non couverte par le système de sécurité sociale. Une enquête d’évaluation contingente a été menée en Tunisie en 2013, se proposant d’estimer les consentements à payer (CAP) pour deux régimes hypothétiques d’assurance volontaire : un régime d’assurance maladie géré par la ‘Caisse Nationale d’Assurance Maladie’ et un régime vieillesse géré par la ‘Caisse Nationale de Sécurité Sociale’.
L’échantillon se compose de 456 individus non couverts par un régime de sécurité sociale (maladie ou vieillesse), interrogés dans les régions Nord, Centre et Sud du pays. Les personnes interrogées ont été recrutées sur les marchés (souks) – caractérisés par la forte présence d’acteurs du secteur informel – et les places publiques (Al-mydan) – où s’organisaient régulièrement des rassemblements pacifiques de chômeurs pour revendiquer des droits sociaux peu après ce qui a été appelé ‘le printemps Arabe’ qui a débuté en Tunisie fin 2010.
L’intention d’adhésion déclarée par les travailleurs informels et les sans-emploi varie selon le type de filière de soins proposée et selon les risques couverts (avec ou sans assurance-vieillesse). Les résultats confirment les hypothèses selon lesquelles une affiliation volontaire à deux régimes d’assurance serait majoritairement acceptée par les non couverts et les CAPs déclarés pour cette affiliation seraient substantiels. Ils apportent donc des éléments de discussion en termes de politiques tunisiennes de santé (objectif de couverture santé universelle) et d’assurance-vieillesse.
Finalement, nos résultats montrent d’une part que l’informalité n’est pas un choix des individus et que le contrôle de l’évasion sociale en Tunisie est possible. D’autre part, la comparaison manifestants/non manifestants montre qu’il est possible de généraliser une offre d’assurance sociale au-delà du cercle restreint des « activistes ».
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.
This paper analyses how French general practitioners? (GPs) labour supply would respond to changes in their fee per consultation, seeking to determine whether there is a backward-bending curve.?Because French GPs? fees only evolve very slowly and are generally fixed by the National Health Insurance Fund, fee variability is not sufficient to observe changes in labour supply.?Therefore, we designed a contingent valuation survey randomly presenting GPs with three hypothetical fee increases.?Empirical evidence from 1,400 GPs supports the hypothesis of a negative slope in their labour supply curve.?This suggests that increasing fees is not an effective policy to increase the supply of medical services. JEL Codes: C21, I12, J22, J4.
From November 2014 to November 2015, an experiment in French community pharmacies replaced traditional pre-packed boxes by per-unit dispensing of pills in the exact numbers prescribed, for 14 antibiotics.
A cluster randomised control trial was carried out in 100 pharmacies. 75 pharmacies counted out the medication by units (experimental group), the other 25 providing the treatment in the existing pharmaceutical company boxes (control group). Data on patients under the two arms were compared to assess the environmental, economic and health effects of this change in drug dispensing. In particular, adherence was measured indirectly by comparing the number of pills left at the end of the prescribed treatment.
Out of the 1185 patients included during 3 sessions of 4 consecutive weeks each, 907 patients experimented the personalized delivery and 278 were assigned to the control group, consistent with a 1/3 randomization-rate at the pharmacy level. 80% of eligible patients approved of the per-unit dispensing of their treatment. The initial packaging of the drugs did not match with the prescription in 60% of cases and per-unit dispensing reduced by 10% the number of pills supplied. 13.1% of patients declared that they threw away pills residuals instead of recycling—no differences between groups. Finally, per-unit dispensing appeared to improve adherence to antibiotic treatment (marginal effect 0.21, IC 95, 0.14–0.28).
Supplying antibiotics per unit is not only beneficial in terms of a reduced number of pills to reimburse or for the environment (less pills wasted and non-recycled), but also has a positive and unexpected impact on adherence to treatment, and thus on both individual and public health.
Introduction Patients with complex care needs (PCCNs) often suffer from combinations of multiple chronic conditions, mental health problems, drug interactions and social vulnerability, which can lead to healthcare services overuse, underuse or misuse. Typically, PCCNs face interactional issues and unmet decisional needs regarding possible options in a cascade of interrelated decisions involving different stakeholders (themselves, their families, their caregivers, their healthcare practitioners). Gaps in knowledge, values clarification and social support in situations where options need to be deliberated hamper effective decision support interventions. This review aims to (1) assess decisional needs of PCCNs from the perspective of stakeholders, (2) build a taxonomy of these decisional needs and (3) prioritise decisional needs with knowledge users (clinicians, patients and managers).
Methods and analysis This review will be based on the interprofessional shared decision making (IP-SDM) model and the Ottawa Decision Support Framework. Applying a participatory research approach, we will identify potentially relevant studies through a comprehensive literature search; select relevant ones using eligibility criteria inspired from our previous scoping review on PCCNs; appraise quality using the Mixed Methods Appraisal Tool; conduct a three-step synthesis (sequential exploratory mixed methods design) to build taxonomy of key decisional needs; and integrate these results with those of a parallel PCCNs’ qualitative decisional need assessment (semistructured interviews and focus group with stakeholders).
Ethics and dissemination This systematic review, together with the qualitative study (approved by the Centre Intégré Universitaire de Santé et Service Sociaux du Saguenay-Lac-Saint-Jean ethical committee), will produce a working taxonomy of key decisional needs (ontological contribution), to inform the subsequent user-centred design of a support tool for addressing PCCNs’ decisional needs (practical contribution). We will adapt the IP-SDM model, normally dealing with a single decision, for PCCNs who experience cascade of decisions involving different stakeholders (theoretical contribution). Knowledge users will facilitate dissemination of the results in the Canadian primary care network.
PROSPERO registration number CRD42015020558.
The literature offers competing estimates of disease costs, with each study having its own data and methods. In 2007, the Dutch Center for Public Health Forecasting of the National Institute for Public Health and the Environment provided guidelines that can be used to set up cost-of-illness (COI) studies, emphasising that most COI analyses have trouble accounting for comorbidity in their cost estimations. When a patient has more than one chronic condition, the conditions may interact such that the patient’s healthcare costs are greater than the sum of the costs for the individual diseases. The main objective of this work was to estimate the costs of 10 non-communicable diseases when their co-occurrence is acknowledged and properly assessed.
Antimicrobial resistance challenge requests to be able to measure patient medication-adherence in outpatient setting, where more than 90% of antibiotics are prescribed. We take advantage of an original dataset where adherence to treatment has been measured through two alternative measurements: pills count and the Morisky scale. Considering the first measure as benchmark, we test the validity of each of the Morisky items and their composition in a synthetic scale. We show that the short-form version of the medication-adherence scale with three items has the best predictive properties in the domain of antibiotic treatments. Given its concision, this tool could even be used by clinicians to quickly assess patients’ adherence and modify it in the course, when needed.
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.