Issues in Health Economics

Issues in Health Economics (in French : Questions d’économie de la santé) is a monthly publication presenting syntheses of latest Irdes research on health economics. Benefiting from a high public visibility, this publication is systematically translated in English.

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Is there a Relationship between Volume of Activity and Quality of Care in French Hospitals?
Questions d'Úconomie de la santÚ n° 149. 2009/12.
Or Z., Renaud T.

Concentration of certain procedures in high-volume hospitals is increasingly being presented as a means of improving the quality of care. However, until now no study has verified the link between volume of activity and quality of the care in France. This study provides new quantitative evidence on the correlation between the volume and outcomes of care exploiting French hospital data. For six out of eight conditions studied, results show that the probability of readmission and mortality is higher in low-volume hospitals. The intensity and the functional form of the link differ by condition and depend on the technical complexity of the procedure/treatment. Moreover, the relation is not linear: the impact of volume on the outcomes flattens gradually as the activity increases. In certain domains, it may be efficient to limit the number of hospitals with very low volume but there would be little additional benefit to centralize hospital activity beyond a certain point.

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Pathways to Retirement in Europe: Individual Determinants and the Role of Social Protection.
Questions d'Úconomie de la santÚ n° 148. 2009/11.
Debrand T., Sirven N.

In Europe, the pathways to retirement are determined by individual factors such as age, gender, education level and health status, and contextual factors such as family and professional environments. In addition to these usual explanatory factors, this analysis equally focuses on the role of social protection systems. It demonstrates that European disparities in the employment rate of older workers, varying from 34% in Italy to 70% in Sweden, can largely be explained by the complementary and combined effects of the three facets of social protection: employment, pensions, disability.
Any public policy aiming to increase the workforce participation of older citizens in Europe should therefore take into account not only the complexity of individual determinants influencing the retirement decision, but also the interactive effect of all social protection categories and not simply those relating to pensions.

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An Exploratory Evaluation of Multidisciplinary Primary Care Group Practices in Franche-Comté and Bourgogne
Questions d'Úconomie de la santÚ n° 147. 2009/10.
Bourgueil Y., Clément M.-C., Couralet P.-E., Mousquès J., Pierre A.

The creation of maisons de santé pluridisciplinaires1 , grouping together first-contact medical and paramedical private practitioners providing a multidisciplinary healthcare service, is expanding throughout France. In view of the medical demographics crisis and geographical inequalities in the distribution of healthcare supply, this form of organisation is perceived as a means of ensuring a satisfactory, modern, good quality healthcare service throughout the country whilst improving health professionals’ working conditions.
An exploratory evaluation of nine MSPs conducted in the French regions Franche-Comté and Bourgogne confirms that these structures, compared with traditional general medical practice, allows for a better balance between private life and professional practice. The MSPs present further advantages: greater accessibility due to longer opening hours, efficient cooperation between professionals –notably between general practitioners and nurses–, and a more extensive care supply.
Follow-up care for type 2 diabetes patients equally seems of better quality in MSPs despite the heterogeneity of results. At this stage, it is impossible to clearly ascertain whether office-based medical care expenditures have increased or decreased among MSPs patients.

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Immigrants’ Access to Ambulatory Care in France
Questions d'Úconomie de la santÚ n° 146. 2009/09.
Dourgnon P., Jusot F., Sermet C., Silva J.

Immigrants have a lower rate of access to office-based medical practices (whether general practitioners or specialists) than the rest of the French population. This can be explained more by immigrants’ disadvantaged social conditions than differences in age, gender and health status between the two populations.
This analysis remains valid whatever the region of origin with the exception of North Africa whose immigrant population has a higher GP consultation rate.
This study also reports a more contrasted situation with regard to preventive care; immigrants are more numerous in declaring themselves vaccinated than the French but fewer to use screening tests.

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Fifty Years of Deinstitutionalisation Policy of Psychiatric Services in France: Persistent Inequalities in Terms of Resources and Organisation Between Psychiatric Sectors
Questions d'Úconomie de la santÚ n° 145. 2009/08.
Coldefy M., Le Fur P., Lucas-Gabrielli V., Mousquès J.

Fifty years after the mental health policy of deinstitutionalisation introduced psychiatric sectors in France, these elementary state-running psychiatric-caredelivering units are marked by considerable geographical disparities in the human and financial resources allocated, facilities and equipment capacity, and the degree of commitment to reaching the initial goals set in the policy.
To describe these disparities, a typology of adult psychiatry sectors was established using a three-factor classification: the allocation of facilities and personnel by number of inhabitants covered, the range of services and types of care delivered, and the way the services are used.
This typology goes beyond the clear distinction between adequate and underresourced psychiatric sectors, and offers a more detailed analysis of the organisation and degree to which French sectorisation policy has been completed, notably in terms of providing and developing alternatives to inpatient facilities.

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Estimating French GPs Weekly Working Hours by Activity A summary of available data
Questions d'Úconomie de la santÚ n° 144. 2009/07.
Le Fur P., in collaboration with Bourgueil Y. and Cases C.

GP working hours are at the core of current transformations in the ambulatory care system and as such, constitute a major challenge in terms of measurement and evaluation.
Though often fragmentary or dated, the multiple sources of available data collated in this study nevertheless provide sufficient information to estimate not only GPs overall working hours but also to provide a breakdown by broad category of activity.
GPs thus declare working on average between 52 and 60 hours per week distributed in the following manner: 61% of their weekly working time is devoted to the provision of medical care in private practice activity, 19% to the provision of care outside private practice activity and 20% in activities other than those directly involving medical care.
The current sources of information nevertheless reveal a lack of representative and non-commercial data on GPs work schedules, their organisation methods, and the precise contents of their practice particularly with regards to patients’ medical characteristics.

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Cost-of-Illness Studies: a Five-Country Methodological Comparison - Australia, Canada, France, Germany and the Netherlands
Questions d'Úconomie de la santÚ n° 143. 2009/06.
Heijink R. (RIVM, Netherlands), Renaud T. (Irdes)

Produced in different countries from the National Health Accounts* (NHAs), cost-of-illness* (COI) studies estimate the distribution of health care expenditure across major diagnostic categories.
The use of equivalent methodologies permitted a comparative COI study between the five countries retained (Australia, Canada, France, Germany and the Netherlands) but differences in health care system structures and national accounting rules somewhat jeopardised total comparability.
In all five countries studied, health care expenditure (hospitals, physicians, dentists and prescribed medicines) is predominated by three major diagnostic categories: cardiovascular diseases, digestive diseases and mental disorders.
If in the future these comparative studies are to become effective tools in the understanding and improvement of health systems and provide meaningful international comparisons of health system performance, it would be advisable to adopt a common NHA accounting nomenclature and to elaborate institutionalised and standardised methodological rules for national COI studies.

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Self-assessed health of individuals aged 55 and over in France and Québec: differences and similarities
Questions d'Úconomie de la santÚ n° 142. 2009/05.
Camirand J.*, Sermet C.**, Dumitru V.*, Guillaume S.**

A comparison of the self-assessed health status of the French and Québécois population aged 55 and over living at home reveals both significant differences and similarities.
The Québécois aged 55 and over have a better subjective perception of their health than the French of the same age and express it with more enthusiasm. Cultural differences and the higher percentage of elderly Québécois living in institutions are the main contributing factors in these diverging perceptions.
In France as in Québec, the presence of chronic medical conditions and disabilities largely explains the increase with age in the percentage of the population self-reporting poor health. The majority of diseases retained for the study reveal a striking parallel between the presence of a disease and the self-reported health status. In Québec, cancer, high blood pressure and thyroid disease stand out as being more frequently associated with poor health reporting. Inversely, certain disabilities seem to have less impact on self-assessed health in Québec than in France.

* Québec Institute for Statistics (ISQ)
** Institute for research and information in health economics (Irdes)

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Three Models of Primary Care Organisation in Europe, Canada, Australia and New-Zealand
Questions d'Úconomie de la santÚ n° 141. 2009/04.
Bourgueil Y., Marek A., Mousquès J. (Prospere/Irdes)

The concept of ‘primary care’ conveys an ambition of social justice which aims at equal access to basic medical care for all. ‘Primary care’ also refers to organisation of outpatient care systems. 
In developed countries, three models of primary care organisation have been identified: the hierarchical normative model in which the health system is organized around primary care and regulated by the State (Spain/Catalonia, Finland, Sweden); the hierarchical professional model where the general practitioner is the cornerstone of the health system (Australia, New Zealand, the Netherlands and the United Kingdom) and the non-hierarchical professional model in which the organization of primary care is left to the initiative of healthcare professionals (Germany, Canada).
The evolution of health systems along with the reforms implemented since the 1990’s have tended to bring the different primary care systems closer together. This hybridisation of models notably characterises the French organization model: initially based on the non-hierarchical professional model, its health system now borrows organisational characteristics from the other two types of model.

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Hospital at home (HAH), a structured, individual care plan for all patients. An exploitation of data from the 2006 HAH Medical Information Systems Program
Questions d'Úconomie de la santÚ n° 140. 2009/03.
Afrite A. (Irdes), Chaleix M. (Drees), Com-Ruelle L. (Irdes), Valdelièvre H. (Drees)

This study examines the patient profiles and medical treatments administered in 2006 to define the place of HAH in patients’ care pathway.
In 2006, over two million days of hospitalization at home (HAH*) were realised in metropolitan France. Majorities of patients were elderly men and just delivered women. HAH admissions primarily concerned palliative care, cancer treatment and perinatal care. The clinical conditions dealt with vary largely and three patients out of ten are moderately to highly dependent. HAH permitted to shorten or avoid a stay in health care institution for one out of three patients. Around 7% of HAH stays ended with the patient dying at home.

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Geographic Context and Population’s Health Status: from the CUA Effect to Neighbourhood Effects
Questions d'Úconomie de la santÚ n° 139. 2009/02.
Allonier C., Debrand T., Lucas-Gabrielli V., Pierre A.

A previous Irdes study indicated a poorer health status among residents of critical urban areas* (CUA*). In line with this finding, this new study shows the impact of neighbourhood characteristics on inhabitants’ health status. Indeed, independently of individual characteristics, contextual variables can also affect health status.
The results suggest that living in a neighbourhood exposed to economic and social problems increases the probability of declaring a poor health status. The same observation has been made for inhabitants of neighbourhoods with a low residential mobility. Lastly, inhabitants of neighbourhoods with a predominantly young population and with recently built report better health than those living in old neighbourhoods inhabited by older households.
Defined at the administrative level, the CUA criteria is a good zoning method for observing health status evolution in the most disadvantaged areas. However, CUAs do not permit a holistic understanding of all the geographic contextual factors that affect the population’s health.
These results confirm the importance of implementing localized policies in order to reduce health inequalities.

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November 3rd, 2010