Apport de la téléconsultation et de l’isolement des cas symptomatiques dans la maîtrise de l’épidémie COVID-19 au sein d’une base militaire

BackgroundThe first wave of COVID-19 swept over France during the first quarter of 2020, leading to saturation of the health care system. We wished to study, in a French military medical unit assisting one of the country's largest armed forces populations, the impact of teleconsultation and the systematic isolation of all possible, probable and confirmed cases of COVID-19.MethodsThis is a retrospective study carried out from March 9 to May 31, 2020 on the basis of our activity register. The variables collected included type of medical consultation procedure, occupational status, classification of cases and date of onset of first symptoms. We have paralleled our activity with that of SOS Médecins and the emergency departments of the Île-de-France region.Results/discussionDuring this period, 1719 episodes of care (teleconsultations or physical consultations) were recorded, of which 91% (n = 1561) were linked to COVID-19. We identified 598 “suspected” (possible and probable) and confirmed cases. “Isolated” teleconsultations (not followed by a face-to-face medical consultation, sample taking or necessitating the dispatch of prompt assistance) represented 86% of episodes of care (n = 1482). Comparison of our activity and the number of new cases with the databases of SOS Médecins and the Île-de-France emergency services suggests that our isolation strategy was timely and effective.ConclusionThe contribution of teleconsultation was substantial and reassuring. Teleconsultation makes it possible to absorb a large volume of patients, is easy to implement, and entails no nosocomial risk. Isolation of infected patients should be a priority during an outbreak. Once it has become a priority to rapidly bring an epidemic under control, this attitude must be extended to all symptomatic patients.     

Rôles des patients dans le système de santé, la formation et la recherche en santé : une perspective française

In 2002, patients were transformed into users of the French health system. As this opinion piece demonstrates, in 2021 they may at least potentially participate more actively than before. They can convey their knowledge of a disease and its treatments, and voluntarily share their experience. They can intervene in user representation and therapeutic patient education, the objective being to increase the autonomy of one and all, patients and public, in the training of professionals, clinical research and evolution of the health system. The rationale for the involvement of patients and their roles in provision of care, training and clinical research are analyzed from a French perspective. The obstacles to overcome and improvements to be achieved are reviewed, the objective being to promote enhanced health democracy through increased patient engagement. In 2021, however, the role of patients in the design and implementation of therapeutic patient education (TPE) and in the development of medical studies curricula remains limited if not restricted; this is due not only to a lack of information, but also to the resistance of health professionals and universities. Patients could and should assume a major role, fostering evolution toward a more just and effective health care system.     

La prévention des maladies cardiovasculaires et des cancers dès l’école primaire : « Être & Savoir,l’école de la santé », évaluation d’une intervention sur 2207 enfants

BackgroundAn assessment of the primary school prevention program “To be and to behave, the health school” was necessary to pursue the activity and enable the development of health education at school.Methods“To be and to behave, the health school” is a health education program designed for primary school pupils in the Auvergne region in France whose targets are primary prevention of cardiovascular diseases and cancers. The program involves a three steps sequence: delivery of a teaching kit, intervention of a health bus, health olympiads. The health assessment focused on resources allocated (program content and functioning of tools created for the program), processes employed (number of schools voluntarily participating and number of pupils who effectively participated with the olympiads of the “health” bus), immediate impact (short-term knowledge acquired by pupils, by class, before the bus arrived and during the olympiads).ResultsThe program involved the participation of 28 schools, 90 classes and 2,137 children. The tools conceived were well adapted. Knowledge scores achieved in the different domains of the program fields progressed significantly for participating classes (p < 10^?5) except for smoking where pupils’ knowledge was already good (baseline score = 14.42/20). This progression in knowledge was better in participating schools than in control schools (p < 0.05).ConclusionThe program “To be and to behave” has enabled pupils to progress in their health knowledge. The present results are currently being considered for continuing the program.     

Intérêt de la détection et de la prise en compte d’une surdispersion dans un modèle de Poisson : illustration à partir d’un exemple

BackgroundResearchers often use the Poisson regression model to analyze count data. Overdispersion can occur when a Poisson regression model is used, resulting in an underestimation of variance of the regression model parameters. Our objective was to take overdispersion into account and assess its impact with an illustration based on the data of a study investigating the relationship between use of the Internet to seek health information and number of primary care consultations.MethodsThree methods, overdispersed Poisson, a robust estimator, and negative binomial regression, were performed to take overdispersion into account in explaining variation in the number (Y) of primary care consultations. We tested overdispersion in the Poisson regression model using the ratio of the sum of Pearson residuals over the number of degrees of freedom (χ²/df). We then fitted the three models and compared parameter estimation to the estimations given by Poisson regression model.ResultsVariance of the number of primary care consultations (Var[Y] = 21.03) was greater than the mean (E[Y] = 5.93) and the χ²/df ratio was 3.26, which confirmed overdispersion. Standard errors of the parameters varied greatly between the Poisson regression model and the three other regression models. Interpretation of estimates from two variables (using the Internet to seek health information and single parent family) would have changed according to the model retained, with significant levels of 0.06 and 0.002 (Poisson), 0.29 and 0.09 (overdispersed Poisson), 0.29 and 0.13 (use of a robust estimator) and 0.45 and 0.13 (negative binomial) respectively.ConclusionDifferent methods exist to solve the problem of underestimating variance in the Poisson regression model when overdispersion is present. The negative binomial regression model seems to be particularly accurate because of its theorical distribution ; in addition this regression is easy to perform with ordinary statistical software packages.     

Appariement entre un registre régional de pratiques en cardiologie interventionnelle et la base médico-administrative d’hospitalisation française : développement et validation d’un algorithme d’appariement déterministe

BackgroundTo recreate the in-hospital healthcare pathway for patients treated with coronary angiography or percutaneous coronary intervention, we linked the interventional cardiology registry (ACIRA) and the pseudonymized French hospital medical information system database (PMSI) in the Aquitaine region. The objective of this study was to develop and validate a deterministic merging algorithm between these exhaustive and complementary databases.MethodsAfter a pre-treatment phase of the databases to standardize the 11 identified linking variables, a deterministic linking algorithm was developed on ACIRA hospital stays between December 2011 and December 2014 in nine interventional cardiology centers as well as the data from the consolidated PMSI databases of the Aquitaine region from 2011 to 2014. Merging was carried out through 12 successive steps, the first consisting in strict linking of the 11 variables. The performance of the algorithm was analyzed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Strategies complementary to the initial algorithm (change in the order of variables and base preprocessing) were tested. Comparative analysis of merged/unmerged patients explored potential causes of mismatch.ResultsThe algorithm found 97.2% of the 31,621 ACIRA stays to have sensitivity of 99.9% (95% CI [99.9; 99.9]), specificity of 97.9% (95% CI [97.7; 98.1]), PPV of 99.9% (95% CI [99.9; 99.9]) and NPV of 96.9% (95% CI [96.7; 97.1]). Complementary strategies did not yield better results. The unmerged patients were older, and hospitalized mostly in 2012 in two interventional cardiology centers.ConclusionThis study underscored the feasibility and validity of an indirect deterministic pairing to routinely link a registry of practices using hospital data to pseudonymized medico-administrative databases. This method, which can be extrapolated to other health events leading to hospitalization, renders it possible to effectively reconstruct patients’ hospital healthcare pathway.     

Simplifier le dépistage de la dénutrition du sujet âgé en médecine générale : test de concordance entre un outil simple,le « Malnutrition Universal Screening Tool » (« MUST ») et le « Mini Nutritional Assessment-Short Form » (« MNA-SF »)

ObjectiveThe main goal of this study is to assess how results from two clinical tools, the Mini Nutritional Assessment-Short Form (MNA-SF) and the Malnutrition Universal Screening Tool (MUST), correlate in the framework of nutritional status evaluation of elderly under ambulatory care. Additionally, determinants of nutritional risk have been analyzed.MethodsThe evaluation of a multicentric diagnostic test has been carried out with 81 patients over 70-years-old, while consulting at their general practitioner's office, or at home. For each patient, MUST and MNA-SF scores were calculated and compared with the kappa coefficient. Subjects were classified into two groups according to the absence or presence of nutritional risk. Univariate comparative analyses were realized between MUST and MNA-SF data.ResultsRespectively, MNA-SF and MUST screened 33.3% and 18.5% of the patients at nutritional risk. Consistency between both tools was moderate: κ = 0.438 ± 0.2058. Compared with subjects at nutritional risk, patients with a good nutritional status were younger, took less drugs, their body mass index was higher (for a limit at 23), they were less lonely and tended to have a higher weight.ConclusionsMUST isn’t a satisfying screening tool of elderly malnutrition in ambulatory primary care. Thus, MNA-SF remains the gold standard.