Increased risk of contralateral breast cancers among overweight and obese women: a time-dependent association

Abstract Breast cancer (BC) survivors are at increased risk of second cancers. Obesity is commonly recognized as a risk factor of BC in postmenopausal period and a prognosis factor in BC regardless of menopausal status. Our aim was to study whether overweight BC survivors were at increased risk of contralateral BC (CBC). Our population was a large cohort of women followed since a first BC without distant spread and/or synchronous CBC. Body mass index (BMI) was assessed at diagnosis time. Binary codings of BMI were used to oppose overweight and obese patients to the others. Survival analyses were used including Cox models. Assumed hypothesis of proportional hazards was explored using graphical methods, Schoenfeld residuals and time-dependant covariates. In case of nonproportional hazards, survival models were computed over time periods. Over 15,000 patients were included in our study. Incidence of CBC was 8. 8 (8.3-9.3)/1000 personyears and increased during follow-up. A significant timedependent association between overweight and CBC was observed. After 10 years of follow-up, we found a significant increased hazard of CBC among patients with a BMI above 25 kg/m 2 : the adjusted hazard ratio was 1.50(1.21-1.86), P = 0.001. After 10 years of follow-up, our study found a poorer prognosis among overweight BC survivors regarding CBC events. While benefits from diet habits and weight control may be expected during the long-term follow-up, they have yet to be established using randomized clinical trials. Keywords Contralateral breast cancer Á Non-proportional hazards Body mass index Á Overweight Á Time-dependent covariate Á Breast cancer prognosis Abbreviations BC Breast cancer BMI Body mass index CBC Contralateral breast cancer HR Hazard rati

ISQUA16-3191 What Can Be Learned from the Implementation of a Pay for Performance Programme?

International audienceObjectivesIn France, quality indicators have been compulsory for acute care hospitals since 2008. After a decade of public reporting, the context was favorable to the introduction of a pay for performance scheme. Indeed, the French hospitals financing model, based on DRGs, has not been taking quality into account. A financial incentive based on results on quality dimensions could be a tool to promote quality of care.MethodsA research program named IFAQ was launched in 2012. The steering committee was co-chaired by the Ministry of health and the French National Authority for Health. A working group was set up, with experts appointed by hospital representatives, to specify the model. An independent research team was selected to act as scientific advisor. The objective was to develop a national P4P program (metrics, incentive model and incentive size), to evaluate its effects and the appropriation by the professionals.The Ministry of Health launched a call for application in June 2012. Out of 450 hospitals, a panel of 222 hospitals was randomly selected for the first experimentation which ended in December 2014. A second call for application was launched in June 2014 and 490 hospitals were included in the second phase which ended in December 2015.The guiding principles of the program were to develop a composite score able to discriminate hospitals, to reward both achievement and improvement in quality, to ensure consistency with other policies regarding quality of care, to limit the workload for the hospitals, and to use only positive incentive without financial penalty. Furthermore, financial incentive was conditional upon the accreditation results (minimal level) and upon the collection of needed data to calculate quality indicatorsResultsThe lessons learned from experimentation are : first, the relatively small size of financial incentive was however a powerful argument and generate interest; second, the score had a good discriminative power even if for a few small hospitals it was questionable because of unavailability of some indicators ; third, when using a single composite score, it is difficult to individualize the contribution of achievement and improvement in the final score; finally, the calculation formula was too complex to be easily communicated and to permit teams to take this challenge on boardAs a result, the final model links incentive payments to 52 nationally defined compulsory measures addressing process of care, including compliance with clinical guidelines for specific diseases such as myocardial infarction, level of computerization and patient experience. The weights have been revised and range from 1 to 3. Two composite scores are calculated for every eligible hospital: one for the achievement score and the other on improvement. Hospitals are ranked and the top performers (first two deciles) for each score are rewarded. The financial reward is a function of the rank and the hospital budget. Hospitals could potentially earn a maximum of 1.2% of their annual DRGs based payments by the health insurance funds.ConclusionThis type of program was considered by all stakeholders as a model of co-management which led to a better acceptability and to an easier implementation. The 2015 Social Security Finance act enacted the extension of this quality incentive model to every acute care hospital in 2016. One third of them are expected to receive a financial reward in December for a total amounting to 40 million Euro

Increased risk of contralateral breast cancers among overweight and obese women: a time-dependent association.

International audienceBreast cancer (BC) survivors are at increased risk of second cancers. Obesity is commonly recognized as a risk factor of BC in postmenopausal period and a prognosis factor in BC regardless of menopausal status. Our aim was to study whether overweight BC survivors were at increased risk of contralateral BC (CBC). Our population was a large cohort of women followed since a first BC without distant spread and/or synchronous CBC. Body mass index (BMI) was assessed at diagnosis time. Binary codings of BMI were used to oppose overweight and obese patients to the others. Survival analyses were used including Cox models. Assumed hypothesis of proportional hazards was explored using graphical methods, Schoenfeld residuals and time-dependant covariates. In case of non-proportional hazards, survival models were computed over time periods. Over 15,000 patients were included in our study. Incidence of CBC was 8.8 (8.3-9.3)/1000 person-years and increased during follow-up. A significant time-dependent association between overweight and CBC was observed. After 10 years of follow-up, we found a significant increased hazard of CBC among patients with a BMI above 25 kg/m(2): the adjusted hazard ratio was 1.50(1.21-1.86), P = 0.001. After 10 years of follow-up, our study found a poorer prognosis among overweight BC survivors regarding CBC events. While benefits from diet habits and weight control may be expected during the long-term follow-up, they have yet to be established using randomized clinical trials

Les réadmissions évitables des " pneumopathies communautaires " : utilité et fiabilité d'un indicateur de la qualité du parcours de soins du patient

International audienc

Centre de dépistage anonyme et gratuit : étude de coût et des modes de financement

International audienc

Tabagisme et perception du risque de maladie liées au tabac en france en 2000 (thèse pour l'obtention du doctorat en médecine)

NICE-BU Médecine Odontologie (060882102) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF