Utilisation du PMSI dans l’évaluation de la chirurgie bariatrique

For a quarter of a century, obesity has doubled its prevalence in Western countries. It has become the second cause of preventable death after tobacco and has been recognized as a disease in its own right. At the current stage of our knowledge, surgery is the most effective treatment for this pathology. Obesity surgery, also called "bariatric surgery", has become widely used in France, which has become one of the benchmark countries for this type of treatment.In addition, France has one of the most important information systems in the world on health data: the Medical-Administrative Databases (BDMA). For this thesis work, we used the Information Systems Medicalization Program (PMSI) as a source of data. This database is made up of information on all hospital stays in all establishments in France. Each patient's information can be linked using a unique individual identification number. This allows longitudinal analyzes to be carried out with a depth of ten years.In the first work we analyzed the lifespan of a medical device, the Adjustable Gastric Band (AGA), which is used in the treatment of obesity. The nomenclature of medical acts (“Common Classification of Medical Acts”, CCAM) makes it possible to identify both the insertion of the AGA and its ablation, which is generally considered to be a failure of the treatment. A device-focused survival analysis allows us to estimate the long-term morbidity of this procedure.In the second work, we estimated the rate of recourse to reconstructive surgery in patients who had already undergone bariatric surgery. Indeed, massive weight loss leads to tissue modification, which is often perceived as unsightly by patients. A request for surgical reconstruction is therefore often made, but it is then necessary to deal with the offer of territorial care on the one hand, and acceptance by Social Security on the other. We analyze access to post-bariatric plastic surgery, focusing on territorial heterogeneity.In the third and last work, which is divided into two parts, we analyze rehospitalizations after bariatric surgery. The 30-day rehospitalization rate (RH30) after discharge is considered internationally as an indicator of the quality of care provided by hospitals. Several countries are already using this measure to incentivize the improvement of hospital performance. We analyze the rate of RH30 after bariatric surgery, and the associated factors. The last part focuses on mortality during rehospitalization and the link with the hospital where the readmission takes place.Although it was not designed for research purposes, this thesis work shows that the PMSI (and more generally the BDMAs) are valuable sources of information. The completeness of the information, the large size of the samples and the possible chronological hindsight are the most important assets of the PMSI. These data sources allow studies that were previously unthinkable in clinical research, for cost, logistics or ethical reasons. However, BDMAs have limits on the quality of the information available and its accessibility. The creation of the National Health Data System in 2017 will make it easier to use these databases, and the integration of BDMA with other sources of information will make it possible to carry out its analyzes even more broadly and precisely.Depuis un quart de siècle, l’obésité a doublé sa prévalence dans les pays occidentaux. Elle est devenue la deuxième cause de mort évitable après le tabac et a été reconnue comme une maladie à part entière. Au stade actuel de nos connaissances, la chirurgie est le traitement le plus efficace pour cette pathologie. La chirurgie de l’obésité, appelée aussi « chirurgie bariatrique », s’est largement diffusée en France, qui est devenu un des pays de référence pour ce type de prise en charge.De plus, la France possède un des systèmes d’information les plus important au monde sur les données de santé : les Bases de Données Médico-Administratives (BDMA). Pour ce travail de thèse nous avons utilisé comme source de données le Programme de Médicalisation des Systèmes d’Information (PMSI). Ce database est constitué par les informations des tous les séjours hospitaliers de tous les établissements en France. Les informations de chaque patient peuvent être chaînées grâce à un numéro d’identification individuel unique. Cela permet de réaliser des analyses longitudinales avec une profondeur de dix ans.Dans le premier travail nous avons analysé la durée de vie d’un dispositif médical, l’Anneau Gastrique Ajustable (AGA), qui est utilisé dans le traitement de l’obésité. La nomenclature des actes médicaux (« Classification Commune des Actes Médicaux », CCAM) permet d’identifier à la fois la pose de l’AGA et son ablation, qui est généralement considérée comme un échec du traitement. Une analyse de survie centrée sur le dispositif nous permet de donner une estimation sur la morbidité à long terme de cette procédure.Dans le deuxième travail, nous avons estimé le taux de recours à la chirurgie réparatrice chez les patients déjà opérés d’une chirurgie bariatrique. En effet la perte de poids massive entraine une modification des tissus, qui est souvent perçue comme disgracieuse par les patients. Une demande de reconstruction chirurgicale est donc souvent formulée, mais il faut alors composer avec l’offre de soins territoriale d’une part, et l’acceptation de la part de la Sécurité Sociale d’autre part. Nous faisons une analyse de l’accès à la chirurgie plastique post-bariatrique, en mettant l’accent sur l’hétérogénéité territoriale.Dans le troisième et dernier travail, qui s’articule en deux parties, nous analysons les réhospitalisations après chirurgie bariatrique. Le taux de réhospitalisation à 30 jours (RH30) après la sortie est considéré au niveau international comme un indicateur de la qualité des soins prodigués par les hôpitaux. Plusieurs pays utilisent déjà cette mesure pour inciter à l’amélioration des performances hospitalières. Nous analysons le taux de RH30 après chirurgie bariatrique, et les facteurs associés. Le dernier volet se focalise sur la mortalité lors d’une réhospitalisation et du lien avec l’hôpital ou la réadmission a lieu.8Bien qu’il n’ait pas été conçu à des fins de recherche, ce travail de thèse montre que le PMSI (et plus généralement les BDMA) sont des sources d’information précieuses. L’exhaustivité des informations, les grandes dimensions des échantillons et le possible recul chronologique sont les atouts les plus importants du PMSI. Ces sources de données permettent des études jusqu’alors inenvisageables en recherche clinique, pour des raisons de coût, de logistique ou des raisons éthiques. Les BDMA présentent néanmoins des limites sur la qualité de l’information disponible et leur accessibilité. La création du Système National des Données de Santé en 2017 rendra plus simple l’exploitation de ces bases, et l’intégration des BDMA à d’autres sources d’information permettra de réaliser ses analyses encore plus larges et précises

Trends in emergent diverticular disease management: a nationwide cohort study from 2009 to 2018

International audienceBackgroundDiverticular disease is a common disorder. Several guidelines report on its optimal management. The aim of this study was to describe the evolution of the prevalence of this disease, the treatment strategies, and the mortality rate on a national level.MethodsWe conducted a retrospective study on prospective data using a nationwide database. All consecutive adult patients diagnosed with diverticular disease and admitted via the emergency department from 2009 to 2018 were included in the study. We performed a descriptive analysis for epidemiologic data, diagnosis, and treatment.ResultsDuring the data collection period, 233,386 patients were included in the study. The number of admissions for emergent diverticular disease increased by 65.8%, from 16,754 in 2009 to 27,781 in 2018, for both uncomplicated and complicated diverticular disease. Among these patients, 19,350 (8.3%) were operated on. The rate of surgical treatment progressively decreased from 9.7% in 2009 to 7.6% in 2018. The three main interventions were Hartmann’s procedure (HP, n = 9111, 47.1%), resection with primary anastomosis (RPA, n = 4335, 22.4%), and peritoneal lavage (PL, n = 4836, 25%). We observed a progressive annual increase in HPs (n = 716 in 2009 and n = 1055 in 2018) as well as a decline in PLs since 2015, while the number of RPAs remained stable.ConclusionsAlthough admissions for emergent diverticular disease have increased during the study period, the rate of surgical treatment has decreased, suggesting an evolution toward more conservative management of this pathology

Response to the Comment on “Impact of Oral Immunonutrition on Postoperative Morbidity in Digestive Oncologic Surgery: A Nation-wide Cohort Study”

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Colorectal screening: We have not caught up. A surge of colorectal cancer after the coronavirus disease 2019 (COVID-19) pandemic?

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Effect of bariatric surgery on cancer risk: results from an emulated target trial using population-based data

International audienceAbstract Background The impact of weight loss induced by bariatric surgery on cancer occurrence is controversial. To study the causal effect of bariatric surgery on cancer risk from an observational database, a target-trial emulation technique was used to mimic an RCT. Methods Data on patients admitted between 2010 and 2019 with a diagnosis of obesity were extracted from a national hospital discharge database. Criteria for inclusion included eligibility criteria for bariatric surgery and the absence of cancer in the 2 years following inclusion. The intervention arms were bariatric surgery versus no surgery. Outcomes were the occurrence of any cancer and obesity-related cancer; cancers not related to obesity were used as negative controls. Results A total of 1 140 347 patients eligible for bariatric surgery were included in the study. Some 288 604 patients (25.3 per cent) underwent bariatric surgery. A total of 48 411 cancers were identified, including 4483 in surgical patients and 43 928 among patients who did not receive bariatric surgery. Bariatric surgery was associated with a decrease in the risk of obesity-related cancer (hazard ratio (HR) 0.89, 95 per cent c.i. 0.83 to 0.95), whereas no significant effect of surgery was identified with regard to cancers not related to obesity (HR 0.96, 0.91 to 1.01). Conclusion When emulating a target trial from observational data, a reduction of 11 per cent in obesity-related cancer was found after bariatric surgery

Colorectal screening: We have not caught up. A surge of colorectal cancer after the coronavirus disease 2019 (COVID-19) pandemic?

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