Cardiac injuries in blunt chest trauma

Blunt chest traumas are a clinical challenge, both for diagnosis and treatment. The use of cardiovascular magnetic resonance can play a major role in this setting. We present two cases: a 12-year-old boy and 45-year-old man. Late gadolinium enhancement imaging enabled visualization of myocardial damage resulting from the trauma

Centralisation des soins, inégalités d’accès aux soins et adressage des patients pour des soins spécialisés

This PhD dissertation provides empirical evidence on many aspects of the volume-outcome relationship with regard to cancer care. In the first chapter, we explore the relationship between hospital volume activities and patient outcomes for ovarian cancer care. Using a wide-ranging set of clinical characteristics depicting patients’ degree of illness, we identified a strong volume-outcome relationship, with substantial differences in survival between patients treated in high volume and in low volume hospitals. In the second chapter, we look in more depth into what underlies the observed hospital volume-outcome relationship. More specifically, we provide evidence on the contribution of clinician decisions (i.e., which drive patient care pathways) to the causal impact of hospital volume on patient outcomes. Our findings substantiate the contribution of clinician decisions regarding the treatment option to the causal impact of hospital volume on patient outcomes, thereby offering a better understanding of this complex relationship. In chapter 3, we use a nationwide administrative dataset to evaluate the impact that centralization of care for breast cancer and ovarian cancer treatment has on spatial and socioeconomic inequalities in access to specialized care. Our findings indicate a strong and highly unequally distributed deterioration in patient access to specialized care, which highlights a major adverse consequence of such a policy. From a broader perspective, there is a need to understand the mechanisms of patient referral to hospitals to better understand the potential necessity of centralized care. The fourth chapter of this thesis provides evidence of patient preferences for cancer care using a revealed preferences framework, taking into account that patient choice sets are actually unobserved. Our findings highlight the importance of the choice set preselection, which could be related to the role of general practitioners in the referral process and substantiate several barriers to patient choice.Cette thèse de doctorat étudie la question de la centralisation des soins pour le traitement du cancer, et apporte des preuves empiriques sur de nombreux aspects liés à cette problématique. Le chapitre 1 explore la relation entre le volume d’activité des hôpitaux et la qualité des soins pour le traitement du cancer de l’ovaire. L’exploitation d’une base de données comprenant des informations très détaillées sur le degré de sévérité du cancer nous a permis de mettre en évidence de très fortes disparités de survie en fonction du volume d’activité de l’établissement de prise en charge. Le deuxième chapitre de cette thèse vise à identifier les mécanismes soutenant cette relation, et plus particulièrement la contribution du choix du traitement par les cliniciens dans l’effet causal du volume d’activité sur la qualité des soins. Les résultats confirment la contribution du processus de sélection du traitement par les cliniciens dans l’effet causal du volume d’activité sur la qualité des soins, et apportent ainsi de nouveaux éléments permettant caractériser l’effet d’apprentissage induit par le volume d’activité. Le chapitre 3 a pour objectif d’évaluer l'impact d'une centralisation des soins pour le traitement du cancer du sein et de l’ovaire sur les inégalités spatiales et socioéconomiques d'accès aux soins spécialisés. En exploitant une base de données administrative nationale, nos résultats indiquent une forte détérioration de l’accès aux soins spécialisés si une telle réforme était appliquée, ainsi qu’une répartition territoriale et socioéconomique très inégale du fardeau de la centralisation. Dans une perspective plus large, il est primordial de mieux comprendre les mécanismes liés à l’adressage des patients vers les hôpitaux, afin de mieux saisir la nécessité - ou non - de centraliser les soins. L’objectif du quatrième chapitre de cette thèse est d’identifier les préférences des patients dans le choix de leur établissement de prise en charge pour le traitement du cancer, en tenant compte du rôle du médecin traitant dans l’adressage. Nos résultats soulignent le rôle central du médecin traitant dans le processus de d’adressage, et mettent en évidence des facteurs limitant le libre choix de l’établissement de prise en charge

Impact d’une centralisation des soins en termes d’accès aux soins pour les cancers de l’ovaire et cancers du sein en France : une simulation à partir des données médico-administratives

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L’exposition des travailleurs de nuit aux facteurs de pénibilité en France : les enseignements de l’enquête SUMER 2010

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How We Can Reap the Full Benefit of Teleconsultations: Economic Evaluation Combined With a Performance Evaluation Through a Discrete-Event Simulation

Background In recent years, the rapid development of information and communications technology enabled by innovations in videoconferencing solutions and the emergence of connected medical devices has contributed to expanding the scope of application and expediting the development of telemedicine. Objective This study evaluates the use of teleconsultations (TCs) for specialist consultations at hospitals in terms of costs, resource consumption, and patient travel time. The key feature of our evaluation framework is the combination of an economic evaluation through a cost analysis and a performance evaluation through a discrete-event simulation (DES) approach. Methods Three data sets were used to obtain detailed information on the characteristics of patients, characteristics of patients' residential locations, and usage of telehealth stations. A total of 532 patients who received at least one TC and 18,559 patients who received solely physical consultations (CSs) were included in the initial sample. The TC patients were recruited during a 7-month period (ie, 2020 data) versus 19 months for the CS patients (ie, 2019 and 2020 data). A propensity score matching procedure was applied in the economic evaluation. To identify the best scenarios for reaping the full benefits of TCs, various scenarios depicting different population types and deployment strategies were explored in the DES model. Associated break-even levels were calculated. Results The results of the cost evaluation reveal a higher cost for the TC group, mainly induced by higher volumes of (tele)consultations per patient and the substantial initial investment required for TC equipment. On average, the total cost per patient over 298 days of follow-up was \texteuro 356.37 (US \392) per TC patient and \texteuro 305.18 (US \336) per CS patient. However, the incremental cost of TCs was not statistically significant: \texteuro 356.37 \textendash \texteuro 305.18 = \texteuro 51.19 or US \392 \textendash US \336 = US \56 (95% CI \textendash 35.99 to 114.25; P=.18). Sensitivity analysis suggested heterogeneous economic profitability levels within subpopulations and based on the intensity of use of TC solutions. In fact, the DES model results show that TCs could be a cost-saving strategy in some cases, depending on population characteristics, the amortization speed of telehealth equipment, and the locations of telehealth stations. Conclusions The use of TCs has the potential to lead to a major organizational change in the health care system in the near future. Nevertheless, TC performance is strongly related to the context and deployment strategy involved

What underlies the observed hospital volume- outcome relationship?

International audienceStudies of the hospital volume-outcome relationship have highlighted that a greater volume activity improves patient outcomes. While this finding has been known for years in health services research, most studies to date have failed to delve into what underlies this relationship. This study aimed to shed light on the basis of the hospital volume effect by comparing treatment modalities for epithelial ovarian carcinoma patients. Hospital volume activity was instrumented by the distance from patients' homes to their hospital, the population density, and the median net income of patient municipalities. We found that higher volume hospitals appear to more often make the right decisions in regard to how to treat patients, which contributes to the positive impact of hospital volume activities on patient outcomes. Based on our parameter estimates, we found that the rate of complete tumor resection would increase by 10% with centralized care, and by 6% if treatment decisions were coordinated by high volume centers compared to the ongoing organization of care. In both scenarios, the use of neoadjuvant chemotherapy would increase by 10%. As volume alone is an imperfect correlate of quality, policy makers need to know what volume is a proxy for in order to devise volume-based policies

What Underlies The Observed Hospital Volume-Outcome Relationship?

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