Failure of catecholamines to shift T-cell cytokine responses toward a Th2 profile in patients with rheumatoid arthritis

To further understand the role of neuro-immunological interactions in the pathogenesis of rheumatoid arthritis (RA), we studied the influence of sympathetic neurotransmitters on cytokine production of T cells in patients with RA. T cells were isolated from peripheral blood of RA patients or healthy donors (HDs), and stimulated via CD3 and CD28. Co-incubation was carried out with epinephrine or norepinephrine in concentrations ranging from 10(-5 )M to 10(-11 )M. Interferon (IFN)-γ, tumour necrosis factor (TNF)-α, interleukin (IL)-4, and IL-10 were determined in the culture supernatant with enzyme-linked immunosorbent assay. In addition, IFN-γ and IL-10 were evaluated with intracellular cytokine staining. Furthermore, basal and agonist-induced cAMP levels and catecholamine-induced apoptosis of T cells were measured. Catecholamines inhibited the synthesis of IFN-γ, TNF-α, and IL-10 at a concentration of 10(-5 )M. In addition, IFN-γ release was suppressed by 10(-7 )M epinephrine. Lower catecholamine concentrations exerted no significant effect. A reduced IL-4 production upon co-incubation with 10(-5 )M epinephrine was observed in RA patients only. The inhibitory effect of catecholamines on IFN-γ production was lower in RA patients as compared with HDs. In RA patients, a catecholamine-induced shift toward a Th2 (type 2) polarised cytokine profile was abrogated. Evaluation of intracellular cytokines revealed that CD8-positive T cells were accountable for the impaired catecholaminergic control of IFN-γ production. The highly significant negative correlation between age and catecholamine effects in HDs was not found in RA patients. Basal and stimulated cAMP levels in T-cell subsets and catecholamine-induced apoptosis did not differ between RA patients and HDs. RA patients demonstrate an impaired inhibitory effect of catecholamines on IFN-γ production together with a failure to induce a shift of T-cell cytokine responses toward a Th2-like profile. Such an unfavorable situation is a perpetuating factor for inflammation

Attitudes towards digital treatment for depression: A European stakeholder survey

The integration of digital treatments into national mental health services is on the agenda in the European Union. The E-COMPARED consortium conducted a survey aimed at exploring stakeholders' knowledge, acceptance and expectations of digital treatments for depression, and at identifying factors that might influence their opinions when considering the implementation of these approaches. An online survey was conducted in eight European countries: France, Germany, Netherlands, Poland, Spain, Sweden, Switzerland and The United Kingdom. Organisations representing government bodies, care providers, service-users, funding/insurance bodies, technical developers and researchers were invited to participate in the survey. The participating countries and organisations reflect the diversity in health care infrastructures and e-health implementation across Europe. A total of 764 organisations were invited to the survey during the period March–June 2014, with 175 of these organisations participating in our survey. The participating stakeholders reported moderate knowledge of digital treatments and considered cost-effectiveness to be the primary incentive for integration into care services. Low feasibility of delivery within existing care services was considered to be a primary barrier. Digital treatments were regarded more suitable for milder forms of depression. Stakeholders showed greater acceptability towards blended treatment (the integration of face-to-face and internet sessions within the same treatment protocol) compared to standalone internet treatments. Organisations in countries with developed e-health solutions reported greater knowledge and acceptability of digital treatments. Mental health stakeholders in Europe are aware of the potential benefits of digital interventions. However, there are variations between countries and stakeholders in terms of level of knowledge about such interventions and their feasibility within routine care services. The high acceptance of blended treatments is an interesting finding that indicates a gradual integration of technology into clinical practice may fit the attitudes and needs of stakeholders. The potential of the blended treatment approach, in terms of enhancing acceptance of digital treatment while retaining the benefit of cost-effectiveness in delivery, should be further explored. The E-COMPARED project has received funding from the European Union Seventh Framework Programme (FP7/2007–2013) under grant agreement no. 603098

Reported barriers to evaluation in chronic care: experiences in six European countries.

INTRODUCTION: The growing movement of innovative approaches to chronic disease management in Europe has not been matched by a corresponding effort to evaluate them. This paper discusses challenges to evaluation of chronic disease management as reported by experts in six European countries. METHODS: We conducted 42 semi-structured interviews with key informants from Austria, Denmark, France, Germany, The Netherlands and Spain involved in decision-making and implementation of chronic disease management approaches. Interviews were complemented by a survey on approaches to chronic disease management in each country. Finally two project teams (France and the Netherlands) conducted in-depth case studies on various aspects of chronic care evaluation. RESULTS: We identified three common challenges to evaluation of chronic disease management approaches: (1) a lack of evaluation culture and related shortage of capacity; (2) reluctance of payers or providers to engage in evaluation and (3) practical challenges around data and the heterogeity of IT infrastructure. The ability to evaluate chronic disease management interventions is influenced by contextual and cultural factors. CONCLUSIONS: This study contributes to our understanding of some of the most common underlying barriers to chronic care evaluation by highlighting the views and experiences of stakeholders and experts in six European countries. Overcoming the cultural, political and structural barriers to evaluation should be driven by payers and providers, for example by building in incentives such as feedback on performance, aligning financial incentives with programme objectives, collectively participating in designing an appropriate framework for evaluation, and making data use and accessibility consistent with data protection policies

Muscle inactivation of mTOR causes metabolic and dystrophin defects leading to severe myopathy

mTor, acting mainly via mTORC1, controls dystrophin transcription in a raptor- and rictor-independent mechanism

Standard comparison of local mental health care systems in eight European countries

Aims. There is a need of more quantitative standardised data to compare local Mental Health Systems (MHSs) across international jurisdictions. Problems related to terminological variability and commensurability in the evaluation of services hamper like-with-like comparisons and hinder the development of work in this area. This study was aimed to provide standard assessment and comparison of MHS in selected local areas in Europe, contributing to a better understanding of MHS and related allocation of resources at local level and to lessen the scarcity in standard service comparison in Europe. This study is part of the Seventh Framework programme REFINEMENT (Research on Financing Systems' Effect on the Quality of Mental Health Care in Europe) project. Methods. A total of eight study areas from European countries with different systems of care (Austria, England, Finland, France, Italy, Norway, Romania, Spain) were analysed using a standard open-access classification system (Description and Evaluation of Services for Long Term Care in Europe, DESDE-LTC). All publicly funded services universally accessible to adults (>= 18 years) with a psychiatric disorder were coded. Care availability, diversity and capacity were compared across these eight local MHS. Results. The comparison of MHS revealed more community-oriented delivery systems in the areas of England (Hampshire) and Southern European countries (Verona - Italy and Girona - Spain). Community-oriented systems with a higher proportion of hospital care were identified in Austria (Industrieviertel) and Scandinavian countries (Sor-Trondelag in Norway and Helsinki-Uusimaa in Finland), while Loiret (France) was considered as a predominantly hospital-based system. The MHS in Suceava (Romania) was still in transition to community care. Conclusions. There is a significant variation in care availability and capacity across MHS of local areas in Europe. This information is relevant for understanding the process of implementation of community-oriented mental health care in local areas. Standard comparison of care provision in local areas is important for context analysis and policy planning.Peer reviewe

Pay-for-performance in French and German health reforms:: similar instruments, distinct trajectories

International audienceHealth systems undergo important transformations, triggered by budgetary pressure and rationalisation. In this context, France and Germany have introduced pay-for-performance (P4P) measures to provide financial incentives for providers meeting certain objectives. While there are similarities in both systems, the nature and timing of these policies differ, which we hypothesised to be related to differences in the collective organisation and institutionalisation of physicians. We used a comparative study design: the introduction of P4P in ambulatory care in France in 2009 and its potential introduction in Germany. We performed a literature review and semi-structured interviews of 23 actors. From an analytical perspective, we blended the approaches of public policy instruments, policy transfer and programmatic actors. We advance two main arguments. First, development of P4P in both countries is intrinsically linked to preceding policies as instruments prolonging the larger, long-term system transformations: the growing role of the State and statutory health insurance (SHI) in parallel to a fragmentation of the medical profession. It was embodied in France by the 2004 reform redefining the mission of SHI. In Germany, in addition, we emphasise the growing role of competition elements since the 1990s. This leads to our second argument: the prolongation of the long-term transformations did not lead to the same results in France and in Germany. In fact, P4P has seen a rapid uptake in France, facilitated by a relatively strong and proactive coalition led by SHI, which suggested that the reform be set within a coherent line of measures and ideas. Arguments of de-professionalization and ethics played a role in the ensuing discussions, with the majority of individual practitioners ultimately opting for P4P in balancing cognitive and material implications. A clear leadership role was assumed by the SHI director, by starting with P4P as individual contracts and then later integrating it in collective agreements. The cognitive focus was on cost containment via generic prescription, with SHI’s strategic goal of fostering IT in physician offices. Its backbone was a well-staffed strategy department scanning foreign experience. However, in the case of Germany, the picture is less clear, with many providers remaining reserved towards the idea of P4P and key actors uncertain about the net political gains. One major initiative for P4P in ambulatory care came from physician representatives in self-regulating bodies in a move to regain regulatory edge, hoping also to gain control over data or at least over data collection methods. Yet, it was rejected by its base over concerns about de-professionalization and the allocation of funds. It was followed by long technical debates about quality indicators that may be seen as delay tactics. The ensuing debate concerned issues over data and the balance of power among the self-regulating partners (physicians, SHI, hospitals). A P4P component will be introduced for hospital payment and is likely to yield advantages for SHI and private hospitals. In both countries, these developments challenge established patterns, pointing towards a “divergent convergence” of healthcare arrangements

Idées globalisées, défis nationaux : l’introduction du Disease Management et du paiement à la performance en France et en Allemagne

Health systems in many welfare states are undergoing important transformations, triggered by increasing budgetary pressures and characterized by the growing role of market and rationalization measures. In this context, France and Germany have introduced disease management (DM) programs to deliver more structured patient care and pay-for-performance (P4P) measures to provide financial incentives for providers meeting certain objectives.These reforms, which reflect the increasing role of the State in both statutory health insurance systems, were inspired by Anglo-Saxon models but translated in distinct ways, owing to differences in the two countries’ systems. In Germany, DM and P4P were based on increasing competition between sickness funds and between hospitals, while in France these reforms reflected a shift by its central insurance system “from payer to player”.The positioning of the medical profession vis-a-vis these new instruments of governance, which are hierarchical in nature and impose stronger public accountability, was a key issue in both France and Germany. The negotiation processes were accompanied by a growing disconnect between physician representatives and their memberships in both countries, despite significant differences in the way physicians are traditionally integrated into health system regulation.Dans de nombreux états providences, les systèmes de santé subissent de nos jours d’importantes transformations en réponse aux pressions budgétaires et caractérisées par le rôle croissant du marché et des mesures de rationalisation. C’est dans ce contexte que la France et l’Allemagne ont mis en place des programmes de Disease Management (DM) dans le but de fournir des soins plus structurés et de paiement à la performance (P4P) pour inciter financièrement les fournisseurs à répondre à certains objectifs.Ces réformes, qui reflètent le rôle croissant de l’État dans les deux systèmes d’assurance maladie, se sont inspirées des modèles anglo-saxons mais se concrétisent de manière distincte en fonction des caractéristiques des systèmes des deux pays. En Allemagne, DM et P4P se sont basés sur la concurrence croissante entre les caisses d’assurance maladies et entre les hôpitaux tandis qu’en France, ces réformes ont reflété un changement du rôle de l’assurance maladie « de payeur à acteur ».Le positionnement de la profession médicale vis-à-vis de ces nouveaux instruments de gouvernance, qui sont de nature hiérarchique et qui imposent une logique comptable, est une question clef en France et en Allemagne. Dans les deux pays, les processus de négociations ont été lié à un écart grandissant entre les représentants des médecins et leurs membres, et ce malgré les différences dans la manière dont les médecins sont traditionnellement intégrés dans la régulation des systèmes de santé respectifs

Global ideas, national challenges : the introduction of disease management and pay-for-performance in France and Germany

Dans de nombreux états providences, les systèmes de santé subissent de nos jours d’importantes transformations en réponse aux pressions budgétaires et caractérisées par le rôle croissant du marché et des mesures de rationalisation. C’est dans ce contexte que la France et l’Allemagne ont mis en place des programmes de Disease Management (DM) dans le but de fournir des soins plus structurés et de paiement à la performance (P4P) pour inciter financièrement les fournisseurs à répondre à certains objectifs.Ces réformes, qui reflètent le rôle croissant de l’État dans les deux systèmes d’assurance maladie, se sont inspirées des modèles anglo-saxons mais se concrétisent de manière distincte en fonction des caractéristiques des systèmes des deux pays. En Allemagne, DM et P4P se sont basés sur la concurrence croissante entre les caisses d’assurance maladies et entre les hôpitaux tandis qu’en France, ces réformes ont reflété un changement du rôle de l’assurance maladie « de payeur à acteur ».Le positionnement de la profession médicale vis-à-vis de ces nouveaux instruments de gouvernance, qui sont de nature hiérarchique et qui imposent une logique comptable, est une question clef en France et en Allemagne. Dans les deux pays, les processus de négociations ont été lié à un écart grandissant entre les représentants des médecins et leurs membres, et ce malgré les différences dans la manière dont les médecins sont traditionnellement intégrés dans la régulation des systèmes de santé respectifs.Health systems in many welfare states are undergoing important transformations, triggered by increasing budgetary pressures and characterized by the growing role of market and rationalization measures. In this context, France and Germany have introduced disease management (DM) programs to deliver more structured patient care and pay-for-performance (P4P) measures to provide financial incentives for providers meeting certain objectives.These reforms, which reflect the increasing role of the State in both statutory health insurance systems, were inspired by Anglo-Saxon models but translated in distinct ways, owing to differences in the two countries’ systems. In Germany, DM and P4P were based on increasing competition between sickness funds and between hospitals, while in France these reforms reflected a shift by its central insurance system “from payer to player”.The positioning of the medical profession vis-a-vis these new instruments of governance, which are hierarchical in nature and impose stronger public accountability, was a key issue in both France and Germany. The negotiation processes were accompanied by a growing disconnect between physician representatives and their memberships in both countries, despite significant differences in the way physicians are traditionally integrated into health system regulation

Tools of power: pay-for-performance in French and German health reforms

International audiencePurposePay-for-performance (P4P) as an innovation for improved health care has been introduced in many health systems worldwide. The aim of this article is to apply and refine a specific theoretical angle for the analysis of these reforms, the theoretical frameworks of public policy instruments and programmatic actors, in order to highlight differences between countries.Design/methodology/approachThis analysis is based on a comparative case study of the introduction of P4P in France and Germany in the ambulatory sector for the period from 2007 until 2017. This included a literature review and semi-structured interviews with 23 actors between 2013 and 2015.FindingsThe introduction of a supposedly clear-cut policy instrument – P4P in health care – is distinctly shaped by the intertwined configuration of institutional architecture and the policy programme of key system actors. This can be understood as a continuation of long-term transformations, most importantly the increasingly direct influence of the state and a weakening of the representation of the medical profession, as well as an internal fragmentation of the latter.Originality/valueThis analysis illustrates the applicability of the policy instrument approach to the heath sector. In addition, the authors have applied the dual perspective of policy instruments and programmatic actors. Both proved complementary and appropriate for the study of a highly technical instrument such as P4P