La toxicologie au coeur des problématiques de médecine légale : à propos de quelques observations

Date du colloque&nbsp;: 12/01/2009</p

Multidisciplinary intensive functional restoration versus outpatient active physiotherapy in chronic low back pain: a randomized controlled trial.

STUDY DESIGN: Randomized parallel group comparative trial with a 1-year follow-up period. OBJECTIVE: To compare in a population of patients with chronic low back pain, the effectiveness of a functional restoration program (FRP), including intensive physical training and a multidisciplinary approach, with an outpatient active physiotherapy program at 1-year follow-up. SUMMARY OF BACKGROUND DATA: Controlled studies conducted in the United States and in Northern Europe showed a benefit of FRPs, especially on return to work. Randomized studies have compared these programs with standard care. A previously reported study presented the effectiveness at 6 months of both functional restoration and active physiotherapy, with a significantly greater reduction of sick-leave days for functional restoration. METHODS: A total of 132 patients with low back pain were randomized to either FRP (68 patients) or active individual therapy (64 patients). One patient did not complete the FRP; 19 patients were lost to follow-up (4 in the FRP group and 15 in the active individual treatment group). The number of sick-leave days in 2 years before the program was similar in both groups (180 ± 135.1 days in active individual treatment vs. 185 ± 149.8 days in FRP, P = 0.847). RESULTS: In both groups, at 1-year follow-up, intensity of pain, flexibility, trunk muscle endurance, Dallas daily activities and work and leisure scores, and number of sick-leave days were significantly improved compared with baseline. The number of sick-leave days was significantly lower in the FRP group. CONCLUSION: Both programs are efficient in reducing disability and sick-leave days. The FRP is significantly more effective in reducing sick-leave days. Further analysis is required to determine if this overweighs the difference in costs of both programs

International comparison of health spending and utilization among people with complex multimorbidity.

OBJECTIVE: The objective of this study was to explore cross-country differences in spending and utilization across different domains of care for a multimorbid persona with heart failure and diabetes. DATA SOURCES: We used individual-level administrative claims or registry data from inpatient and outpatient health care sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States (US). DATA COLLECTION/EXTRACTION METHODS: Data collected by ICCONIC partners. STUDY DESIGN: We retrospectively analyzed age-sex standardized utilization and spending of an older person (65-90 years) hospitalized with a heart failure exacerbation and a secondary diagnosis of diabetes across five domains of care: hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, and outpatient drugs. PRINCIPAL FINDINGS: Sample sizes ranged from n = 1270 in Spain to n = 21,803 in the United States. Mean age (standard deviation [SD]) ranged from 76.2 (5.6) in the Netherlands to 80.3 (6.8) in Sweden. We observed substantial variation in spending and utilization across care settings. On average, England spent $10,956 per person in hospital care while the United States spent$30,877. The United States had a shorter length of stay over the year (18.9 days) compared to France (32.9) and Germany (33.4). The United States spent more days in facility-based rehabilitative care than other countries. Australia spent $421 per person in primary care, while Spain (Aragon) spent$1557. The United States and Canada had proportionately more visits to specialist providers than primary care providers. Across almost all sectors, the United States spent more than other countries, suggesting higher prices per unit. CONCLUSION: Across 11 countries, there is substantial variation in health care spending and utilization for a complex multimorbid persona with heart failure and diabetes. Drivers of spending vary across countries, with the United States being the most expensive country due to high prices and higher use of facility-based rehabilitative care

Differences in health outcomes for high-need high-cost patients across high-income countries.

ObjectiveThis study explores variations in outcomes of care for two types of patient personas-an older frail person recovering from a hip fracture and a multimorbid older patient with congestive heart failure (CHF) and diabetes.Data sourcesWe used individual-level patient data from 11 health systems.Study designWe compared inpatient mortality, mortality, and readmission rates at 30, 90, and 365 days. For the hip fracture persona, we also calculated time to surgery. Outcomes were standardized by age and sex.Data collection/extraction methodsData was compiled by the International Collaborative on Costs, Outcomes and Needs in Care across 11 countries for the years 2016-2017 (or nearest): Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.Principal findingsThe hip sample across ranged from 1859 patients in Aragon, Spain, to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia, and the majority of hip patients across countries were female. The congestive heart failure (CHF) sample ranged from 742 patients in England to 21,803 in the United States. Mean age ranged from 77.2 in the United States to 80.3 in Sweden, and the majority of CHF patients were males. Average in-hospital mortality across countries was 4.1%. for the hip persona and 6.3% for the CHF persona. At the year mark, the mean mortality across all countries was 25.3% for the hip persona and 32.7% for CHF persona. Across both patient types, England reported the highest mortality at 1 year followed by the United States. Readmission rates for all periods were higher for the CHF persona than the hip persona. At 30 days, the average readmission rate for the hip persona was 13.8% and 27.6% for the CHF persona.ConclusionAcross 11 countries, there are meaningful differences in health system outcomes for two types of patients

Differences in health care spending and utilization among older frail adults in high-income countries: ICCONIC hip fracture persona.

ObjectiveThis study explores differences in spending and utilization of health care services for an older person with frailty before and after a hip fracture.Data sourcesWe used individual-level patient data from five care settings.Study designWe compared utilization and spending of an older person aged older than 65 years for 365 days before and after a hip fracture across 11 countries and five domains of care as follows: acute hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, and outpatient drugs. Utilization and spending were age and sex standardized..Data collection/extraction methodsThe data were compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries as follows: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.Principal findingsThe sample ranged from 1859 patients in Spain to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia. The majority of patients across countries were female. Relative to other countries, the United States had the lowest inpatient length of stay (11.3), but the highest number of days were spent in post-acute care rehab (100.7) and, on average, had more visits to specialist providers (6.8 per year) than primary care providers (4.0 per year). Across almost all sectors, the United States spent more per person than other countries per unit ($13,622 per hospitalization,$233 per primary care visit, $386 per MD specialist visit). Patients also had high expenditures in the year prior to the hip fracture, mostly concentrated in the inpatient setting.ConclusionAcross 11 high-income countries, there is substantial variation in health care spending and utilization for an older person with frailty, both before and after a hip fracture. The United States is the most expensive country due to high prices and above average utilization of post-acute rehab care

A methodology for identifying high-need, high-cost patient personas for international comparisons.

ObjectiveTo establish a methodological approach to compare two high-need, high-cost (HNHC) patient personas internationally.Data sourcesLinked individual-level administrative data from the inpatient and outpatient sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.Study designWe outline a methodological approach to identify HNHC patient types for international comparisons that reflect complex, priority populations defined by the National Academy of Medicine. We define two patient profiles using accessible patient-level datasets linked across different domains of care-hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, long-term care, home-health care, and outpatient drugs. The personas include a frail older adult with a hip fracture with subsequent hip replacement and an older person with complex multimorbidity, including heart failure and diabetes. We demonstrate their comparability by examining the characteristics and clinical diagnoses captured across countries.Data collection/extraction methodsData collected by ICCONIC partners.Principal findingsAcross 11 countries, the identification of HNHC patient personas was feasible to examine variations in healthcare utilization, spending, and patient outcomes. The ability of countries to examine linked, individual-level data varied, with the Netherlands, Canada, and Germany able to comprehensively examine care across all seven domains, whereas other countries such as England, Switzerland, and New Zealand were more limited. All countries were able to identify a hip fracture persona and a heart failure persona. Patient characteristics were reassuringly similar across countries.ConclusionAlthough there are cross-country differences in the availability and structure of data sources, countries had the ability to effectively identify comparable HNHC personas for international study. This work serves as the methodological paper for six accompanying papers examining differences in spending, utilization, and outcomes for these personas across countries

Is the occurence of musculoskeletal disorders predictable ? A case study in a large shoe factory

International audienc

Détermination de l'âge des adultes en post-mortem: intérêt de l'utilisation des critères de Gustafson

Introduction: In the context of a prospective study, we tested a simple method using Gustafson�s criteria and compared the results with those obtained via the Lamendin method. Material: A total of 43 monoradicular teeth (among them incisors, canines and premolars) from 43 caucasians were examined. The age range was 13-73 years. We worked with the sample as a whole in order to test our method. However, so as to compare the method with Lamendin�s method, we only worked with teeth from individuals who were over 30 years of age. Teeth were intact without pathological processes or marginal periodontitis. Method: First, we estimated age using the Lamendin technique. Next, we measured Gustafson�s criteria on a tooth grind-prepared using an abrasion technique combined with a tungsten drill bit mounted on a turbine. We used Gustafson�s regression curve. Descriptive and comparative statistics were obtained using SPSS 13.0 software. Comparative studies between the two techniques were only carried out for the over-30 age group. Result: Using Gustafson�s criteria results in a good correlation between the actual and estimated ages except for the over-60 group (under estimation). The average error is 6.26 years. A comparison of the two methods does not highlight any significant difference for the 30-60 age range. Error is significant for both methods in the over-60 group. Discussion: Our �method� is relatively easy to implement (requires a turbine, 15 minutes� preparation). It is of limited use for the 30-60 age range, since, for equivalent results, the Lamendin technique is easier. However, it can still be used. On the other hand, it can be used in young subjects. In older subjects, the age estimation error is as large as for the Lamendin technique. However, by using a correction coefficient, under certain conditions, better results can be obtained. Conclusion: This method is technically easier than Gustafson�s method and there is a good correlation between criteria and age. It may be beneficial to use Gustafson�s criteria when the pelvis can no longer be used, as a complement to the Lamendin method. In addition, this method can be useful in estimating age in young subjects.Introduction: Dans le cadre d'une enquête prospective, nous avons testé une méthode simple utilisant les critères de Gustafson et comparé les résultats avec ceux obtenus par la méthode de Lamendin. Matériel: L'étude a porté sur 43 dents monoradiculées (incisives, canines, prémolaires) provenant de 43 sujets de race caucasienne. La moyenne d'âge est de 38 ans (13-73 ans). Nous avons travaillé sur tout l'échantillon pour tester notre méthode. Mais pour comparer celle ci avec la méthode de Lamendin, nous n'avons conservé que les dents des sujets âgés de plus de 30 ans. Méthode: L'âge a été estimé par la technique de Lamendin. Puis, nous avons mesuré les critères de Gustafson sur une dent préparée par meulage par technique d'usure à l'aide d'une fraise en tungstène montée sur turbine. Nous avons utilisé la courbe de régression de Gustafson. Les statistiques ont été réalisées avec SPSS 13.0 (analyses descriptives et comparatives). Les études comparatives entre les deux techniques n'ont été réalisées que chez les plus 30 ans. Résultat: L'utilisation des critères de Gustafson donne une bonne corrélation entre l'âge réel et l'âge estimé sauf pour le groupe des plus de 60 ans (sous estimation). La moyenne des erreurs est de 6,26 ans. La comparaison entre les deux méthodes ne montre pas de différence significative pour les 30-60 ans. L'erreur est importante pour les deux méthodes chez les plus de 60 ans. Discussion: Notre " méthode " est de réalisation relativement facile (nécessité d'une turbine, 15 mn de préparation). Elle n'a pas un grand intérêt pour les 30-60 ans car, à résultats équivalents, la technique de Lamendin est plus facile. Cependant, elle peut-être utilisée. Par contre, elle est applicable chez le sujet jeune. Chez le sujet âgé, l'erreur d'appréciation de l'âge est aussi importante que celle retrouvée avec la technique de Lamendin. Cependant, l'utilisation d'un coefficient correcteur, dans certaines conditions, permet d'obtenir de meilleurs résultats. Conclusion: Cette méthode est techniquement plus facile que la méthode de Gustafson et il existe une bonne corrélation entre les critères et l'âge. Il peut être intéressant d'utiliser les critères de Gustafson lorsque le bassin n'est pas disponible, en complément de la méthode de Lamendin. Cette méthode peut être, de plus, intéressante pour l'estimation de l'âge chez les sujets jeunes

Maintien en emploi d’un agriculteur atteint d’une pneumopathie d’hypersensibilité

National audienc