Integrated Health System for Chronic Disease Management: Lessons Learned From France

doi:10.1378/chest.125.2.695

Chest

Volume 125, Issue 2, February 2004, Pages 695-703

https://doi.org/10.1378/chest.125.2.695 Get rights and content

Rated number one in overall health system performance by the World Health Organization, the French spend less than half the amount on annual health care per capita that the United States spends. One contributing factor may be the attention given to chronic care. Since the mid-1900s, the French have developed regional community-based specialty systems for patients with chronic respiratory insufficiency or failure. COPD is the major cause of respiratory failure, the fourth leading cause of death in the United States, and its prevalence is increasing. Despite the clinical success of home mechanical ventilation and the potential for cost savings, providing such services in the United States remains a challenge. Lessons from France can inform the development of cost-effective chronic care models in the United States In this article, we review the French experience in the context of the United States Supreme Court's Olmstead decision, mandating that people in “more restrictive settings” such as nursing homes be offered community-based supports. We suggest that regional demonstration projects for patients with chronic respiratory failure or insufficiency can provide an important step in the development of effective chronic care systems in the United States

Section snippets

French System for Patients With CRI

To fully understand the significance of the French system for US health reform, it must be placed in an historical perspective. The key to its development was the evolution of two systems in the regions surrounding Lyon and Paris, the two largest cities in France. The regional system serving Lyon and the surrounding area is known as L'Association de la Region de Lyon pour la Lutte contre la Poliomyélite (ALLP) and began in 1960. The system serving Paris, known as Association d'Entraide des

Clinical Outcomes

ANTADIR, ALLP, and other components of the French health-care system were not established as randomized prospective experiments in patient care or health-care organization and delivery, so it is difficult to isolate and attribute changes in patient outcomes over time to the effects of these organizations. Nonetheless, from its inception ANTADIR has used the large scale of its population base to systematically study and optimize the parameters for home oxygen therapy.²⁷²⁸ The 10-year survival

French Financing

France has a universal health insurance system. This system is employer-based, offers consumers the freedom to choose their providers and hospitals, and includes both for-profit and nonprofit providers. Health insurance is compulsory, and the unemployed are subsidized through a centralized indigent fund administered by the Ministry of Health.³¹ Public health policy is determined by “les caisses,” which are quasi-public agencies. Overall national policy is determined by the major caisse, Caisse

Prevalence and Costs of Chronic Respiratory Patients in the United States

Chronic respiratory failure is caused by intrinsic pulmonary diseases (including restrictive diseases, developmental disorders, infectious diseases, and, most commonly, COPD) and diseases affecting the chest wall, component muscles, and their neurologic control (most commonly poliomyelitis, cervical spine injury, amyotrophic lateral sclerosis, muscular dystrophies, and kyphoscoliosis). The American Association for Respiratory Care defines a chronic ventilator-dependent patient as “… a patient

Experience With HMV in the United States

HMV for patients with respiratory failure also began in the United States as a result of the polio epidemics. With the decline of polio after the introduction of polio vaccines, the specialized centers and expertise to manage these patients atrophied.⁴² HMV became a relative rarity until the development of the “Katie Beckett” waivers, developed in the 1980s under the leadership of Surgeon General Koop, allowed Medicaid funding for children requiring HMV.⁴³ Thus, the data describing the recent

Recent Trends Affecting Chronic Care

As a result of the Olmstead decision, “thousands of people currently living in ‘more restrictive settings’ such as public institutions and nursing homes must be offered housing and community-based supports.”⁵⁰ The lead agency for Olmstead planning efforts in most states is the state Medicaid agency. The Olmstead decision potentially requires that Medicaid beneficiaries receiving long-term mechanical ventilation who currently reside in institutional settings be offered the opportunity for

Lessons Learned From France

What are the lessons from France and the Lyonnaise regional system for CRI that might be useful as states seek to comply with Olmstead?

1.
The importance of physician leadership. Our study of the Lyonnaise regional system, as well as other international best practices,⁵³ highlights the importance of physician leadership coupled with support from key public officials. Throughout our interviews, public officials and others cited Dr. Robert's dedication to quality patient care, commitment to

Conclusion

France is rated by the World Health Organization as No. 1 in overall health system performance among all 191 member states⁵⁸(by comparison, the United States ranked No. 37). The French health system is considerably less costly than the US system. France spends $2,115 per capita per year on health care, or 9.3% of the gross domestic product, as opposed to the United States, which spends $4,358, or 12.9% of gross domestic product. Between 1990 and 1999, health spending increased 2.1% in France,

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Cited by (41)

Mental health reported in adult invasive home mechanical ventilation through a tracheostomy: A scoping review
2022, International Journal of Nursing Studies Advances
Citation Excerpt :
However, being profoundly disabled, such as those who are mechanically tracheostomy-ventilated at home, is associated with natural and expected limitations in terms of their opportunity to handle the responsibilities in life in a meaningful way on their own (Dreyer et al., 2010a; Briscoe and Woodgate, 2010; Dyrstad et al., 2013; Stuart and Weinrich, 2004). Therefore, these findings highlight the need for organised and individualised treatment and care for the people receiving this treatment (Stuart and Weinrich, 2004). The findings also highlight the need for mental health competencies among personal assistants to ensure successful collaboration (Dreyer et al., 2010a; Briscoe and Woodgate, 2010; Dyrstad et al., 2013) allowing tracheostomy-ventilated people to take on the desired responsibility.
Although people receiving invasive home mechanical ventilation through a tracheostomy are facing both physical and mental health challenges, healthcare services often focus mainly on physical symptoms. To ensure well-functioning treatment and care for people receiving tracheostomy ventilation in a home setting, their mental health needs to be promoted and seen as an integral part of their health in general.
This scoping review aimed to provide a summary of the current knowledge on the mental health of people receiving invasive home mechanical ventilation through a tracheostomy.
A scoping review of published and gray literature based on the framework developed by Arksey and O'Malley and refined by the JBI was performed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews checklist was used for reporting the findings.
A literature search was conducted by two researchers independently in the PubMed, CINAHL and PsycINFO databases. Additional searches for gray literature were conducted in Google, Google Scholar, websites of selected organisations, and the reference lists of included studies. The software system Covidence was used in the study selection process. For critical appraisal, the Mixed Methods Appraisal Tool was used.
Thirteen studies were included in this review, of which six used qualitative, six quantitative, and one mixed methods. The majority of studies were authored in Europe (n = 10), followed by the Americas (n = 2) and the Western Pacific (n = 1). Mental health was investigated both directly and indirectly (61.5% vs. 38.5%). Categorizing the reported mental health outcomes, we found that emotional well-being was reported widely across the studies (n = 13), while psychological well-being (n = 5) and social well-being (n = 4) were less widely reported.
The mental health of people receiving home tracheostomy ventilation has received some scholarly attention. A heterogeneity of mental health outcomes was reported in the literature with emotional well-being being an important mental health area both in relation to the sub-components positive affect and quality of life appraisal. Mental health outcomes in relation to psychological well-being and social well-being were fragmented and only sparsely investigated.
Growth of home respiratory equipment from 2006 to 2019 and cost control by health policies
2022, Respiratory Medicine and Research
Citation Excerpt :
Impaired airway clearance in a context of neuromuscular disease can be reduced by prescribing mechanical insufflation-exsufflation (MI-E) [5]. In France, home respiratory equipment can be easily used at home as a result of the optimal collaboration between hospital medical teams, physiotherapists and home health care providers [6]. However, the number of patients treated by HRE, the associated costs and the variations of these parameters over recent years remain unknown.
Home respiratory equipment (HRE) designed for the management of chronic respiratory failure includes oxygen therapy (O₂), noninvasive ventilation (NIV) and mechanical insufflation-exsufflation (MI-E). The growth of the number of patients treated by HRE, the prevalence and the associated costs in France have not been determined.
The French open access national health insurance aggregated data was used to estimate the evolution of theses parameters from 2006 to 2019.
The number of patients treated by HRE increased by 117% between 2006 and 2019, reaching a total of 245,896 patients (367/100,000). Prescriptions for O₂, NIV, and MI-E increased by 88%, 189% and 162%, respectively. In 2019, 139,323 patients received long-term home O₂ alone (208/100,000) with a 13% decrease for liquid O₂ compared to a 44% increase for O₂ concentrator. The number of patients treated by portable oxygen concentrator increased by 509% over the last 5 years. In 2019, 96,126 patients received NIV (144/100,000) and 97% of these patients were treated by NIV for less than 12 h/day. A total of 9,158 patients were treated by MI-E in 2019 (13.6/100,000). Despite the global increase in the number of patients, health costs decreased from 9% to 8% of total medical device spending in 2019 due to adjustment of health policies, such as a reduction of reimbursement rates.
Our results highlighted the high rate of HRE prescription, but with cost control as a result of adapted health policies.
The need to develop competencies for Patient Therapeutic Education in nurse education and practice through cross border conversations
2020, Nurse Education in Practice
Where should we initiate domiciliary noninvasive ventilation in chronic respiratory failure patients? A wrong debate?
2010, Revue des Maladies Respiratoires
À l’initiative de la fédération Antadir, le groupe d’experts CasaVNI a effectué un état des lieux et une prospective à moyen terme concernant la mise en place de la ventilation non invasive (VNI) au long cours en France et dans d’autres pays.
Trois enquêtes ont été réalisées : (1) une première concernant les modalités d’installation et de surveillance de la VNI au long cours en France, (2) une deuxième à propos de ces mêmes modalités à l’étranger, (3) une troisième à propos de la prévalence actuelle et l’incidence attendue de la VNI au long cours au cours des prochaines années.
La mise en route de la VNI au long cours s’effectue majoritairement en hospitalisation conventionnelle (France = 76 % des cas, étranger = 79 % des cas) et le suivi s’effectue surtout en hôpital de jour (France = 59 % des cas, étranger = 43 % des cas). Malgré de multiples sources interrogées, il a été impossible au groupe de travail de déterminer une incidence et une prévalence exactes des malades avec VNI au long cours en France.
En matière de mise en place d’une VNI au long cours, des études cliniques et des recommandations sont encore nécessaires pour valider des alternatives qui permettront de répondre à l’augmentation de la demande tout en gardant une prestation de qualité.
At the initiative of the Antadir Federation, the expert group CasaVNI has undertaken a study of the current situation and the medium term outlook of the initiation of long term non-invasive ventilation (NIV) in France and other countries.
Three surveys have been undertaken: (1) the first concerning the modalities of installation and surveillance of long-term NIV in France, (2) a second concerning the same modalities in other countries, (3) a third concerning the current prevalence and expected incidence of long-term NIV over the next few years.
The initiation of long-term NIV takes place in hospital in the majority of cases (France 76%, elsewhere 79%) and the surveillance mainly at a day hospital (France 59%, elsewhere 43%). Despite the interrogation of many sources, the working party has been unable to determine the exact incidence and prevalence of patients receiving long-term NIV in France.
With regard to the initiation of long-term NIV, clinical studies and guidelines are still necessary to validate the alternatives that will permit a response to the increasing demand while maintaining high standards.
Cardiovascular risk factors in men and women with obstructive sleep apnoea syndrome
2010, Respiratory Medicine
Citation Excerpt :
We wished to compare the prevalence of these risk factors between men and women. Consecutive patients with OSAS were included on CPAP initiation, over a period of eighteen months, in 10 homecare associations in the federated ANTADIR network (Association Nationale pour les Traitements A Domicile, les Innovations et la Recherche).11 The diagnosis of OSAS was established by full polysomnography or by nocturnal respiratory polygraphy.
We wished to evaluate the prevalence of cardiovascular (CV) risk factors in patients with obstructive sleep apnoea syndrome (OSAS) before initiation of continuous positive airway pressure (CPAP), and without any declared or diagnosed pre-existing CV disorder. We wanted to compare the prevalence of these CV risk factors between men and women in an observational study. A questionnaire concerning CV risk factors was submitted to the patients, by a respiratory home-care technician at the time of installation of the CPAP treatment.
The study population consisted of 1117 patients; 834 men, 283 women.
The prevalence of arterial hypertension (HT), diabetes, obesity, active smoking, hyperlipidemia and family history of coronary heart disease was 54.1%, 22.8%, 65.8%, 18.3%, 33.8% and 20%, respectively.
Women had significantly more HT (62.1 vs 51.4%), diabetes (29.9 vs 20.4%), obesity (77 vs 62%) and family history of coronary disease (25.1 vs 18.2%). The prevalence of active smoking was significantly higher in men (20.4 vs 12%). The prevalence of hyperlipidemia was not different between men and women (34.5 vs 31.8%). Stepwise logistic regression showed that HT and diabetes were both independently associated with BMI and age, while diabetes and not HT was independently associated with female gender.
The prevalence of classical CV risk factors was very high in this population with OSAS requiring CPAP, especially in women. There is thus a very elevated CV risk level independent of that directly related to OSAS. It is important to screen for and treat classical CV risk factors in this population.
Self-reported inhaler use in patients with chronic obstructive pulmonary disease
2010, Respiratory Medicine
Citation Excerpt :
Prescribing simple dosing schedules may also help patients remember to use the inhalers as they are intended. Cost is another important consideration.21,22 Prescribers should continue efforts to use the most cost-effective inhalers or explore financial assistance for patients, where applicable.
COPD is a common disease which is increasing in prevalence. The proportion of patients who vary their inhaler use from what is prescribed and the reasons for variance are largely unknown. The objective of this study was to determine the extent of and reported reasons for patient-reported variance in the use of inhalers prescribed for COPD. A 17-item survey was mailed to 600 ambulatory patients with spirometry-defined COPD. The survey included questions about inhaler use and reasons for using inhalers differently than prescribed. Survey responses were compared between patients reporting no variance vs. variance from prescribed instructions. Logistic regression was used to determine predictors for variance. The response rate was 45.8% (48.7% male; mean age: 73 ± 8 years). Forty percent of respondents were not using inhalers as prescribed. The most common reasons were: feeling the inhalers did not help breathing (20%), forgetting to use inhalers (19%) and cost (15%). Higher education level, home oxygen use and prescriptions for ipratropium were predictors for inhaler variance. The impact of inhaler variance on morbidity of COPD should be evaluated.

View all citing articles on Scopus

: This research was partially supported by the Robert Wood Johnson Foundation. The views presented are those of the authors.

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Special ReportIntegrated Health System for Chronic Disease Management: Lessons Learned From France

Section snippets

French System for Patients With CRI

Clinical Outcomes

French Financing

Prevalence and Costs of Chronic Respiratory Patients in the United States

Experience With HMV in the United States

Recent Trends Affecting Chronic Care

Lessons Learned From France

Conclusion

Chest

Chest

Chest

Soc Sci Med

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Heart Lung

Vasc Surg

Chest

Executive Order 13217: Community-based alternatives for individuals with disabilities; press release

Secretary Thompson announces creation of the Office on Disability: press release

HHS urges states to continue to expand home and community based care for disabled residents: press release

Does the chronic care model also serve as a template for improving prevention?

Milbank Q

Changing the chronic care system to meet people's needs

Health Aff (Millwood)

Controlling health care expenditures

N Engl J Med

Medicare

N Engl J Med

Managed care in transition

N Engl J Med

Medicaid

N Engl J Med

Long-term care for the elderly with disabilities: current policy, emerging trends, and implications for the twenty-first century

The organization and financing of health services for persons with disabilities

Milbank Q

Home care services for severely physically disabled people in England and France: case-example; the ventilator-dependent person—international exchange of experts and information in rehabilitation: fellowship report

Home care and alternatives to hospitalization in France for medical technology dependent children and adults with severe chronic respiratory insufficiency: the associative system; fellowship report

Home Care for life-supported persons in France: the regional association

Rehabil Lit

Home care for life-supported persons: the French system of quality control, technology assessment and cost containment

Public Health Rep

Special Report
Integrated Health System for Chronic Disease Management: Lessons Learned From France