RAPP Thomas

With the aging of the population, support for loss of autonomy and aging well have become major public policy issues. A central question is that of the relevance of public aid: is it centered on the needs of people? We show that there is indeed a strong correlation between the health perceived by our seniors and their long-term care needs (family and professional). We recommend the deployment of public aid based on the notion of "value-based aging", i.e. funding aid that is centered on the expectations of seniors.

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This paper explores the association between health measures and long-term care (LTC) use in the 70+ old population. We examine how different measures of health—subjective versus objective—predict LTC use, provided either formally or informally. We consider an absolute measure of subjective health, the grade given by the individual to his/her health status, and additionally construct a relative measure capturing the difference between this grade and the average grade given to health by individuals sharing the same characteristics. Conceptually, this difference comes from the perception of the individual, corresponding to both the private health information and the reporting behavior affecting self-rated health. We use the baseline data from the SPRINTT study, an ongoing randomized control trial on 1519 subjects facing physical frailty and sarcopenia (PF&S) in 11 European countries. Our sample population is older than 70 (mean: 79 years) and comprises a majority (71%) of women. Results show that self-rated health indicators correlate to formal care even when objective health measures are included, while it is not the case for informal care. Formal care consumption thus appears to be more sensitive to the individual's perception of health than informal care.

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The frailty phenotype in the elderly is defined as an increased vulnerability to stressors, leading to health problems. It is recognized as identifying the risk of disability at an early and reversible stage. Although the literature on the socioeconomic determinants of frailty emerges in cross-sections, little was known about the dynamics of this relationship over time. Our paper examines the joint evolution of frailty and changing economic conditions for people aged 65 and over in Europe, and this presentation, shows that the SHARE survey is an interesting tool to analyze these issues requiring a time horizon: because of the richness of the data especially on health and economic issues.

Objectives: This study examines prescribers’ compliance with the 2011 clinical recommendation of the French National Authority for Health (HAS) aiming to limit the use of drugs specific to Alzheimer’s Disease (AD), and whether prescribers’ compliance differs as a function of patient gender. Study design: The sample consisted of quarterly data from the National Health Insurance claims database from 2010 to 2013 (16 quarters) for individuals living in the community, aged 65 or over at baseline. Methods: The probability of consuming AD drugs was estimated using a fixed effects model to account for individual and unobserved heterogeneity. Time-varying covariates were included to control for changes in health status and insurance effects. Estimations were carried out for men and women separately. Results: Discrepancies in trend of the probability of consuming AD drugs between women and men after the HAS’ 2011 recommendation were observed: the probability decreased for women while it remained constant for men. Conclusions: Our case study complements the literature on the influence of clinical recommendations by HTA body on clinical practices. Public health policies should take into account sex and gender differences in the management of AD patients. Further research should investigate how to implement gender targeted therapies and prevention, and their effects.

The long-term care (LTC) sector will soon face a shortage of care workers. The consequences are potentially dramatic, urging the need to design policies aiming at reducing the turnover rate of LTC workers. Immigrant workers are an important part of the LTC workforce. Pooling data from the Annual Social and Economic (ASEC) supplement to the Current Population Survey (CPS) for years 2003-2019, we compare US-born citizens and immigrant LTC workers' propensity to stay in the LTC workforce over one year. We distinguish two categories of LTC workers: personal care workers and nurses. We show that for both categories, naturalized citizens, legal noncitizen immigrants, and unauthorized immigrants have a higher probability of staying in the LTC workforce compared to US-born citizens. We provide two potential explanations: we show that immigrant personal care workers are more likely to report a better health, and that immigrant nurses have a lower wage variation sensitivity. Our results also suggest that wage increases are likely to be associated with high retention rates in the profession.

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Physical frailty and sarcopenia (PF&S) has received growing attention in empirical models of health care use. However, few articles focused on objective measures of PF&S to assess the extent of care consumption among the frail population at risk of dependency. Using baseline data from the SPRINTT study, a sample of 1518 elderly people aged 70+ recruited in eleven European countries, we analyse the association between various PF&S measures and health care / long term care (LTC) use. Multiple health care and LTC outcomes are modelled using linear probability models adjusted for a range of individual characteristics and country fixed effects. We find that PF&S is associated with a significant increase in emergency admissions and hospitalizations, especially among low-income elders. All PF&S measures are significantly associated with increased use of formal and informal LTC. There is a moderating effect of income on LTC use: poor frail elders are more likely to use any of the formal LTC services than rich frail elders. Our results are robust to various statistical specifications. They suggest that the inclusion of PF&S in the eligibility criteria of public LTC allowances could contribute to decrease the economic gradient in care use among the elderly community-dwelling European population.

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Objective. There is relative consensus that chronic conditions, disability and time-to-death are key drivers of age-related health care expenditures. In this paper, we analyse the specific impact of frailty transitions on a wide range of health care outcomes comprising hospital, ambulatory care, and dental care use. Data source. Five regular waves of the SHARE survey collected between 2004 and 2015. Study design. We estimate dynamic panel data models on the balanced panel (N=6,078. NT= 30,390 observations). Our models account for various sources of selection into frailty, i.e. observed and unobserved time-varying and time-invariant characteristics. Principal Findings. We confirm previous evidence showing that frailty transitions have a statistically significant and positive impact on hospital use. We find new evidence on ambulatory and dental care use. Becoming frail has greater impact on specialist compared to GP visit, and frail elderly are less likely to access dental care. Conclusions. By preventing transitions towards frailty policy planners could prevent hospital and ambulatory care uses. Further research is needed to investigate the relationship between frailty and dental care by controlling for reverse causation.

In France, temporary institutionalization solutions for dependent elders have been encouraged since the early 2000s. They are targeting patients who are maintained at home, but may need temporary solutions to adjust the constraints of caregivers, e.g. to facilitate transitions between several informal care providers or to allow informal caregivers to leave for holidays. However, the influence of these solutions on dependent elders and their caregivers has not been explored yet. We use French longitudinal data (REAL.FR, 686 elders and their primary caregivers followed between 2000 and 2006) to explore the impact of institution placement on the wellbeing of both Alzheimer's disease patients and their primary informal caregivers. The data distinguishes permanent placements in institution from temporary stays. Using fixed-effect models, we quantify the change in patients' quality of life and caregivers' burden of care following the placement of patients. We find that permanent and temporary stays are associated with a decrease in informal caregivers' burden. However, only permanent stays lead to an improvement of patients' quality of life. Hence, taken together, the results suggest that while long-run placements may maximize the wellbeing of all the members of a household (patient and caregiver), this is not necessarily the case of short-term placements.

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The objective of the present work is to explore the incremental costs of frailty associated with ambulatory health care expenditures (HCE) among the French population of community-dwellers aged 65 or more in 2012. We make use of a unique dataset that combines nationally representative health survey with respondents’ National Health Insurance data on ambulatory care expenditures. Several econometric specifications of generalized linear models are tested and an exponential model with gamma errors is eventually retained. Because frailty is a distinct health condition, its contribution to HCE was assessed in comparison with other health covariates (including chronic diseases and functional limitations, time-to-death, and a multidimensional composite health index). Results indicate that whatever health covariates are considered, frailty provides significant additional explanative power to the models. Frailty is an important omitted variable in HCE models. It depicts a progressive condition, which has an incremental effect on ambulatory health expenditures of roughly €750 additional euros for pre-frail individuals and €1500 for frail individuals.

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Objective: Hospital services use, which is a major driver of total health expenditures, is expected to rise over the next decades in Europe, especially because of population aging. The purpose of this article is to better understand the dynamics of older people's demand for hospital care over time in a cross-country setting. Data source: We used data from the Survey on Health, Ageing, and Retirement in Europe (SHARE), in 10 countries between 2004 and 2011. Study design: We estimated a dynamic panel model of hospital admission for respondents aged 50 years or more. Principal findings: Following prior research, we found evidence of state dependence in hospital use over time. We also found that rise in frailty-among other health covariates-is a strong predictor of increased hospital use. Progression by one point on the frailty scale [0.5] is associated with an additional risk of about 2.

Abstract Background Exercise may lead to improvements on functional ability, physical function, and neuropsychiatric symptoms (particularly depression) in people with dementia (PWD). However, high-quality randomised controlled trial (RCT), controlling for the socialisation aspect of group-based exercise interventions, and designed to delay the declines on the functional ability of PWD in the nursing home (NH) setting is almost inexistent. This article describes the protocol of the LEDEN study, an exercise RCT for PWD living in NHs. Methods/design LEDEN is a cluster-randomised controlled pilot trial composed of two research arms: exercise training (experimental group) and social/recreational activity (control group). Both interventions will be provided twice a week, for 60 min, during the 6-month intervention. The total duration of the study is 12 months, being six months of intervention plus six months of observational follow-up. Eight French NHs volunteered to participate in LEDEN. they have been randomised to either exercise intervention or social/recreational intervention in a 1:1 ratio. Results The primary objective is to investigate the effects of exercise, compared to a social/recreational intervention, on the ability of PWD living in NHs to perform activities of daily living (ADL). Secondary objectives are related with the cost-effectiveness of the interventions, and the effects of the interventions on patients' physical function, neuropsychiatric symptoms, pain, nutritional status, and the incidence of falls and fractures. Discussion LEDEN will provide the preliminary evidence needed to inform the development of larger and more complex interventions using exercise or non-exercise social interventions.

AbstractBackgroundIt is crucial to define health policies that target patients with the highest needs. In France, public financial support is provided to dependent patients: it can be used to finance informal care time and nonmedical care use. Eligibility for public subsidies and reimbursement of costs is associated with a specific tool: the autonomie gérontologie groupes iso-ressources (AGGIR) scale score.ObjectiveOur objective was to explore whether patients with Alzheimer’s disease who are eligible for public financial support have greater needs than do noneligible patients.MethodsUsing data from the Dépendance des patients atteints de la maladie d’Alzheimer en France study, we calculated nonmedical care expenditures (in €) using microcosting methods and informal care time demand (hours/month) using the Resource Use in Dementia questionnaire. We measured the burden associated with informal care provision with Zarit Burden Interview. We used a modified two-part model to explore the correlation between public financial support eligibility and these three variables.ResultsWe find evidence of higher informal care use, higher informal caregivers’ burden, and higher care expenditures when patients have an AGGIR scale score corresponding to public financial support eligibility.ConclusionsThe AGGIR scale is useful to target patients with the highest costs and needs. Given our results, public subsidies could be used to further sustain informal caregivers networks by financing programs dedicated to lowering informal caregivers’ burden.

Support for the presentation by T.Rapp at the Handicap et Dépendance seminar on March 12, 2015. The purpose of the paper presented here is to evaluate the effect of French public subsidies financing the use of home help (Allocation personnalisée d'autonomie, APA) on the health of dependent elderly people (measured by the rate of emergency room visits). An instrumental variable model is implemented on the sample obtained by the Plasa randomized experiment (Plan of care and assistance in Alzheimer's disease, conducted between 2003 and 2007 at the Toulouse University Hospital). The results show a significant negative effect of the APA on the hospitalization rate.

Elderly people facing dependence are exposed to the financial risk of long lasting care expenditures. This risk is high for people facing cognitive, functional and behavioral problems. In the short-term, dependent elderly people face increased non-medical care expenditures. In the long-term, they face increased medical care expenditures, which are driven by emergency care events such as: emergency hospitalization, emergency medical visits, and emergency institutionalizations. In France, providing public financial assistance has been shown to improve dependent people's access to non-medical care services. However, the impact of public financial assistance on emergency care use has not been explored yet. Our study aims at determining whether financial assistance on non-medical care provision decreases the probability of emergency care rates using data of 1131 French patients diagnosed with Alzheimer's disease, collected between 2003 and 2007. Using instrumental variables to deal with the presence of a potential endogeneity bias, we find that beneficiaries of long-term care subsidies have a significantly lower rate of emergency care than non-beneficiaries. Failing to control for endogeneity problems would lead to misestimate the impact of long-term care subsidies on emergency care rates. Finding that home care subsidies has a protective effect for emergency care confirmed the efficacy of this public policy tool.

It is surprising to observe that the number of patients receiving a late diagnosis for Alzheimer's disease (AD) remains high even in countries promoting early diagnosis campaigns. We explore the impact of family history and family support on the risks of receiving a delayed diagnosis. We use French data of 1131 patients diagnosed between 1991 and 2005. We find that the presence of AD history in the family increased the risks of receiving a delayed diagnosis. This was true especially when AD history involved brothers, sisters and other relatives (uncles or cousins). The presence of an informal caregiver at the time of the first warning signs reduced the risks of receiving a late diagnosis, regardless of the informal caregiver concerned (spouse, son, daughter etc.). We identify several opportunities for early detection campaigns. Families with history of disease should be targeted. Campaigns should also target isolated patients, who do not benefit from informal care. Our results underline the importance of improving the diagnosis access for old patients and for men.

At the global level the large deployment of telemedicine raises needs for cost-effectiveness evaluations. The objective of this literature review is to explore to what extend telemedicine innovations that were implemented in many countries were cost-effective. Specifically, we explore whether the model used to evaluate the cost-effectiveness can be adapted to the evaluation of telemedicine technologies. So, what answers can a review of the international literature relating to the medico-economic evaluation of telemedicine provide?.

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The present research proposes a theoretical and empirical analysis of the mechanisms of employee savings, with a particular focus on the influence of employee savings on the accumulation choices of employees who benefit from them. The first chapter provides a generic definition of the concept of employee savings and a typology of this savings instrument. It provides an exhaustive review of the literature on the role of employee shareholders in their firms and on the effectiveness of tax incentives to save in firms. The second chapter conducts a theoretical analysis of the portfolio allocation choices of employee shareholders in their firms. Savings incentives do not always have the expected effects and sometimes carry very high risks for the employees concerned. Chapter three presents an econometric analysis of the specific investment determinants of employee shareholders in a large French firm. Chapter four deals with the crucial role played by the terms of the employee savings offer, through a second econometric study.