Texte remanié de: Thesis--University of Sheffield, 1996. / Bibliogr. p. 257-265.

Thèse doctorat : Géographie : Université Panthéon-Sorbonne (Paris) : 2003. / Bibliogr. p. 287-299. Index.

A large number of people all over the world suffer from skin conditions. Dermatological problems comprise about 10 % of a general practitioner's caseload and probably more for pharmacists. The literature furthermore emphasises that skin diseases are becoming a significant problem in the developing world. There is a need to establish an effective method to achieve good health and quality of life for patients with dermatological problems. The general objective of this study was to investigate the usage patterns and cost of dermatological products in the private health care sector of South Africa by using a medicine claims database. The focus was specifically on dermatological products with a prevalence of more than 10 % in the database. A quantitative retrospective drug utilisation research design was used to evaluate the usage patterns and costs of dermatological products in three four-monthly intervals of 2001 and 2004. Data were analysed by using the Statistical Analysis System, 9.1 (SAS). The dermatological product groups for this study were antibacterial and antifungal drugs, corticosteroids and anti-acne products and were analysed according to the MIMS classification. Of all analysed prescriptions issued only 8.57 % (n = 126 447) during 2001 (N = 1 475 380) and 6.82 % (n = 177 122) during 2004 (N = 2 595 254) consisted of dermatological products. Of the total number of products prescribed, the dermatological products constituted 4.77 %I (n = 140 701) for 2001 (N = 2 95 1 326) and 3.77 % (n = 199 976) for 2004 (N = 5 305 882). The total cost of the dermatological products was 4.98 % (n = R18 913 889.92) of the total cost of all medicine products during 200 1 (N = R379 708 489). During 2004 (N = R66 1 223 146) the total cost of dermatological products was 4.09 % (n = R27 025 540.48) of the total cost of all medicine products in the database. The cost-prevalence index for 2001 and 2004 respectively showed that the dermatological products were relatively expensive with values of 1.03 and 1.09. The antibacterial and antifungal drugs, corticosteroids and anti-acne products represented 91.92 % (n = 129 336) and 87.97 % (n = 175 9 16) of all dermatological products during 2001 (N = 140 701) and 2004 (N = 199 976), respectively. These dermatological groups named above represented 91.57 % (n = R17 319 645.61) and 85.85 '% (n = R23 200 594.71), respectively, of the total cost of dermatological products during 200 1 (N = R18 9 13 889.92) and 2004 (N = R27 025 540.48). It was further found that the majority of dermatological products prescribed during the research periods was innovator products. The prevalence of innovator products for 2001 was 86.17 % (n = 12 1 249) with a total cost representing 94.16 % (n = R17 809 603.12). For 2004 the prevalence was 82.33 % (n = 164 640) with a total cost representing 91 .O1 '% (n = R24 594 923.72) of all the dermatological products prescribed. The number of innovator and generic products claimed during 2001 amounted to 86.17 % (n = 12 1 249) and 13.83 % (n = 19 452) respectively of the total number of products claimed (N = 140 701). During 2004 the number of innovator and generic products represented respectively 82.33 % (n = 164 640) and 17.67 O/o (n = 35 336) of the total number of products claimed (N = 199 976). The prevalence in the use of the dermatological products during 2004 increased with 55.25 % from January to April versus September to December. The cost-prevalence index indicated that the dermatological products were relatively expensive during January to August 2004. During September to December 2004 the cost-prevalence decreased and indicated that dermatological products became inexpensive. The average cost of dermatological products during the 2004 study period showed that the cost decreased. January to April (before implementation of the new single exit price structure) was compared to September to December (after implementation of the new single exit price structure). This comparison indicated that the average cost decreased by 22.88 %. It can be summarised that the average cost in the last study period decreased due to the changed price structure. The innovator products' prevalence was high and therefore more generics are needed in dermatology. If more generics are used the total cost of dermatological products might also decrease. The number of dermatological prescriptions increased towards 2004, but this may be because of more members or more medical aids claiming through this database. / Thesis (M.Pharm.)--North-West University, Potchefstroom Campus, 2006.

Depuis plusieurs années, le nombre de personnes atteintes de maladies chroniques ne cesse d'augmenter au sein de toute la population en général, et au sein de la population âgée en particulier. Le vieillissement de la population et les mauvaises habitudes de vie contribuent à accentuer ce phénomène. Aujourd'hui, avec le progrès scientifique, la médecine est capable de soigner, de contrôler et de guérir des maladies chroniques, ce qui jadis, n'était pas possible. Le fait que les gens vivent plus longtemps et contrôlent leur état chronique, rend la facture médicale très élevée. Cette étude a pour objectif de mesurer l'impact des maladies chroniques sur l'utilisation des services de santé. L'étude utilise les données longitudinales de l'Enquête Nationale sur la Santé de la Population, effectuée sur huit cycles, de 1994 à 2009, avec 17 276 individus de tous les âges. En nous inspirant d'une étude de Verbrugge et Patrick (1995), nous sélectionnons huit maladies chroniques, composées de maladies fatales et non fatales. Ces maladies sont : l'arthrite, le rhumatisme ou les maux de dos, les troubles visuels (cataracte et glaucome), l'hypertension artérielle, les maladies respiratoires (l'asthme, la bronchite chronique ou l'emphysème), le diabète, les maladies cardiaques, les maladies mentales (l'Alzheimer ou autre démence mentale) et le cancer. Nous mesurons ensuite l'utilisation des services de santé des personnes atteintes de ces huit maladies chroniques comparativement aux personnes ne souffrant d'aucune maladie chronique, et à l'ensemble de la population. Les services de santé retenus sont : le séjour dans un hôpital, les consultations avec un autre professionnel de la santé, les consultations avec un spécialiste de la médecine douce et alternative, les soins reçus à domicile, le nombre de nuits comme patient, le nombre de consultations avec un médecin et le nombre de consultations avec une infirmière. Deux types de variables dépendantes, à savoir binaires et discrètes positives, sont traitées respectivement avec le modèle de régression xtlogit et le modèle de régression linéaire xtreg, avec des effets fixes et aléatoires. Le modèle population average est également utilisé parce qu'il est plus efficient et tient compte des autocorrélations. Il ressort que les personnes atteintes des huit maladies chroniques sélectionnées utilisent plus intensément les services de santé que la moyenne de la population. Les motifs d'utilisation peuvent être différents de la maladie chronique dont l'individu est atteint. Le modèle de régression avec effets fixes permet de mieux mesurer les impacts des maladies chroniques sur l'utilisation des services de santé, parce qu'il traite l'ensemble des spécificités inobservables qui sont corrélées avec les variables des maladies chroniques et les variables de contrôle. ______________________________________________________________________________ MOTS-CLÉS DE L’AUTEUR : Données longitudinales, maladies chroniques, services de santé.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Cette étude a pour ambition d'améliorer les connaissances thématiques sur l'évolution de l'occupation et de l'utilisation des sols et des structures paysagères. Les recherches et les analyses faites sur cette thématique forment une base d'information nécessaire aux différents utilisateurs. Elles sont intéressantes pour mettre l'accent sur les problèmes environnementaux en général. L'objectif principal de la présente étude est d'élaborer une cartographie détaillée de la dynamique d'occupation et d'utilisation du sol dans le delta de Mejerda. On a essayé de remonter à la moitié du XXème siècle, du fait que la plupart des changements dans la morphologie paysagère du delta se confondait avec celle de son aménagement hydraulique. Outre, cette zone, a subi plusieurs contraintes de diverses origines qui posent des pressions de plus en plus fortes : - Une périurbanisation intense qui transforme le paysage naturel et les terres cultivables (habitats, zones industrielles, infrastructures routières, ...). - Des aménagements (zones industrielles, infrastructures routières...) et des interventions parfois inadéquats au sein des zones à risque d'inondation et de stagnation d'eau (Garaâ). - Au niveau du littoral et notamment le complexe lagunaire de Ghar El Melh, ces interventions se traduisent par une altération du milieu physique (érosion et engraissement) et une transformation de la morphologie de l'occupation du sol... Aujourd'hui, l'extension des méthodes d'analyses intégrées comme les systèmes d'informations géographiques (SIG), et les avantages de la télédétection aérospatiale, nous permettent d'approfondir les études en accédant à une information multi-scalaire et multi-temporelle, jadis inaccessible. Les problèmes soulevés par l'occupation et l'utilisation du sol nous ont amené à suivre les travaux de CORGNE S., (2004) et à développer une méthode reproductible qui permet d'effectuer une prédiction à court terme de la couverture hivernale des sols en contexte agricole intensif (cas du périmètre irrigué de Kalaât Landalous). Une approche approximative qui se base sur un modèle expert et qui utilise la règle des évidences de Dempster-Shafer a été retenue. Des prédictions de la couverture hivernale des sols ont été effectuées selon les deux hypothèses " Sols couverts " et " sols nus à peu couverts " pour la période 2009-2013.

New Zealand is a country populated by migrants and the Asian population is the largest fastest growing cohort and are predicted to outnumber Māori (i.e. the indigenous people of New Zealand) by 2050. Due to the requirements of immigration to New Zealand the Asian community tends to be highly educated, with Asian ethnicities being more likely to have a university bachelors or post-graduate degree. Asian people are distributed more towards lower household income categories than Europeans, but the proportion of Asian people living in the lowest New Zealand deprivation quintile areas has declined in recent years. Migrants applying for residency are required to have, and thus can be expected to arrive in the country, with good health. The research on health care utilisation in geography has suffered by its tendency to neglect migration and culture as an influencing factor. In New Zealand this neglect is compounded by the near absence of a research focus on Asians and where they do appear it is in collated national surveys that have tended to group all sub-Asian ethnicities as one. This study explored the utilisation of health care from two directions. First, the response and perceptions of health care use from the view of the health services and, second, the perceptions of health care provision from the view of Asian migrants. For these reasons qualitative methods were utilised as they allow a focus on the everyday life situations of subjects.They provide opportunity to expand and flow with the research process. In New Zealand, health services are available that specifically target Asian patients, but they are not uniformly available across New Zealand. This study identifies features of mainstream general practice services, as well as factors that migrants bring with them that act as barriers for Asian people accessing health services, including affordability, language and negative experiences that influence trust of the New Zealand health care system. In many cases affordability was linked to a perceived lack of value for money, where no treatment or tangible outcome was received through a visit to the doctor. Language was indicated to be the most pressing barrier to accessing health care and participants’ home country health experiences continued to influence perceptions and use of health care in New Zealand. The study also highlights some strategies that can be implemented into various stages of the Asian patient’s introduction into and then through the health system and health care to improve the availability and acceptability of these services.

A large number of people all over the world suffer from skin conditions. Dermatological problems comprise about 10 % of a general practitioner's caseload and probably more for pharmacists. The literature furthermore emphasises that skin diseases are becoming a significant problem in the developing world. There is a need to establish an effective method to achieve good health and quality of life for patients with dermatological problems. The general objective of this study was to investigate the usage patterns and cost of dermatological products in the private health care sector of South Africa by using a medicine claims database. The focus was specifically on dermatological products with a prevalence of more than 10 % in the database. A quantitative retrospective drug utilisation research design was used to evaluate the usage patterns and costs of dermatological products in three four-monthly intervals of 2001 and 2004. Data were analysed by using the Statistical Analysis System, 9.1 (SAS). The dermatological product groups for this study were antibacterial and antifungal drugs, corticosteroids and anti-acne products and were analysed according to the MIMS classification. Of all analysed prescriptions issued only 8.57 % (n = 126 447) during 2001 (N = 1 475 380) and 6.82 % (n = 177 122) during 2004 (N = 2 595 254) consisted of dermatological products. Of the total number of products prescribed, the dermatological products constituted 4.77 %I (n = 140 701) for 2001 (N = 2 95 1 326) and 3.77 % (n = 199 976) for 2004 (N = 5 305 882). The total cost of the dermatological products was 4.98 % (n = R18 913 889.92) of the total cost of all medicine products during 200 1 (N = R379 708 489). During 2004 (N = R66 1 223 146) the total cost of dermatological products was 4.09 % (n = R27 025 540.48) of the total cost of all medicine products in the database. The cost-prevalence index for 2001 and 2004 respectively showed that the dermatological products were relatively expensive with values of 1.03 and 1.09. The antibacterial and antifungal drugs, corticosteroids and anti-acne products represented 91.92 % (n = 129 336) and 87.97 % (n = 175 9 16) of all dermatological products during 2001 (N = 140 701) and 2004 (N = 199 976), respectively. These dermatological groups named above represented 91.57 % (n = R17 319 645.61) and 85.85 '% (n = R23 200 594.71), respectively, of the total cost of dermatological products during 200 1 (N = R18 9 13 889.92) and 2004 (N = R27 025 540.48). It was further found that the majority of dermatological products prescribed during the research periods was innovator products. The prevalence of innovator products for 2001 was 86.17 % (n = 12 1 249) with a total cost representing 94.16 % (n = R17 809 603.12). For 2004 the prevalence was 82.33 % (n = 164 640) with a total cost representing 91 .O1 '% (n = R24 594 923.72) of all the dermatological products prescribed. The number of innovator and generic products claimed during 2001 amounted to 86.17 % (n = 12 1 249) and 13.83 % (n = 19 452) respectively of the total number of products claimed (N = 140 701). During 2004 the number of innovator and generic products represented respectively 82.33 % (n = 164 640) and 17.67 O/o (n = 35 336) of the total number of products claimed (N = 199 976). The prevalence in the use of the dermatological products during 2004 increased with 55.25 % from January to April versus September to December. The cost-prevalence index indicated that the dermatological products were relatively expensive during January to August 2004. During September to December 2004 the cost-prevalence decreased and indicated that dermatological products became inexpensive. The average cost of dermatological products during the 2004 study period showed that the cost decreased. January to April (before implementation of the new single exit price structure) was compared to September to December (after implementation of the new single exit price structure). This comparison indicated that the average cost decreased by 22.88 %. It can be summarised that the average cost in the last study period decreased due to the changed price structure. The innovator products' prevalence was high and therefore more generics are needed in dermatology. If more generics are used the total cost of dermatological products might also decrease. The number of dermatological prescriptions increased towards 2004, but this may be because of more members or more medical aids claiming through this database. / Thesis (M.Pharm.)--North-West University, Potchefstroom Campus, 2006.

Diabetes is emerging as a major threat to health, with global economic and social implications. Recent research has shown that the morbidity and mortality associated with diabetes can be reduced by timely and effective treatment. However, unless people with diabetes have access to this treatment, the impact of diabetes will continue to rise. This thesis therefore explores the current standards of care which people with diabetes receive. It also looks at factors likely to impact on delivery of diabetes care. Studies were conducted at two levels. In the studies described in Chapters 2 and 3, general data applicable to all or nearly all patients with diabetes were collected. This approach substantially eliminates selection bias but precludes the ability to examine clinical outcomes. In the other studies, detailed in Chapters 4, 5 and 6, specific aspects of diabetes care pertaining to more select groups of diabetic subjects were examined. This approach allows clinical parameters to be examined in more detail but is more subject to selection bias. It is hoped that the combination of these two approaches provides a more balanced view of the topic under examination. In Australia, the Medicare Program, a single government controlled universal health insurance fund, provides access to medical services for all residents. Medicare occasions of service data therefore represent the most comprehensive source of information regarding health service utilisation in Australia. The data does not account for people receiving diabetes care through public hospital based services. However, a survey of public hospitals within NSW (n=198), described in Chapter 2, showed that the number of individuals in this category is relatively small and represents only 5.2% of the diabetic population. Using Medicare item codes, and with the permission and assistance of the Commonwealth Department of Health and Aged Care, data were extracted on attendance to medical practitioners and utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997. All data were stratified by the presence of diabetes, gender and age group. Individuals were deemed to have diabetes if an HbA1c, which can only be ordered for a person with known diabetes, had been performed over the 5-year period and the sample size adjusted for the incidence of diabetes. Once adjusted, the number of people with diabetes in NSW for the individual years 1993 to 1997 were 143,920, 156,234, 168,216, 177,280 and 185,780. Comparison with 1996 census data confirmed a 91.7% capture of the total NSW population (5,495,900/5,995,545 individuals). The data were retrieved for NSW as a whole and for individual postcodes. Postcodes were then classified by population density as either major urban, urban or rural. On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. As seen in Chapter 2, a large proportion of people with diabetes were also under the care of specialists and consultant physicians, up to 51.2% and 41.8% respectively, a 3 to 4 fold increase when compared with their non-diabetic counterparts. In regard to geographical location, once adjusted for age and gender, the odds ratio of attending a specialist was only slightly higher for people with diabetes living in areas of high population density when compared to people with diabetes living in rural areas. This ratio reached as high as 1.85 in regard to attendance to consultant physicians (Chapter 3). The odds ratio for the non-diabetic population was similar indicating that the difference in access to consultant physicians was not disease specific. Analysis of results showed that despite the increase in service utilisation, large proportions of people with diabetes were not routinely monitored in regard to diabetes and its complications across the State. By 1997, HbA1c was still not performed in over 40% of people with diabetes each year and only 11.6% of the diabetic population had undergone microalbuminuria estimation. Interestingly, the differences in levels of monitoring between rural and urban areas were surprisingly small. Monitoring of diabetes and its complications did improve in all parts of the State over the study period. However, the greatest improvement was seen in rural areas, despite rural patients having fewer attendances to general practitioners and fewer patients attending specialist care. In the face of finite resources and the rising prevalence of diabetes, an increasing number of patients will need to rely on general practitioners to provide diabetes care regardless of where they live. A 'shared care' approach which encourages and supports general practitioners to manage patients with diabetes, while giving them access to specialist services for those patients that require them, is increasingly being advocated as a way of maximising efficacy while minimising costs. Yet if health care professionals leave undone what they think is done by others, shared care can become neglected care. Chapter 4 reports a detailed audit of 200 randomly selected shared care patients who were assessed on two or more occasions. This study showed that the majority of specialist treatment recommendations are implemented by general practitioners. Doctors formally registered with the Diabetes Shared Care Programme and those who write longer referral letters were more likely to implement recommendations than their counterparts. Moreover, the average HbA1c and the complication profile of these patients were similar to those found in various studies around the world. This suggests that diabetes can be well managed by a shared care approach that is adequately integrated. To overcome the problem that data is lacking on those patients that did not return for specialist review, a further 200 shared care patients who were lost to follow up from the shared care system were traced. Information regarding whether treatment recommendations had been implemented was sought from both the referring doctor and the patient. Overall, information on 182 of the 200 patients could be obtained. As discussed in Chapter 5, comparison of the returned and non returned patients' demographic and clinical profiles at time of their initial specialist review showed that general practitioners differentiated between the 'more complicated' patients, choosing to re-refer those with macrovascular disease, while maintaining the care of 'less complicated' patients. Re-referral for specialist review was also dependent on the patient remaining under the care of their original doctor. Encouragingly, general practitioners seemed to take a more active role in the non-returned group. They included more details regarding type and duration of diabetes in the referral letters of patients who were not re-referred for specialist review. They also implemented more treatment recommendations in the non-returned group, with the difference in implementation rate for metabolic recommendations reaching statistical significance. This study also showed that movement of patients between doctors raises concern regarding continuity of care. The multi-factorial nature of diabetes means that best practice is not easily accommodated within a single appointment. Thus continuity of care becomes an important issue. To assess the current status, 479 consecutive patients referred to the Royal Prince Alfred Hospital Diabetes Centre in a 6-month period were recruited and underwent a detailed clinical assessment. They were also questioned regarding the number of general practitioners they attended and the length of time they had been under the care of the referring doctor. The results outlined in Chapter 6 showed that the majority of people with diabetes (87.7%) attended only one general practitioner and had been under the care of that doctor medium to long term. Younger patients, who were relatively healthy apart from the presence of diabetes, were more likely to attend several general practitioners or have changed their general practitioner within the last year. This lack of continuity had little difference on acute outcomes such as glycaemic and blood pressure control. Appropriately, continuity of care increased with increasing age and the increasing prevalence of diabetes complications, mainly macrovascular disease. These studies indicate that further efforts are required to improve the overall standard of diabetes care within Australia. At present there is a heavy dependency on specialist services. As the population ages and the number of people with diabetes increases, much of this burden will fall on general practitioners, as is already evident in rural areas. When provided with appropriate support and infrastructure, general practitioners are able to maintain standards of care through referral of patients with more complex medical problems and by maintaining the degree of continuity appropriate to the patient's needs. However, the collection of relevant information to monitor future trends in diabetes services provision is important. As shown in this thesis, Medicare data represents an easy and cost effective method with which to do so.

Thesis--Lyon. / Label mounted on cover: "Diffusion: Librairie Klincksieck ... Paris."