Résumé
Au cours des trente dernières années, les inégalités d’accès aux soins se sont renforcées. La précarité est associée à une réduction de l’accès aux soins primaires, une augmentation des consultations en urgence, des pathologies plus graves et une espérance de vie plus courte. Elle pourrait donc influencer l’épidémiologie et le pronostic des patients admis en réanimation. Les données de la littérature, majoritairement issues d’études rétrospectives, suggèrent que la précarité augmente le risque d’admission en réanimation. Les patients sans couverture sociale, sans domicile fixe (SDF) ou issus d’un milieu défavorisé sont plus jeunes et sont hospitalisés pour des motifs divers, plus souvent médicaux ou chirurgicaux urgents qu’après une chirurgie programmée. Aux États- Unis, l’absence de couverture sociale est associée à une réduction de l’intensité des soins et à une augmentation de la mortalité. En revanche, la plupart des études européennes montrent que les patients bénéficient du même niveau de soins, quel que soit leur niveau socio-économique, mais que les patients en situation de précarité ont des durées de séjour plus longues. La mortalité hospitalière ne semble pas influencée par le niveau socio-économique. Cependant, au sein des patients SDF, ceux vivant dans la rue ont une mortalité hospitalière plus élevée que ceux ayant un hébergement. La précarité étant une notion économique et sociale complexe, une étude prospective semble nécessaire pour confirmer ces résultats et déterminer si certaines de ses caractéristiques sont associées au pronostic. Enfin, l’isolement social soulève des questions éthiques à l’heure où l’accent est mis sur les directives anticipées et la personne de confiance.
Abstract
Over the last thirty years, socioeconomic inequalities in health were reinforced. Socioeconomic deprivation affects access to primary care, increases emergency visits, and is associated with more severe diseases and decreased life expectancy. Also, socioeconomic deprivation might influence epidemiology and prognosis of critically ill patients. Data of the literature, mostly based on retrospective studies, show that uninsured patients, homeless patients and those with low socioeconomic status are younger, more likely to be admitted to intensive care unit, more often admitted for medical reason and surgical emergency than for elective surgery and present with different pathologies. While several American studies found that uninsured critically ill patients are less likely to receive invasive procedures, surgery or post-acute care and more likely to die in ICU or in hospital, most European studies show that socioeconomic status is neither associated with level of care nor with mortality. Moreover, most precarious patients have increased length of stay. However, in homeless subgroup, patients living in street experience higher hospital mortality than sheltered patients. As socioeconomic deprivation definition is complex, a prospective study would be helpful to confirm these results and determine if some of its characteristics are associated with prognosis of critically ill patients. Finally,social isolation raises the question of advance directives including living wills and durable powers of attorney.
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Références
Marmot M, Allen J, Bell R, et al (2012) WHO European review of social determinants of health and the health divide. Lancet 380:1011–29
Haut Conseil de la santé publique (1998) La progression de la précarité en France et ses effets sur la santé (Internet). ENSP, Rennes, available from: http://www.hcsp.fr/Explore.cgi/Ouvrage?clef=15
Fédération hospitalière de France, Médecins du Monde. La prise en charge des personnes vulnérables: agir ensemble à l’hôpital et dans le système de santé (Internet). 2014, mai, available from: http://fichiers.fhf.fr/documents/rapport-FHFMDMbd.pdf
Wresinski J (1987) Grande pauvreté et précarité économique et sociale (Internet). Journal officiel, available from: http://www.lecese.fr/sites/default/files/pdf/Rapports/1987/Rapport-WRESINSKI.pdf
Caton CLM, Dominguez B, Schanzer B, et al (2005) Risk factors for long-term homelessness: findings from a longitudinal study of first-time homeless single adults. Am J Public Health 95:1753–9
FEANTSA (2007) ETHOS: European Typology on Homelessness and Housing Exclusion (Internet) Available from: http://www.feantsa.org/spip.php?article120&lang=en
Bigé N, Hejblum G, Baudel JL, et al (2015) Homeless Patients in the ICU: An Observational Propensity-Matched Cohort Study. Crit Care Med [in press]
Fazel S, Geddes JR, Kushel M (2014) The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet 384:1529–40
Sass C, Moulin JJ, Guéguen R, et al (2006). Le score Epices: un score individuel de précarité. Construction du score et mesure des relations avec des données de santé, dans une population de 197 389 personnes. Bull Epidemiol Hebd 4:93–100
Pascal J, Abbey-Huguenin H, Agard C, et al (2004) Development of a tool for the identification of socially vulnerable hospital patients. Presse Med 33:710–5
Castiel D, Bréchat PH, Segouin C, et al (2006) Hôpitaux publics, T2A et handicap social. Pour interroger nos évidences. Gest Hosp 457:403–7
Bréchat PH, Lansac C, Hasni S, et al (2009). Étude de l’ATIH: prise en charge de la précarité dans les établissements de santé. Gest Hosp 486:269–74
Holstein J, Farge D, Taright N, et al (2009) Hospital LOS, medical complexity and deprivation indicators. Rev Epidemiol Sante Publique 57:205–11
Nandi A, Glymour MM, Subramanian SV (2014) Association among socioeconomic status, health behaviors, and all-cause mortality in the United States. Epidemiol Camb Mass 25:170–7
Marí-Dell’Olmo M, Gotsens M, Palència L, et al (2015) Socioeconomic inequalities in cause-specific mortality in 15 European cities. J Epidemiol Community Health 69:432–41
Alter DA, Franklin B, Ko DT, et al (2014) Socioeconomic status, functional recovery, and long-term mortality among patients surviving acute myocardial infarction. PloS One 8:e65130
Andersen KK, Dalton SO, Steding-Jessen M, Olsen TS (2014). Socioeconomic position and survival after stroke in Denmark 2003 to 2012: nationwide hospital-based study. Stroke 45:3556–60
Byers TE, Wolf HJ, Bauer KR, et al (2008) The impact of socioeconomic status on survival after cancer in the United States: findings from the National Program of Cancer Registries Patterns of Care Study. Cancer 113:582–91
Stringhini S, Tabak AG, Akbaraly TN, et al (2012) Contribution of modifiable risk factors to social inequalities in type 2 diabetes: prospective Whitehall II cohort study. BMJ 345:e5452
Caskey FJ, Roderick P, Steenkamp R, et al (2006) Social deprivation and survival on renal replacement therapy in England and Wales. Kidney Int 70:2134–40
Morrison DS (2009) Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. Int J Epidemiol 38:877–83
Hwang SW, Wilkins R, Tjepkema M, et al (2009) Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. BMJ 339:b4036
Cheung AM, Hwang SW (2004) Risk of death among homeless women: a cohort study and review of the literature. CMAJ 170:1243–7
Roy E, Haley N, Leclerc P, et al (2004) Mortality in a cohort of street youth in Montreal. JAMA 292:569–74
Nordentoft M, Wandall-Holm N (2003) 10 year follow up study of mortality among users of hostels for homeless people in Copenhagen. BMJ 327:81
Nielsen SF, Hjorthøj CR, Erlangsen A, Nordentoft M (2011) Psychiatric disorders and mortality among people in homeless shelters in Denmark: a nationwide register-based cohort study. Lancet 377:2205–14
Baggett TP, Hwang SW, O’Connell JJ, et al (2013) Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med 173:189–95.
Baggett TP, Singer DE, Rao SR, et al (2011) Food insufficiency and health services utilization in a national sample of homeless adults. J Gen Intern Med 26:627–34
Brown RT, Kiely DK, Bharel M, Mitchell SL (2012) Geriatric syndromes in older homeless adults. J Gen Intern Med 27:16–22
Kushel MB, Vittinghoff E, Haas JS (2001) Factors associated with the health care utilization of homeless persons. JAMA 285:200–6
Fazel S, Khosla V, Doll H, Geddes J (2008) The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med 5:e225
Smolderen KG, Spertus JA, Nallamothu BK, et al (2010) Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction. JAMA 303:1392–400
Casale SN, Auster CJ, Wolf F, et al (2007) Ethnicity and socioeconomic status influence use of primary angioplasty in patients presenting with acute myocardial infarction. Am Heart J 154:989–93
Glader EL, Edlund H, Sukhova M, et al (2013) Reduced inequality in access to stroke unit care over time: a 15-year follow-up of socioeconomic disparities in Sweden. Cerebrovasc Dis 36:407–11
Forrest LF, Adams J, Wareham H, et al (2013) Socioeconomic inequalities in lung cancer treatment: systematic review and meta-analysis. PLoS Med 10:e1001376
Mohd Noor A, Sarker D, Vizor S, et al (2013) Effect of patient socioeconomic status on access to early-phase cancer trials. J Clin Oncol 31:224–30
Bieler G, Paroz S, Faouzi M, et al (2012) Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system. Acad Emerg Med 19:63–8
Lindenauer PK, Lagu T, Rothberg MB, et al (2013) Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ 346:f521
Gelberg L, Gallagher TC, Andersen RM, Koegel P (1997) Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Public Health 87:217–20
Zager S, Mendu ML, Chang D, et al (2011) Neighborhood poverty rate and mortality in patients receiving critical care in the academic medical center setting. Chest 139:1368–79
Mendu ML, Zager S, Gibbons FK, Christopher KB (2012) Relationship between neighborhood poverty rate and bloodstream infections in the critically ill. Crit Care Med 40:1427–36
Placzek H, Madoff L (2014) Effect of race/ethnicity and socioeconomic status on pandemic H1N1-related outcomes in Massachusetts. Am J Public Health 104:e31–8
Haas JS, Goldman L (1994). Acutely injured patients with trauma in Massachusetts: differences in care and mortality, by insurance status. Am J Public Health 84:1605–8.
Horner RD, Bennett CL, Rodriguez D, et al (1995) Relationship between procedures and health insurance for critically ill patients with Pneumocystis carinii pneumonia. Am J Respir Crit Care Med 152:1435–42
Curtis JR, Bennett CL, Horner RD, et al (1998) Variations in intensive care unit utilization for patients with human immunodeficiency virus-related Pneumocystis carinii pneumonia: importance of hospital characteristics and geographic location. Crit Care Med 26:668–75
Ruger JP, Richter CJ, Lewis LM (2003) Association between insurance status and admission rate for patients evaluated in the emergency department. Acad Emerg Med. 10:1285–8
Danis M, Linde-Zwirble WT, Astor A, et al (2006) How does lack of insurance affect use of intensive care? A populationbased study. Crit Care Med 34:2043–8
Lyon SM, Benson NM, Cooke CR, et al (2011) The effect of insurance status on mortality and procedural use in critically ill patients. Am J Respir Crit Care Med 184:809–15
O’Brien JM, Lu B, Ali NA, et al (2011) Insurance type and sepsis-associated hospitalizations and sepsis-associated mortality among US adults: a retrospective cohort study. Crit Care 15:R130
Kumar G, Taneja A, Majumdar T, et al (2014) The association of lacking insurance with outcomes of severe sepsis: retrospective analysis of an administrative database*. Crit Care Med 42:583–91
Findlay JY, Plenderleith JL, Schroeder DR (2000) Influence of social deprivation on intensive care outcome. Intensive Care Med 26:929–33
Hutchings A, Raine R, Brady A, et al (2004) Socioeconomic status and outcome from intensive care in England and Wales. Med Care 42:943–51
Welch CA, Harrison DA, Hutchings A, Rowan K (2010) The association between deprivation and hospital mortality for admissions to critical care units in England. J Crit Care 25:382–90
Ho KM, Dobb GJ, Knuiman M, et al (2008) The effect of socioeconomic status on outcomes for seriously ill patients: a linked data cohort study. Med J Aust 189:26–30
Krieger N, Waterman P, Chen JT, et al (2002) Zip code caveat: bias due to spatiotemporal mismatches between zip codes and US census-defined geographic areas—the Public Health Disparities Geocoding Project. Am J Public Health 92:1100–2
Latour J, López V, Rodriguez M, et al (1991) Inequalities in health in intensive care patients. J Clin Epidemiol 44:889–94
Bein T, Hackner K, Zou T, et al (2012) Socioeconomic status, severity of disease and level of family members’ care in adult surgical intensive care patients: the prospective ECSSTASI study. Intensive Care Med 38:612–9
Norris WM, Nielsen EL, Engelberg RA, Curtis JR (2005) Treatment preferences for resuscitation and critical care among homeless persons. Chest 127:2180–7
Song J, Ratner ER, Wall MM, et al (2010) Effect of an Endof- Life Planning Intervention on the completion of advance directives in homeless persons: a randomized trial. Ann Intern Med 20; 153:76–84
Leung AK, Nayyar D, Sachdeva M, et al (2015) Chronically homeless persons’ participation in an advance directive intervention: a cohort study. Palliat Med [Epub ahead of print]
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Bigé, N., Baudel, J.L., Caron, A. et al. Précarité et réanimation : épidémiologie et pronostic. Réanimation 24, 403–423 (2015). https://doi.org/10.1007/s13546-015-1080-4
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DOI: https://doi.org/10.1007/s13546-015-1080-4