Study protocol for two stepped-wedge interventional trials evaluating the effects of holistic information technology-based patient-oriented management in older multimorbid patients with cancer: The GERONTE trials.

INTRODUCTION: Current hospital-based care pathways are generally single-disease centred. As a result, coexisting morbidities are often suboptimally evaluated and managed, a deficiency becoming increasingly apparent among older patients who exhibit heterogeneity in health status, functional abilities, frailty, and other geriatric impairments. To address this issue, our study aims to assess a newly developed patient-centred care pathway for older patients with multimorbidity and cancer. The new care pathway was based on currently available evidence and co-designed by end-users including health care professionals, patients, and informal caregivers. Within this care pathway, all healthcare professionals involved in the care of older patients with multimorbidity and cancer will form a Health Professional Consortium (HPC). The role of the HPC will be to centralise oncologic and non-oncologic treatment recommendations in accordance with the patient's priorities. Moreover, an Advanced Practice Nurse will act as case-manager by being the primary point of contact for the patient, thus improving coordination between specialists, and by organising and leading the consortium. Patient monitoring and the HPC collaboration will be facilitated by digital communication tools designed specifically for this purpose, with the added benefit of being customisable for each patient. MATERIALS AND METHODS: The GERONTE study is a prospective international, multicentric study consisting of two stepped-wedge trials performed at 16 clinical sites across three European countries. Each trial will include 720 patients aged 70 years and over with a new or progressive cancer (breast, lung, colorectal, prostate) and at least one moderate or severe multimorbidity. The patients in the intervention group will receive the new care pathway whereas patients in the control group will receive usual oncologic care. DISCUSSION: GERONTE will evaluate whether this kind of holistic, patient-oriented healthcare management can improve quality of life (primary outcome) and other valuable endpoints in older patients with multimorbidity and cancer. An ancillary study will assess in depth the socio-economic impact of the intervention and deliver concrete implementation guidelines for the GERONTE intervention care pathway. TRIAL REGISTRATION: FRONE: NCT05720910 TWOBE: NCT05423808.

Effects of healthcare system transformations spurred by the COVID-19 pandemic on management of stroke and STEMI: a registry-based cohort study in France.

OBJECTIVE: To assess the impact of changes in use of care and implementation of hospital reorganisations spurred by the COVID-19 pandemic (first wave) on the acute management times of patients who had a stroke and ST-segment elevation myocardial infarction (STEMI). DESIGN: Two cohorts of patients who had an STEMI and stroke in the Aquitaine Cardio-Neuro-Vascular (CNV) registry. SETTING: 6 emergency medical services, 30 emergency units (EUs), 14 hospitalisation units and 11 cathlabs in the Aquitaine region. PARTICIPANTS: This study involved 9218 patients (6436 patients who had a stroke and 2782 patients who had an STEMI) in the CNV Registry from January 2019 to August 2020. METHOD: Hospital reorganisations, retrieved in a scoping review, were collected from heads of hospital departments. Other data were from the CNV Registry. Associations between reorganisations, use of care and care management times were analysed using multivariate linear regression mixed models. Interaction terms between use-of-care variables and period (pre-wave, per-wave and post-wave) were introduced. MAIN OUTCOME MEASURES: STEMI cohort, first medical contact-to-procedure time; stroke cohort, EU admission-to-imaging time. RESULTS: Per-wave period management times deteriorated for stroke but were maintained for STEMI. Per-wave changes in use of care did not affect STEMI management. No association was found between reorganisations and stroke management times. In the STEMI cohort, the implementation of systematic testing at admission was associated with a 41% increase in care management time (exp=1.409, 95% CI 1.075 to 1.848, p=0.013). Implementation of plan blanc, which concentrated resources in emergency activities, was associated with a 19% decrease in management time (exp=0.801, 95% CI 0.639 to 1.023, p=0.077). CONCLUSIONS: The pandemic did not markedly alter the functioning of the emergency network. Although stroke patient management deteriorated, the resilience of the STEMI pathway was linked to its stronger structuring. Transversal reorganisations, aiming at concentrating resources on emergency care, contributed to maintenance of the quality of care. TRIAL REGISTRATION NUMBER: NCT04979208.

Development and evaluation of the accuracy of an indicator of the appropriateness of interventional cardiology generated from a French registry.

BACKGROUND: Development of appropriateness indicators of medical interventions has become a major quality-of-care issue, especially in the domain of interventional cardiology (IC). The objective of this study was to develop and evaluate the accuracy of an indicator of the appropriateness of interventional cardiology acts (invasive coronary angiographies (ICA) and percutaneous coronary interventions (PCI)) in patients with coronary stable disease and silent ischemia, automated from a French registry. METHODS: All ICA and PCI recorded in a Regional IC Registry (ACIRA) and operated for a stable coronary artery disease or silent ischemia from January 1st to December 31th 2013 in eight IC hospitals of Aquitaine, southwestern France, were included. The indicator was developed to reflect European guidelines. Classification of appropriateness by the indicator, measured on the registry database, was compared to the classification of a reference standard (expert judgment applied through complete record review) on a random sample of 300 interventions. Accuracy parameters were estimated. A second version of the indicator was defined, based on the analysis of false negative and positive results, and its accuracy estimated. RESULTS: The second indicator accuracy was: sensitivity 63.5% (95% confidence interval CI [51.7-75.3]), specificity 76.0% (95%CI [70.4-81.6]), PPV 43.0% (95% CI [33.0-53.0]) and NPV 88.0% (95% CI [83.4-92.6]). When stratified on the type of act, parameters were better for ICA alone than for PCI. CONCLUSIONS: Accuracy of the indicator should raise with improvement of database quality. Despite its average accuracy, it is already used as a benchmark indicator for cardiologists. It is sent annually to each IC center with value of the indicator at the region level to allow a comparison.

An evaluation of five regional health information technology-based programmes to improve health and social care coordination: A quasi-experimental controlled before/after mixed design.

OBJECTIVES: Health information technology (HIT) can help coordinate health and social actors involved in patients' pathways. We assess five regional HIT-based programmes ('Territoires de Soins Numériques' or TSN) introduced in France, covering the period 2012-2018. METHODS: This was a quasi-experimental controlled before/after mixed design. We used data from the French National Health Insurance database, qualitative and quantitative surveys, and information extracted from project documents and databases. We assessed the impact of TSN using four main impact indicators: emergency room visits, unplanned hospitalizations, avoidable hospitalizations and rehospitalization within 30 days. We also collected qualitative and secondary quantitative data covering perceived needs, knowledge, use, satisfaction, adoption and understanding of projects, pathway experience, impact on professional practices and appropriateness of hospitalizations. RESULTS: TSN implemented a heterogeneous mix of HIT. Implementation was slower than expected and was not well documented. Users perceived the HIT as having a positive but weak overall effect. There were no significant differences in trends for the main impact indicators, nor on the appropriateness of hospitalizations, but favourable trends on secondary polypharmacy indicators. CONCLUSIONS: If similar innovations take place in future, they should be based on a logical framework that defines causal, measurable links between services provided and expected impacts.

Development of an evidence-based reference framework for care coordination with a focus on the micro level of integrated care: A mixed method design study combining scoping review of reviews and nominal group technique.

BACKGROUND: Because of the limits in conceptualisation of care coordination linked to a large array of care coordination models and definitions available, a care coordination framework is needed with a particular focus on the micro level. OBJECTIVE: To develop an evidence-based reference framework for person-centred care coordination interventions based on international validated definitions. METHODS: This two-step mixed-methods study included first, a scoping review of reviews focus on the impact of care coordination interventions and then, a nominal group technique. The scoping review aimed at identifying the components of the four dimensions of the framework (contexts, activities, actors and tools, and effects). The nominal group technique was to select the relevant components of the dimension 'activities' of the reference framework. RESULTS: The scoping review selected 52 articles from the 1407 retrieved at first. The nominal group selected the 66 most relevant activities from the 159 retrieved in the literature (28 activities of care organisation, 24 activities of care, and 14 activities of facilitation). CONCLUSION: This operational framework focused on care coordination at the micro level, is a useful and innovative tool, applicable in any clinical condition, and in any health care system for describing, implementing and evaluating care coordination programmes.

Pre-operative peripheral intravenous cannula insertion failure at the first attempt in adults: Development of the VENSCORE predictive scale and identification of risk factors.

STUDY OBJECTIVE: Our objective was to develop a clinical scale (the VENSCORE) to predict pre-operative peripheral intravenous cannula (PIVC) insertion failure at the first attempt in adults. DESIGN: This was a prospective multicenter cohort study that included internal validation with bootstrapping. SETTING: The operating rooms of 14 hospitals in southern France from June 2016 to June 2018. PATIENTS: Consecutive adult patients aged 18 years or older were recruited upon arrival to the operating room, regardless of American Society of Anaesthesiology (ASA) physical status. INTERVENTIONS: PIVC insertion on arrival to the OR. MEASUREMENTS: PIVC insertion failure at the first attempt was the outcome of interest. Data collected included the number of PIVC insertion attempts and potential predictors of the risk of failure (including pre-operative patient characteristics and data relative to the procedure). Uni- and multivariable logistic analyses were performed. Based on these results, the VENSCORE scale was developed to predict the risk of failure of the first PIVC insertion. MAIN RESULTS: In total, 3394 patients were included, and 27 were excluded because of protocol violations. The PIVC insertion failure rate at the first attempt was 20.3%. Based on multivariable analysis, a history of difficult PIVC insertions, high-risk surgery, poor vein visibility, and moderate to poor vein palpability were identified as risk factors for insertion failure at the first attempt. The area under the curve of the predictive model was 0.82 (95% confidence interval: 0.80-0.84). A VENSCORE value of 0 points was associated with a failure rate of 7%, versus 97% for a score of 6. CONCLUSIONS: The four-item VENSCORE scale could be useful for prospectively identifying adults at risk of first PIVC insertion attempt failure.

Effectiveness and organizational conditions of effectiveness of telemedicine in nursing homes. A study protocol of a comparative prospective cohort (EFFORT study).

The profile of nursing home (NH) residents has changed over the past decade with more dependency, more severe chronic diseases and more treatments prescribed. For residents, the major consequence is the higher risk of unplanned hospitalization. French guidelines recommend the development of interactive telemedicine (InT) in NHs in order to improve access to care, and to decrease the rate of avoidable unplanned hospitalizations. Methods and analysis: The aim of this study is to analyze the impact of an InT protocol delivered in NHs on the rate of unplanned hospitalizations, and on the quality of life at work and the organizational conditions of effectiveness of telemedicine in NHs. We will perform a mixed methods study combining a cluster non-randomized controlled trial in two matched parallel arms (telemedicine group and control group) and qualitative analysis of the evolution of organizational and professional contexts in NHs. Ethics and dissemination: The study protocol was approved and sponsored by the French Ministry of Health. The study received ethical approval from the Bordeaux University Hospital Institutional Review Board. We will communicate the final results to the public via conferences and results will also be submitted for publication in international peer-reviewed scientific journals. Trial registration number NCT03486977.

The ACIRA Registry: A Regional Tool to Improve the Healthcare Pathway for Patients Undergoing Percutaneous Coronary Interventions and Coronary Angiographies in the French Aquitaine Region: Study Design and First Results.

BACKGROUND: In France, there is a lack of information about practices and pathways of coronary angiographies and percutaneous coronary interventions (PCI). We present the design and the first results of the ACIRA registry, the goal of which is to answer questions about quality, security, appropriateness, efficiency of, and access to interventional cardiology (IC) healthcare pathway in the French Aquitaine region. METHODS: The ACIRA registry is an on-going, multicenter, prospective, exhaustive, scalable, and nominative cohort study of patients who undergo coronary angiographies or percutaneous coronary intervention in any of the catheterization laboratories. The data related to hospitalizations and procedures are directly extracted from hospital information systems. In-hospital mortality, readmissions, and cardiovascular morbidity are collected from the French hospital medical information system database. An identity management system has been implemented to create the patient health care pathway. RESULTS: From January 1, 2012, to June 30, 2018, 147,136 procedures performed on 106,005 patients have been included in the ACIRA registry. CONCLUSIONS: ACIRA has shown its ability to study the patient IC healthcare pathway, up to 1 year after the procedure. Nominative data enable the linkage between clinical and medico-administrative databases and possible supplementary data collection. The use of existing databases allowed us to limit patients lost to follow-up, prevent the double entry of data, improve data quality, and reduce the operating costs. The prospect of linkage with the French National Health Data System may offer promising opportunities for future medical research projects and for developing collaboration and benchmarking with other IC registries abroad.

The development of a regional referral pathway for locally recurrent rectal cancer: A Delphi consensus study.

BACKGROUND: The management of patients with locally recurrent rectal cancer (LRRC) is often complex and requires multidisciplinary input whereas only few patients are referred to a specialist centre. The aim of this study was to design a regional referral pathway for LRRC, in Nouvelle Aquitaine (South-West, France). METHODS: In 2016, we conducted with a Study Steering Committee (SC) a three phase mixed-methods study including identification of key factors, identification of key stakeholders and Delphi voting consensus. During three rounds of Delphi voting, a consensus was defined as favorable, if at least 80% of participating experts rate the factor, below or equal to 3/10 using a Likert scale, or consider it as "useful" using a binary scale (third round only). Finally, the SC drafted guidelines. RESULTS: Among the 423 physicians involved in 29 regional digestive Multi-Disciplinary Team (MDT) meeting, 59 participants (from 26 MDT meeting) completed all three rounds of Delphi voting. Thirteen out of twenty initially selected factors reached a favorable consensus. All patients with a LRRC need to be included into a referral pathway. Patients with a central pelvic recurrence offered curative treatment in their local hospital and patients with unresectable metastatic disease were excluded of the referral. Key performance indicators were also agreed including the time to referral and completion of pelvic MRI-, CT-, PET-scan prior to MDT referral. CONCLUSION: The development of this referral pathway represents an innovative health service, which will improve the management of patients with LRRC in France.

Sequelae and Quality of Life in Patients Living at Home 1 Year After a Stroke Managed in Stroke Units.

Introduction: Knowledge about residual deficiencies and their consequences on daily life activities among stroke patients living at home 1-year after the initial event managed in stroke units is poor. This multi-dimensional study assessed the types of deficiencies, their frequency and the consequences that the specific stroke had upon the daily life of patients. Methods: A cross-sectional survey, assessing, using standardized scales, 1 year post-stroke disabilities, limitations of activities, participation and quality of life, was carried out by telephone interview and by mail in a sample of stroke patients who returned home after having been initially managed in a stroke unit. Results: A total of 161 patients were included (142 able to answer the interview on their own; 19 needing a care-giver). Amongst a sub-group of the patients interviewed, 55.4% (95% Confidence Interval [47.1-63.7]) complained about pain and 60.0% (95% CI [51.4-68.6]) complained of fatigue; about 25% presented neuropsychological or neuropsychiatric disability. Whilst 87.3% (95% CI [81.7-92.9]) were independent for daily life activities, participation in every domains and quality of life scores, mainly in daily activity, pain, and anxiety subscales, were low. Conclusion: Despite a good 1-year post-stroke functional outcome, non-motor disabling symptoms are frequent amongst patients returned home and able to be interviewed, contributing to a low level of participation and a poor quality of life. Rehabilitation strategies focused on participation should be developed to break the vicious circle of social isolation and improve quality of life.

[Analysis of circumstances of occurrence of contrast media in imaging services]. / Analyse des circonstances de survenue des extravasations de produits de contraste en imagerie.

INTRODUCTION: To prevent extravasations in medical imaging, analyses of organizational and professional circumstances of the occurrence of extravasations have been conducted in the Bordeaux University Hospital (BUH). METHOD: Two parallel studies were conducted: (i) clinical practice evaluation (CPE) including practice analysis groups and development of indicator of extravasation occurrence; (ii) Case-control study analyzing the factors associated with the occurrence of extravasations. Cases were constituted with consecutive series of patients with extravasation occurred in the BUH; controls were constituted of series of patients managed in medical imaging in the BUH without any extravasation. Statistical analysis included univariate and multivariate regression logistic models. RESULTS: CPE identified the following circumstances: patient' characteristics (female gender, low blood vessels) and professional situations (lack of check of: peripheral veinous access, contrast media temperature, injection process and lack of matching between injection amount and veinous access diameter). In the case-control analysis, patients' gender and catheter placement in medical imaging were significantly associated with the occurrence of extravasations. Guidelines have been drafted allowing the decrease of extravasation incidence. CONCLUSION: Adherence to guidelines of contrast media preparation and injection process is very important to prevent extravasation and improve patient safety.

Appropriateness of psychotropic drug prescriptions in the elderly: structuring tools based on data extracted from the hospital information system to understand physician practices.

BACKGROUND: The appropriateness of psychotropic prescriptions in the elderly is a major quality-of-care challenge at hospital. Quality indicators have been developed to prevent inappropriate psychotropic prescriptions. We aimed to select and automatically calculate such indicators, from the Bordeaux University Hospital information system, and to analyze the appropriateness of psychotropic prescription practices, in an observational study. METHODS: Experts selected indicators of the appropriateness of psychotropic prescriptions in hospitalized elderly patients, according to guidelines from the French High Authority for Health. The indicators were reformulated to focus on psychotropic administrations. The automated calculation of indicators was analyzed by comparing their measure to data collected from a clinical audit. In elderly patients hospitalized between 2014 and 2015, we then analyzed the evolution of the appropriateness of psychotropic prescription practices during hospital stay, using methods of visualization, and described practices by considering patients' characteristics. RESULTS: Two indicators were automated to detect overuse and misuse of psychotropic drugs. Indicators identified frequent inappropriate drug administrations, but practices tended to become more appropriate after quality-of-care improvement actions. In the majority of patients (85%), there was no inappropriate administration of psychotropic drugs during hospital stay; for the remaining 15% with at least one inappropriate administration, physicians tended to limit overuse or misuse during hospital stay. Inappropriate administrations were more frequent in patients suffering from psychiatric disorders, dependence and associated complications or morbidities. CONCLUSIONS: The automated indicators are structuring tools for the development of a drug prescription monitoring system. Inappropriate psychotropic administrations were limited by physicians during hospital stay; some inappropriate prescriptions might be explained by clinical characteristics of patients.

Definition of indicators of the appropriateness of oral anticoagulant prescriptions in hospitalized adults: Literature review and consensus (PACHA study).

BACKGROUND: Indicators of the appropriateness of oral anticoagulant prescriptions are lacking, despite the major contribution they could make to improve quality of care. AIM: To identify and select such indicators according to their utility and operational implementation. METHODS: A literature review was conducted to identify indicators of the appropriateness of oral anticoagulant prescriptions according to the guidelines of health authorities and European learned societies. A first list of indicators was identified from guidelines related to general or targeted clinical situations. A two-round Delphi consensus process, completed by a synthesis meeting, was then set up to ask European experts to rate the utility and operational implementation of the indicators on a qualitative binary scale. An indicator was selected if ≥80% of the experts judged it both useful and implementable (strong consensus). RESULTS: We selected 32 references, from which 84 indicators were identified. Nineteen indicators were short-listed for submission to expert judgment. Twenty-two experts participated in the Delphi process. Sixteen indicators obtained strong consensus for selection; three indicators did not achieve consensus. Two-thirds of the selected indicators focused on the appropriateness of oral anticoagulant prescriptions in general or in patients with atrial fibrillation; the other third focused on the appropriateness of prescriptions in patients with a prosthetic heart valve, venous thromboembolism or trauma. CONCLUSION: This work addresses the current lack of indicators of the appropriateness of oral anticoagulant prescriptions. The selected indicators will be implemented from the hospital information system to assess their metrological properties to detect inappropriate prescriptions.

Organizational and managerial factors associated with clinical practice guideline adherence: a simulation-based study in 36 French hospital wards.

OBJECTIVES: To identify managerial and organizational characteristics of multi-specialty medicine wards and individual characteristics of health professionals that are most strongly associated with clinical practice guidelines (CPG) adherence. DESIGN: Cross-sectional stratified cluster sample design. SETTING: Data were gathered from 36 randomly selected multi-specialty medicine wards. PARTICIPANTS: The study population included all health professionals involved in patient care working in the participating wards. MAIN OUTCOME MEASURES: The degree of CPG adherence was measured using clinical vignettes on three topics: pain management, managing heart failure and managing diabetes. Responses from each professional to each clinical case were quantified using a 10-point scale. Managerial and organizational characteristics of medical department and individual characteristics of health professionals were obtained using three questionnaires. RESULTS: The study sample consisted of 859 professionals (362 orderlies, 361 nurses and 136 physicians). Factors independently and positively associated with CPG adherence were (i) individual factors: low age of professionals, expertise in diabetology and activity in cardiology; (ii) organizational and managerial factors: good understanding between physicians and other personnel; and (iii) structural factors: computer-based test results and prescriptions, presence of medical specialists, inter-department mobility of orderlies, medium-length stay (between 7 and 10 days) and large bed capacity. CONCLUSIONS: Good CPG adherence in general medicine needs institutional dynamism, availability of clinical competence and team culture based on cooperation.

Development and validation of hospital information system-generated indicators of the appropriateness of oral anticoagulant prescriptions in hospitalised adults: the PACHA study protocol.

INTRODUCTION: The appropriateness of oral anticoagulant prescriptions is a major challenge to improve quality and safety of care. As indicators of the appropriateness of oral anticoagulant prescriptions are lacking, the aim of the study is to develop and validate a panel of such indicators, in hospitalised adults, from the hospital information system of two university hospitals in France. METHODS AND ANALYSIS: The study will be carried out in four steps: (1) a literature review to identify indicators of the appropriateness of oral anticoagulant prescriptions and their conditions of appropriateness; (2) a Delphi consensus method to assess the potential utility and operational implementation of the selected indicators; (3) techniques of medical data search to implement indicators from the hospital information system and; (4) a cross-sectional study to assess the ability of indicators to detect inappropriate oral anticoagulant prescriptions, performance of medical data search techniques for tracking or retrieving information and the ability of tools to be transferred into other institutions. The fourth step will include up to 80 patient hospital stays for each indicator, depending on the prevalence of inappropriate prescriptions estimated in interim analyses. ETHICS AND DISSEMINATION: This work addresses the current lack of quality indicators of the appropriateness of oral anticoagulant prescriptions. We aim to develop and validate such indicators for integrating them into hospital clinical practice, as part of a structured approach to improve quality and safety of care. As each hospital information system is different, we will propose tools transferable to other healthcare institutions to allow an automated construction of these indicators. The PACHA study protocol was approved by institutional review boards and ethics committees (CPP Sud-Ouest et Outre Mer III-DC 2016/119; CPP Ile-de-France II-CDW_2016_0014). REGISTRATION DETAILS: Clinical Trial.gov registration: NCT02898090.

Protocole of a controlled before-after evaluation of a national health information technology-based program to improve healthcare coordination and access to information.

BACKGROUND: Improvement of coordination of all health and social care actors in the patient pathways is an important issue in many countries. Health Information (HI) technology has been considered as a potentially effective answer to this issue. The French Health Ministry first funded the development of five TSN ("Territoire de Soins Numérique"/Digital health territories) projects, aiming at improving healthcare coordination and access to information for healthcare providers, patients and the population, and at improving healthcare professionals work organization. The French Health Ministry then launched a call for grant to fund one research project consisting in evaluating the TSN projects implementation and impact and in developing a model for HI technology evaluation. METHODS: EvaTSN is mainly based on a controlled before-after study design. Data collection covers three periods: before TSN program implementation, during early TSN program implementation and at late TSN program implementation, in the five TSN projects' territories and in five comparison territories. Three populations will be considered: "TSN-targeted people" (healthcare system users and people having characteristics targeted by the TSN projects), "TSN patient users" (people included in TSN experimentations or using particular services) and "TSN professional users" (healthcare professionals involved in TSN projects). Several samples will be made in each population depending on the objective, axis and stage of the study. Four types of data sources are considered: 1) extractions from the French National Heath Insurance Database (SNIIRAM) and the French Autonomy Personalized Allowance database, 2) Ad hoc surveys collecting information on knowledge of TSN projects, TSN program use, ease of use, satisfaction and understanding, TSN pathway experience and appropriateness of hospital admissions, 3) qualitative analyses using semi-directive interviews and focus groups and document analyses and 4) extractions of TSN implementation indicators from TSN program database. DISCUSSION: EvaTSN is a challenging French national project for the production of evidenced-based information on HI technologies impact and on the context and conditions of their effectiveness and efficiency. We will be able to support health care management in order to implement HI technologies. We will also be able to produce an evaluation toolkit for HI technology evaluation. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02837406 , 08/18/2016.

Comparing Graphical Formats for Feedback of Clinical Practice Data. A Multicenter Study among Anesthesiologists in France.

OBJECTIVES: Although graphical formats used to feedback clinical practice data may have an important impact, the most effective formats remain unknown. Using prevention of postoperative nausea and vomiting by anesthesiologists as an application, the objective of this study was to assess which graphical formats for feedback of clinical practice data are the most incentive to change practice. METHODS: We conducted a multicenter cross-sectional study among anesthesiologists randomized in two groups between March and June 2014. Each anesthesiologist assessed 15 graphical formats displaying an indicator of either prescription conformity or prescription effectiveness. Graphical formats varied by: type of graph (bar charts, linear sliders, or pictographs), presence or not of a target to reach, presence or not of a contrast between a hypothetical physician and his / her team, direction of the difference between the physician and his / her team, and restitution or not of the quality indicator evolution over the previous six months. The primary outcome was a numerical scale score expressing the anesthesiologists' motivation to change his / her practice (ranging from 1 to 10 points). A linear mixed model was fitted to explain variation in motivation. RESULTS: Sixty-six anesthesiologists assessed the conformity indicator and 67 assessed the effectiveness indicator. Factors associated with an increased motivation to change practice were: (i) presence of a clearly defined target to reach (conformity: ß = 0.24 points, p = 0.0046; effectiveness: ß = 1.11 points, p < 0.0001); (ii) contrast between the physician and his / her team (conformity: ß = 0.38 points, p < 0.0001; effectiveness: ß = 0.33 points, p = 0.0021); (iii) better results for the team than for the physician (conformity: ß = 0.65 points, p < 0.0001; effectiveness ß = 1.16 points, p < 0.0001). For the effectiveness indicator, anesthesiologists were more motivated to change practice with bar charts (ß = 0.24 points, p = 0.0447) and pictographs (ß = 0.45 points, p = 0.0001) than with linear sliders. CONCLUSIONS: Graphs associated with a defined target to reach should be preferred to deliver feedback, especially bar graphs or pictographs for indicators which are more complex to represent such as effectiveness indicators. Anesthesiologists are also more motivated to change practice when graphs report contrasted data between the physician and his / her team and a lower conformity or effectiveness for the physician than for his / her team.

[Assessment of the announcement procedure in 29 cancer-accredited hospitals in the Aquitaine region: the EVADA project]. / Évaluation du dispositif d’annonce au sein de 29 établissements de santé d’'Aquitaine autorisés en cancérologie: le projet EVADA.

INTRODUCTION: An announcement procedure is mandatory to obtain accreditation to treat cancer patients. Health care professionals in the Aquitaine region evaluated the organization of this announcement procedure in their institutions and the patients' perception, in order to initiate actions to improve the structure and traceability of this procedure. METHOD: Self-assessment approach based on a retrospective study plan comprising three concomitant steps: organizational audit, medical records audit and patient experience survey. RESULTS: 29 institutions participated in the study. Heterogeneous organizations were observed, although progress had been made in the deployment of the announcement procedure in terms of personnel training,formal organization and the resources devoted to this procedure, but there remains considerable room for improvement in terms of traceability, coordination between doctors and nursing staff, and referral of patients to supportive care. CONCLUSION: This evaluation triggered active mobilization of hospital teams concerning the announcement procedure in the Aquitaine region and a better awareness of the patient's perception. The regional dynamic allowed exchanges between institutions, facilitating the implementation of improvement actions.

[Clinical features, care pathways and behaviors of patients with high level of cardiovascular risk: transversal study in south-west region of France]. / Profil clinique, parcours de soins et comportements des patients à haut risque cardiovasculaire : étude transversale en Aquitaine.

INTRODUCTION: To screen and to follow-up the patients with high cardiovascular risk in general practice may amplify the decrease of the cardiovascular morbi-mortality observed since a few years. The objective of this study is to identify the patients with high cardiovascular risk and to describe the management of these patients by general practitioners in Aquitaine. METHODS: Transversal study of a sample of patients from 18 to 70 years old with high cardiovascular risk (combining at least 3 factors), included by voluntary general practitioners (GP). RESULTS: Forty-seven GP included 102 patients, presenting on average 3.7 risk factors among which 2.6 modifiable. The target values were reached for 59 % of patients with high blood pressure, 56 % of patients with diabetes and 53 % of patients with high cholesterol level. The analysis of care pathways identified the cardiologist as the privileged interlocutor. The doctors thought that seven patients out of 10 could change their risk behaviors. For the patients, the scale of declared importance to change was 6.6 on 10 for tobacco, 6.0 for food habits and 6.2 for physical activity. The confidence in their capacity to change was 3.8 on 10 for the tobacco, 5.2 for the food habits and 4.7 for the physical activity. DISCUSSION: Although doctors' sample is not representative, these results give an original overview of the management of patients with high cardiovascular risk and their care pathways. Medical treatments were globally in accordance with guidelines. The difficulty to change risk behaviors illustrates the necessity of patient therapeutic education.