Non-drug and drug alternatives to benzodiazepines for insomnia in primary care: Study among GPs and pharmacies in a Southwest region of France.

OBJECTIVES: Benzodiazepines and related drugs are the most commonly prescribed drugs in the treatment of insomnia, and referral to psychotherapy is rare when recommended as first-line treatment for chronic insomnia. The frequency of referral to psychologists, of use of alternative drugs to benzodiazepines, either prescribed by general practitioners (GPs) or dispensed by community pharmacies, is unknown in France. We aimed to describe the non-pharmacological approaches recommended, such as cognitive behavioral therapies (CBT), and the drugs, including alternatives drugs to benzodiazepines, used by GPs and community pharmacies for patients complaining of insomnia. METHODS: A cross-sectional study was conducted during 3 months in 2015 on the management of individual GPs' patients and pharmacies' customers consecutively consulting for insomnia in the Midi-Pyrénées region of southwest France. Participating GPs and pharmacists completed a form, for each patient, on their management (drugs, sleeping advices, referral to psychotherapy). RESULTS: Fifty-five GPs included 263 patients and 43 community pharmacies included 354 customers in the study. Among patients, 193 (73,4%) had already used benzodiazepine. Thirty-eight patients (14.4%) and 2 customers (0.5%) were recommended non-drug therapies (mostly CBT). Benzodiazepines were prescribed 188 times (69.1% of the prescriptions) by GPs. Alternative drugs prescribed were mostly antihistamines (n=26; 9.6%) and antidepressants (n=17; 6.3%). Antihistamines were the most commonly dispensed drugs by pharmacists (n=149; 39.4%). CONCLUSIONS: While non-pharmacological treatments, such as CBT, are safe and widely recommended, benzodiazepines and antihistamines remain widely used despite the lack of long term benefit and the risk of adverse drug reactions.

[Satisfaction of a pharmacovigilance declaration support network in general practice]. / Satisfaction des médecins généralistes d'un réseau d'aide à la déclaration de pharmacovigilance PharmacoMIP-MG.

OBJECTIVE: General practitioners (GPs) report little adverse drug reactions (ADR), although it is mandatory in France. The objective was to evaluate the satisfaction of the GPs who participated to a pharmacovigilance ADR declaration support network via a clinical research assistant (CRA) moving to their GP office in the French South-West region of Midi-Pyrénées. STUDY DESIGN: A satisfaction questionnaire was sent to the 59 active GPs of this network in November 2016. RESULTS: A total number of 44 GPs responded to the survey (mean age 44±11years; 48% of women). The overall satisfaction grade was rated 9/10 (SD±1). The personalized help from a CRA was highly appreciated (n=39; 89%), reduced time-loss (n=35; 90%), and facilitated communication with the local pharmacovigilance department (n=33; 85%). Most GP (95%; n=35) stated that they would keep reporting ADRs, 83% (n=35) stated to declare ADRs via the CRA, the others stated to declare ADRs directly to the Regional Pharmacovigilance Center, mainly via numerical or online tools. For 59% (n=26) their participation to the network had a positive impact on their relationship with patients through the improvement of their vigilance to ADR. DISCUSSION: Most of the active GP answered. They were very satisfied of the pharmacovigilance CRA network helping ADR reports. It may corroborate the increase of ADRs reporting in Midi-Pyrénées since this network was set up.

Management of first depression or generalized anxiety disorder episode in adults in primary care: A systematic metareview.

CONTEXT: General Practitioners (GPs) are the leading antidepressants prescribers in Europe and in France. Difficulties in implementing existing recommendations in daily practice have been described. OBJECTIVE: The objective of this study was to elaborate two algorithms to guide GPs in the patient management for a first major depressive disorder (MDD) or generalized anxiety disorder (GAD) episode in primary care. DATA SOURCES: PubMed, Cochrane, and ISI Web of Science were explored using mainly the following keywords: depressive disorder, anxiety disorders, antidepressive agents or antidepressant. PubMed was explored using Medical Subject Headings (MeSH). Grey literature was also considered through the analysis of articles references, congress publications, guidelines and clinical practice recommendations. STUDY SELECTION: A systematic meta-review (overview of reviews) including systematic reviews, meta-analyses, guidelines and clinical practice recommendations, published from January 2002 to December 2015, was performed. The methodological and report qualities were assessed by the AGREE II, PRISMA checklist and R-AMSTAR grid. Each step was performed independently by two researchers following a process derived from the PRISMA statement. A narrative synthesis on main clinical data to collect before prescription in primary care, key information for patients, and recommended follow-up was realized. RESULTS: Thirty articles were included: 11 meta-analyses, 19 guidelines. For moderate to severe MDD, selective serotonin reuptake inhibitors (SSRI) should be associated with psychotherapy (cognitive behavioral therapy). For GAD, SSRI or CBT should be proposed if functional impairment is marked. Two algorithms to guide GPs for the management of MDD and or the management of GAD were created based on the data synthesis of this review. A GPs expert group discussed and adapted the algorithms to match with GPs expectancies. LIMITS: Few articles dealt specifically with primary care practice, and only one meta-analysis of clinical trial on antidepressants in primary care was found. CONCLUSIONS: From the best evidence-based data, we created two algorithms to guide GPs for the management of MDD and or the management of GAD. These algorithms will be implemented through a website available for GPs consultation.

[Improving adverse drug reaction reporting by general practitioners through clinical research assistants visits]. / Apport de la visite d'assistants de recherche clinique aux cabinets de médecins généralistes sur la notification des effets indésirables médicamenteux.

The main limitation of adverse drug reactions (ADRs) reporting, particularly by general practitioners (GP), to the regional pharmacovigilance centers is under-reporting. The Midi-Pyrénées Regional Pharmacovigilance Center (South western, France) sets up regular visits by a clinical research assistant (CRA) to GP in order to increase the number of ADR reports. The aim of this pilot study was to assess the effect of regular visits of a CRA in GPs offices on the rate of ADR reporting. After one year, CRA visits permit a two-fold increase in ADR reporting.

[Effect of High Council for Public Health on September 28th 2012 recommendation about antipapillomavirus vaccination on antipapillomavirus and trivalent or tetravalent DTP or DTCP co-vaccination in South Western France]. / Impact de l'avis du Haut conseil à la santé publique du 28 septembre 2012 à propos de la vaccination antipapillomavirus : une étude de l'évolution de la co-délivrance des vaccins antipapillomavirus et vaccin tri ou tétravalent DTP ou DTCP en Midi-Pyrénées.

INTRODUCTION: Antipapillomavirus vaccination is used to prevent genital infection by papilloma virus, responsible for a high morbidity. In France, the High Council for Public Health published on September 28th 2012 a new guideline decreasing the age of vaccination from 16 to between 11 to 14 allowing a joint vaccination with mandatory tetravalent or trivalent (against diphtheria, tetanus, pertussis and poliomyelitis Tdap-IPV or Td/IPV booster) vaccination. Our study aimed to assess if this guideline changed the rate of joint vaccinations. METHODS: A descriptive before/after study was conducted on French health insurance reimbursement database at the regional level (Midi-Pyrénées area). The study period comprised 1 year before and 1 year after the publication of the new guideline. We assess the rate of co-vaccinations in these 2 periods and compared them by a Chi2 test. RESULTS: On the study period, 35,647 vaccines were reimbursed corresponding to 18,230 complete vaccinations. Concerning co-vaccinations, 3287 were reimbursed: 1406 (16.4%) before the publication of the guideline and 1881 (19.4%) after (P<0.01). DISCUSSION: The new guideline was accompanied by a rapid increase in the rate of co-vaccinations. It did not diminish the rate of vaccination by antipapillomavirus.

[The «not substitutable¼ using: a comparative study of general practitioners and community pharmacists' views from prescription to delivery]. / La mention « non substituable ¼ de la prescription à la délivrance: comparaison des points de vue des médecins généralistes libéraux et des pharmaciens d'officine de la région Midi-Pyrénées.

BACKGROUND: The "nonrefundable" term use leads to the princep's drug dispensing. The aim of our study was to compare the views of its use between general practitioners and community pharmacists. METHODS: We conducted a descriptive study with similar questionnaires about "nonfundable" term use. A chi-2 test was used in order to detect a difference between the answers of general practitioners ant pharmacists. RESULTS: The general practitioners and pharmacists views of "nonrefundable" used was different (p<0.05). General practitioners majority used this term because of their patients demand. DISCUSSION: General practitioners are using the term "nonrefundable" because of their patients demand and they don't integrate this use in their therapeutics decision.

Identifying competencies required for medication prescribing for general practice residents: a nominal group technique study.

BACKGROUND: Teaching of medication prescribing is a specific challenge in general practice curriculum. The aim of this study was to identify and rank the competencies required for prescribing medication for general practice residents in France. METHODS: Qualitative consensus study using the nominal group technique. We invited different stakeholders of the general practice curriculum and medication use in primary care to a series of meetings. The nominal group technique allowed for the quick development of a list of consensual and ranked answers to the following question: "At the end of their general practice curriculum, in terms of medication prescribing, what should residents be able to do?". RESULTS: Four meetings were held that involved a total of 31 participants, enabling the creation of a final list of 29 ranked items, grouped in 4 domains. The four domains identified were 'pharmacology', 'regulatory standards', 'therapeutics', and 'communication (both with patients and healthcare professionals)'. Overall, the five items the most highly valued across the four meetings were: 'write a legible and understandable prescription', 'identify specific populations', 'prescribe the doses and durations following the indication', 'explain a lack of medication prescription to the patient', 'decline inappropriate medication request'. The 'communication skills' domain was the domain with the highest number of items (10 items), and with the most highly-valued items. CONCLUSION: The study results suggest a need for developing general practice residents' communication skills regarding medication prescribing.

[Not Available]. / La mention « non substituable ¼ de la prescription à la délivrance : comparaison des points de vue des médecins généralistes libéraux et des pharmaciens d'officine de la région Midi-Pyrénées.

BACKGROUND: The "nonrefundable" term use leads to the princep's drug dispensing. The aim of our study was to compare the views of its use between general practitioners and community pharmacists. METHODS: We conducted a descriptive study with similar questionnaires about "nonfundable" term use. A chi-2 test was used in order to detect a difference between the answers of general practitioners ant pharmacists. RESULTS: The general practitioners and pharmacists views of "nonrefundable" used was different (p<0.05). General practitioners majority used this term because of their patients demand. DISCUSSION: General practitioners are using the term "nonrefundable" because of their patients demand and they don't integrate this use in their therapeutics decision.

Delivering the faecal occult blood test: More instructions than shared decisions. A qualitative study among French GPs.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer worldwide. In France, mass screening has been established with FOBT since 2008. The participation rate remains too low. Previous studies were conducted to explore doctors' and patients' perspectives. OBJECTIVE: This study was conducted to explore GPs' performance during consultations in which patients ask for FOBT, focusing on two different aspects: the core content of the consultation and the communication style used between GPs and patients. METHODS: Nine purposively sampled GPs were asked to audiotape specific consultations. Content analysis was performed using Nvivo 9 software. Communication between doctors and patients was explored using RIAS coding. RESULTS: GPs audio taped specific parts of 35 different consultations when they discussed and delivered the FOBT. The core content included primarily biomedical statements with a large portion dedicated to technical aspects. The communication style was not patient-centred. CONCLUSION: While the participation rate of mass screening in France is still low, the analysis of recorded consultations by French GPs confirms that the way of delivering FOBT can be improved.

["Local" or "mobile" screening for diabetic retinopathy in general practice by non-mydriatic digital cameras? about the Diabetes Midi-Pyrénées network activity between 2005 and 2010]. / Dépistage "fixe" ou "itinérant" de la rétinopathie diabétique par rétinographe non mydriatique? A propos du bilan d'activité du réseau Diabète Midi-Pyrénées entre 2005 et 2010.

Fundus photographs using non-mydriatic digital cameras for diabetic retinopathy screening have been studied in France during the past 10 years. Nevertheless, the different screening modalities have not been compared. The main goal of this study was to compare patient recruitment with two different screening modalities, and secondarily to compare diagnostic effectiveness and cost. A retrospective study analyzed data from the Diabetes Midi Pyrenees Network in 2005 and between 2006 and 2010. In 2005, a vehicle with digital camera traveled through a rural department in order to screen diabetic patients whose last fundus examination was performed greater than 1 year previously. Between 2006 and 2010, general practitioners sent their diabetic patients whose last fundus examination was performed greater than 1 year previously to a "local" screening site. In the two cases, fundus photographs were made by trained operator at screening site and analyzed by an ophthalmologist. The "mobile" screening recruited 698 patients, and the "local" screening 345 patients. Patients recruited by "mobile" screening were older than those recruited by "local" screening. They were preferentially men and suffered from diabetes from far longer The diagnostic performance of "local" screening was 26.8%, and it was 28.6% for "mobile" screening (p = 0.47). The cost of screening was higher for "mobile" screening: 116 Euro against 61 Euro for "local" screening. "Mobile" screening could allow more patient recruitment than "local" screening when geographic and demographic constraints are more important.

[Family pharmacy: survey of a sample of patients in Midi-Pyrénées]. / La pharmacie familiale : enquête auprès d'un échantillon de patients en Midi-Pyrénées.

OBJECTIVE: Possession of drugs at home in the family pharmacy and self-medication are at risk. METHOD: Appraisal based upon an analysis of 247 questionnaires completed by patients and 116 questionnaires completed by general practitioners in the French department of Haute Garonne (Southwestern, France). RESULTS: Two hundred and forty-four patients were involved in the study. In 80% of cases, women were in charge of family pharmacy who was located in 66% of cases in a unsecurise room and could be reached by children in 17% of cases. Drugs most frequently found: antiseptics (97%), paracetamol (91%), anti-inflammatory drugs (68%), anti-diarrhea (60%). For the physicians 52 useable questionnaires, 80% of physician were confronted with one of three risks: self-medication, drug autolysis, poisoning in children. CONCLUSION: Women are the referent of the family pharmacy. The doctors seem best placed to a message of prevention through minimal advice.

[Self-medication in children by parents: a real risk? A cross-sectional descriptive study]. / Automédication des enfants par les parents: un vrai risque? Enquête descriptive transversale.

Self-medication is a common practice in France. What is parent's behaviour towards their children? Trying to draw an inventory of this practice, we carried out a survey of self-medication of children under 12 years of age by their parents. The main objective was to assess the frequency of self-medication and the secondary purposes were to describe habits, dangerous behaviours and common mistakes. The results speak for themselves: 96% of parents self-medicate their children, very early, between 6 and 24 months, mostly for mild pathologies; 39% believe they are taking a risk doing it; most frequently used medecines are paracetamol and ibubrofene; 55% of them make a mistake when self-medicating their children (21% combine two brands of paracetamol or two anti-inflammatories, 10% swap pipettes...). Mistakes revealed by this study could be the bases of an education program for parents displayed by GPs and health care workers.