[Situations regarding the labour market for people suffering from chronic diseases]. / Situations à l'égard du travail des personnes atteintes de maladies chroniques.

BACKGROUND: This paper is aimed at investigating the extents to which illness modifies labour supply and employment conditions of people with chronic diseases (defined as severe diseases giving rise to 100% coverage of health expenditures by the Sickness Fund). METHODS: It is based on the data of 35073 individuals interviewed in the 2002-2003 French Decennial Health Survey, reporting their health, health care consumption and socioeconomic characteristics, and collected by the French National Institute of Statistics and Economic Studies. Models have been estimated with logistic strategies. RESULTS: Participation in labour market appears, all other things being equal, to be less important for people with chronic diseases. Chronic diseases are more deleterious for blue collar than for white collars workers. The probability to have a part-time job is raised by 60% for people with chronic diseases (100% for men, 50% for women). Suffering from chronic diseases raises the probability to have a desired part-time job rather than a full-time job by 80% (170% for men, 60% for women) and the probability to have an undesired part-time job rather than a full-time job by 50% (30% for men, 50% for women). For the elderly (50-65 years), chronic diseases multiply by three the probability to be out-of-work (and not retired), by two the probability to be retired and by 1.5 the probability to be unemployed compared to being employed. CONCLUSION: The consequences of chronic diseases on the workplace are not negligible, creating new social inequalities that the French social protection system does not seem to be able to completely cover.

[Collaboration between general practitioners and pharmacists in the management of patients on high-dosage buprenorphine treatment. Prescribers' practices]. / Collaboration entre médecins et pharmaciens pour le suivi des patients sous buprénorphine haut dosage. Pratiques des médecins prescripteurs.

OBJECTIVES: This paper examines the collaboration between general practitioners (GPs) and pharmacists in the outpatient management of patients on high-dosage buprenorphine (HDB) treatment. METHODS: A telephone survey of a sample of HDB prescribers in southeastern France questioned them about their knowledge, practices, and opinions about HDB treatment in October 2002; data from the national health insurance fund and the national statistics institute completed the study. Logistic regression was used to investigate factors associated with collaboration with pharmacists. GPs' practices were compared to assess their correlation, if any, with this collaboration. RESULTS: 345 GPs participated in the study. Only 54% reported collaborating with dispensing pharmacists in managing patients on HDB, despite official guidelines encouraging it. Collaboration was independently related to training in addiction treatment, a favorable opinion of maintenance treatment by GPs, long experience in HDB prescription, and participation in a specialized medical network. CONCLUSION: Implementation of recommendations on physician-pharmacist collaboration requires additional training in addiction medicine for GPs and the encouragement of their participation in medical networks. On the other hand, increasing the constraints on GPs may negatively affect patients' access to care.

[Demographic and socioeconomic factors associated with needs for home assistance among community-dwelling elderly: a study from the French Home Survey Handicaps-Disabilities-Dependence]. / Facteurs démographiques et socio-économiques associés aux besoins d'aide des personnes âgées vivant à domicile: une étude à partir de l'enquête Handicaps-Incapacités-Dépendance.

BACKGROUND: Gains in life expectancy in western countries have mainly come hand in hand with growing chronic diseases and disabilities related to the activities of daily living (ADL) and instrumental activities of daily living (IADL). Although these disabilities have been identified as predictors of institutionalization, the elderly in France continue to live at home, in the community, alone or with others. This work aims at identifying and assessing their needs for assistance and looks especially at the demographic and socioeconomic associated features. METHODS: Reported needs for assistance with ADL and IADL are studied through a representative sample of 8,745 people aged 60 years and older and living at home in 1999, taken from the French cross-sectional "Handicaps-Disabilities-Dependence" survey. Statistical associations (non-adjusted and adjusted Odds-Ratio-OR) have been computed in a conceptual framework derived from Andersen and Newman's behavioural model. RESULTS: More than 1 million people aged 60 years and older need assistance from another person to perform at least one ADL (bathing, dressing, going to toilet, eating, transferring, getting outside) and about 2.5 millions persons for at least one IADL (shopping, food preparation, housekeeping). Need for assistance for at least one ADL is associated with age (OR=1.4 for 70-79, 3.6 for 80+); male aged 80 and older (OR=0.5); low educational status (OR=1.5); being married (OR=1.7) or living with an other person (OR=2); a disposable income less than 540 euro per capita and per month or between 540 and 1,080 euro (OR=1.3); impairments: motor (OR=3), language (OR=2.1), visual (OR=1.7), mental (OR=1.5) and other (OR=1.2); availability of home equipment devices (OR=3.5), technical devices for moving inside (OR=3) and others (OR=2.1). Need for assistance is especially high among those who required assistance (OR=4) or proxies (OR=5.5) to answer. Declared need for assistance for at least one IADL is roughly associated with the same factors. CONCLUSION: These results suggest that the declared needs for human assistance are based not exclusively on functional limitations but are also related to the social and environmental setting.

Delivering generics without regulatory incentives? Empirical evidence from French general practitioners about willingness to prescribe international non-proprietary names.

France presents a unique situation in which the take-off of a generic drug market depends, out of regulatory incentives, on whether physicians choose a prescription method (international non-proprietary names, INN) that can lead to the delivery of these drugs and on whether patients accept them. This paper is aimed at pointing out factors explaining general practitioners' (GPs') willingness to prescribe in INN through data collected from a South-Eastern France representative sample of 600 GPs in March 2002. The main results shed light on the key-role played by GPs' information about drugs and the source which they take it from, by GPs' volume of services and caseloads, and slightly by socio-economic characteristics of patients.

[General practitioners' health care for disabled patients: a survey among a panel of general practitioners in Southeastern France, in 2002]. / La prise en charge des patients handicapés en médecine générale libérale: une enquête auprès d'un panel de médecins généralistes en Provence Alpes Côte d'Azur, en 2002.

OBJECTIVES: This article presents a study on General Practitioners' (GPs) knowledge, attitudes and practice towards disabled patients. MATERIAL: A sample of 600 private general practitioners practising in Southeastern France was selected in 2002 with a random sampling approach stratified according to age, sex, and size of the urban unit. METHOD: A standardised questionnaire was used to collect data by telephone. Results are presented as percentages. Comparisons used Pearson's chi2 test. RESULTS: Ninety percent of the GPs reported that they had to provide social assistance to their disabled patients (protecting their rights, administrative assistance, family counselor, etc.) as well as coordinating care by various other professionals. GPs frequently reported the presence of barriers that compromised the health care of disabled patients: lack of information (62.8%), time (50.2%), co-ordination between health professionals (37.7%), and training (37.7%), as well as communication problems (20.7%) and the need for assistance in clinical examinations (16.2%). More than 25% of the GPs suggested breast cancer screening (27.6%), contraceptive prevention (29.5%) or hepatitis B vaccination (29,3%) less often to their disabled than non disabled patients and 25.8% reported they had not evaluated the patients' dependency levels. CONCLUSION: This study suggests that GPs face several barriers in caring for disabled persons. A lack of knowledge may explain inappropriate care for this population. GPs need more support and guidance in dealing with disabled patients, and coordination with other health professionals must be encouraged.

[Prescription of high dose buprenorphine by general practitioners]. / Prescription de buprénorphine haut dosage par des médecins généralistes.

BACKGROUND: Since 1996, prescribing buprenorphine in high dosage as a drug maintenance treatment has been allowing French general practitioners to undertake drug addicts with a pharmacological support. In France, buprenorphine prescriptions seem to spread over general practitioners (buprenorphine was given to 74,300 patients in 2001). This paper assesses the different factors associated with buprenorphine prescription by general practitioners and with the different degrees of general practitioners' commitment in actually caring drug addicts with the help of buprenorphine. METHODS: Two representative samples of private general practitioners, either prescribing buprenorphine (345 over a population of 876) or not prescribing (355 over a population of 1380) have been questioned through a phone interview in the department of South-Eastern France in November and December 2002. Samples have been constituted with the help of a random stratified survey according to sex, age and volume of services (acceptance rate: 65.5%). Survey data have been completed with general practitioners' activity data from Health Insurance and local socioeconomic data from Insee. RESULTS: 37.5% of general practitioners have at least once prescribed buprenorphine during the considered period, but only 26% of the prescribers treated 75% of patients. Prescribers are most often men, younger than 49 years, working in the fixed fees sector and having group practice. They are also most often members of a health care network, trained for drug maintenance treatments and, from an individual point of view, have relatives suffering cancer, or having HIV, or hepatitis C, or who are drug addicts. Low socioeconomic status of the area where GPs exert seems to be particularly associated with general practitioners' prescription of buprenorphine. CONCLUSION: Data handled in this paper show that supply of substitutive treatments is concentrated among a reduced number of general practitioners and in particularly deprived geographic areas. Workload in deprived areas combined to great professional commitment in maintenance treatment reveals unexpected and unwanted specialisation behaviours by general practitioners, as well as more isolated behaviours by general practitioners who do not ask for particular training program or help by colleagues. These results question the consistency of the general framework of support to general practitioners proposed by health authorities with general practitioners actual practice and needs.

[Survey on the treatment of hospitalised community-acquired lower respiratory tract infections]. / Enquête sur la prise en charge thérapeutique des malades hospitalisés pour infection respiratoire basse communautaire.

OBJECTIVES: The assessment of treatment habits regarding community-acquired lower respiratory tract infections and comparison with current national recommendations. METHOD: Prospective survey of treatment habits. Patients hospitalised for community-acquired pneumonia in the department of internal medicine, the department of neurology and the department of respiratory diseases (127 beds) at the Sainte-Marguerite Hospital in Marseilles were included. We studied the socio-economical context, the presence of severity factors, the analysis of risk factors, the antibiotic treatments prescribed (type, route of administration, duration) and the outcome of the patients. RESULTS: From November 2001 to February 2002, 98 patients with community-acquired pulmonary infections were included (61 men with a mean age of 72.5 years). The treatment of these patients conformed to guidelines in 79 cases. In 19 cases, the prescription did not conform (unjustified bi-therapy in 8 patients; absence of bi-therapy in suspected cases of intra-cellular bacteria in 4 patients; insufficient dose in 2 patients; and non-adapted antibiotherapy in 5 patients). CONCLUSION: In the study conditions, the management of community-acquired pneumonia in the hospital most often conformed to current guidelines. Nevertheless, efforts made for initial and continued medical training together with the wide circulation of the guidelines must be continued.

[Willingness to prescribe by international non proprietary names: general practitioners attitudes in South East France in 2002]. / Disposition à prescrire en dénomination commune internationale. Attitudes des médecins libéraux en PACA en 2002.

OBJECTIVES: To evaluate the willingness, reasons and perceived obstacles to prescription by international non-proprietary name (INN) among general practitioners (GPs) in private practice. Method A panel of private GPs practicing in South-eastern France was surveyed twice, 2 months before and 5 months after a new contract between the National Health Insurance system and GP associations (5 June 2002). The panel was constructed with a random sampling approach stratified according to age, sex, and size of the urban unit. RESULTS: Between March-April and November-December 2002, the percentage of GPs willing to prescribe according to INN rose from 76.2% to 89.7%. These physicians reported that their principal reasons for such prescription were the June agreement and concern about the finances of the Health Insurance system. The principal obstacles they mentioned were the complexity of prescription by INN (66%), lack of appropriate information and tools (47%), and patient reticence (41%). CONCLUSION: More effort must be devoted to providing adequate information to patients and GPs. GPs need better training, information, and tools to help transform their willingness into action.

[Macro-economic calculation of spending versus micro-economic follow-up of costs of breast cancer]. / Reconstitution macro-économique des dépenses, suivi micro-économique des coûts du cancer du sein.

BACKGROUND: In the healthcare field, the ability to make economic forecasts requires knowledge of the costs of caring for major diseases. In the case of a semi-chronic condition like cancer, this cost covers all the episodes of care associated with a patient. An evaluation of a macro-economic method of calculating costs for treating non-metastatic cancer, covering all hospital episodes, is proposed. This method is based entirely on the use of annual hospital activity databases, linked to data concerning the incidence of cancer. It allows us to obtain the global cost of care for a neoplasm of a particular site, without the need to reconstruct the whole care pathway of the patients. METHODS: The model was assessed by comparing it's own results, in the particular case of breast cancer to those issuing from a micro-economic follow-up of 115 patients. Data for macro-economic calculation are extracted from the national French hospital database for the year 1999 and from cancer incidence data. The prospective study was done in 1995, in a comprehensive cancer centre. RESULTS: Macro-economic calculation leads to a cost of 14,555 Euro, for primary breast cancer. Prospective follow-up showed a cost of 14,350 Euro (data corrected, 1999 value). With a difference of 1%, there was a clear cohesion of the two results, while a higher level of divergence was noticed (from 1 to 15%) in the comparison between therapeutic techniques. Accuracy and reliability of results were evaluated. CONCLUSION: This method may be extended to all types of neoplasms. This method cannot be used instead of follow-up studies, for cost-efficacy or cost-severity analysis, but may be interesting beyond economic forecasts, in the field of payment per pathology.