Identifying available substance use disorder screening tests feasible for use in primary care: A systematic review.

Substance use disorders substantially contribute to the global burden of disease. Early detection in primary care is recommended, and numerous screening tests are available. However, barriers to addictive disorder screening exist and the feasibility of using these tests in primary care is unclear. This study aims to identify available addictive disorder screening tests whose feasibility has been evaluated in primary care. This systematic literature review was performed using Pubmed, PsycINFO, and the Cochrane Library databases. The search strategy included four research topics: addictive disorders, screening, primary care, and feasibility. Selection criteria included published studies evaluating the feasibility of an addictive disorder screening test in primary care. Data were extracted for each included article, and each analyzed screening test. Of the 4911 articles selected, 20 were included and 16 screening tests were studied. Physician feasibility was evaluated with satisfaction questionnaires or qualitative studies, mainly measuring test administration time. Patient feasibility was measured using criteria including "ease of use", comprehension, or format preference. Self-administered formats were preferred, especially electronic versions. Overall, the TAPS (Tobacco, Alcohol, Prescription medication, and other Substance use) tool provides a good balance between ease of use, brevity of administration and more extensive screening for substance use disorders. Feasibility appears to be a set of heterogeneous criteria relating to users, including comprehension or satisfaction, and practical aspects, including administration time or format preference. The criteria synthesized in this review could serve as a basis for screening test feasibility studies in primary care given the absence of feasibility study guidelines.

General practice-related MeSH terms in main journals: a bibliometric analysis from 2011 to 2021.

BACKGROUND: There are various Medical Subject Headings (MeSH) terms used to index general practice research, without consistency. AIM: To understand how general practice-related research is indexed in the main general practice journals between 2011 and 2021, and to analyse the factors that influenced the choice of the general practice-related MeSH. DESIGN AND SETTING: This was a quantitative bibliometric study conducted on MEDLINE. METHOD: MeSH were selected according to the international definition of General Practice/Family Medicine: 'General Practice', 'Primary Health Care', 'Family Practice', 'General Practitioners', 'Physicians, Primary Care', and 'Physicians, Family'. Their use was studied from 2011 to 2021 on MEDLINE, reviewing the 20 general practice journals with the highest impact factors. A descriptive and analytical approach was used; the association of the country, journal, and year with the choice of general practice-related MeSH terms was analysed. RESULTS: A total of 8514 of 150 286 articles (5.7%) were using one of the general practice-related MeSH terms. The most used were 'Primary Health Care' (4648/9984, 46.6%) and 'General Practice' (2841/9984, 28.5%). A total of 80.0% (6172/7723) of the articles were related to the UK or US and 71.0% (6055/8514) of the articles came from four journals (BJGP, BMJ, Journal of General Internal Medicine, and Annals of Family Medicine). Two main country clusters emerged from the use of general practice-related MeSH: a British cluster mainly using 'General Practice' and an American cluster using 'Primary Health Care'. The journals also mainly differed in their used of these two MeSH terms. CONCLUSION: Important variations in the indexation of general practice research were found. Researchers should consider combining 'Primary Health Care' and 'General Practice' in their PubMed searches to access all the general practice research, regardless of their country of origin.

Exploring the general practitioners' point of view about clinical scores: a qualitative study.

BACKGROUND: Clinical scores help physicians to make clinical decisions, and some are recommended by health authorities for primary care use. As an increasing number of scores are becoming available, there is a need to understand general practitioner expectations for their use in primary care. The aim of this study was to explore general practitioner opinions about using scores in general practice. METHOD: This qualitative study, with a grounded theory approach, used focus groups with general practitioners recruited from their own surgeries to obtain verbatim. Two investigators performed verbatim analysis to ensure data triangulation. The verbatim was double-blind labeled for inductive categorization to conceptualize score use in general practice. RESULTS: Five focus groups were planned, 21 general practitioners from central France participated. Participants appreciated scores for their clinical efficacy but felt that they were difficult to use in primary care. Their opinions revolved around validity, acceptability, and feasibility. Participants have little regard for score validity, they felt many scores are difficult to accept and do not capture contextual and human elements. Participants also felt that scores are unfeasible for primary care use. There are too many, they are hard to find, and either too short or too long. They also felt that scores were complex to administer and took up time for both patient and physician. Many participants felt learned societies should choose appropriate scores. DISCUSSION: This study conceptualizes general practitioner opinions about score use in primary care. The participants weighed up score effectiveness with efficiency. For some participants, scores helped make decisions faster, others expressed being disappointed with the lack of patient-centeredness and limited bio-psycho-social approach.

Cross-analyzing addiction specialist and patient opinions and experiences about addictive disorder screening in primary care to identify interaction-related obstacles: a qualitative study.

BACKGROUND: Promptly identifying individuals with addictive disorders reduces mortality and morbidity and improves quality of life. Although screening in primary care with the Screening, Brief Intervention and Referral Treatment strategy has been recommended since 2008, it remains underutilized. This may be due to barriers including lack of time, patient reluctance or perhaps the timing and approach for discussing addiction with their patients. OBJECTIVE: This study aims to explore and cross-analyze patient and addiction specialist experiences and opinions about early addictive disorder screening in primary care to identify interaction-related screening obstacles. DESIGN AND PARTICIPANTS: Qualitative study with purposive maximum variation sampling among nine addiction specialists and eight individuals with addiction disorders conducted between April 2017 and November 2019 in Val-de-Loire, France. MAIN MEASURES: Using a grounded theory approach, verbatim data was collected from face-to-face interviews with addiction specialists and individuals with addiction disorders. These interviews explored their opinions and experiences with addiction screening in primary care. Initially, two independent investigators analyzed the coded verbatim according to the data triangulation principle. Secondly, convergences and divergences between addiction specialist and addict verbatim categories were identified, analyzed, and conceptualized. KEY RESULTS: Four main interaction-related obstacles to early addictive disorder screening in primary care were identified and conceptualized: the new concepts of shared self-censorship and the patient's personal red line, issues not addressed during consultations, and opposition between how physicians and patients would like to approach addictive disorder screening. CONCLUSIONS: To continue analysis of addictive disorder screening dynamics, further studies to examine the perspectives of all those involved in primary care are required. The information revealed from these studies will provide ideas to help patients and caregivers start discussing addiction and to help implement a collaborative team-based care approach. TRIAL REGISTRATION: This study is registered with the Commission Nationale de l'Informatique et des Libertés (CNIL) under No. 2017-093.

Impact of a phone call with a medical student/general practitioner team on morbidity of chronic patients during the first French COVID-19 lockdown (COVIQuest): a cluster randomised trial.

OBJECTIVES: The first COVID-19 lockdown led to a significantly reduced access to healthcare, which may have increased decompensations in frail patients with chronic diseases, especially older patients living with a chronic cardiovascular disease (CVD) or a mental health disorder (MHD). The objective of COVIQuest was to evaluate whether a general practitioner (GP)-initiated phone call to patients with CVD and MHD during the COVID-19 lockdown could reduce the number of hospitalisation(s) over a 1-month period. DESIGN: This is a cluster randomised controlled trial. Clusters were GPs from eight French regions. PARTICIPANTS: Patients ≥70 years old with chronic CVD (COVIQuest_CV subtrial) or ≥18 years old with MHD (COVIQuest_MH subtrial). INTERVENTIONS: A standardised GP-initiated phone call aiming to evaluate patients' need for urgent healthcare, with a control group benefiting from usual care (ie, the contact with the GP was by the patient's initiative). MAIN OUTCOME MEASURES: Hospital admission within 1 month after the phone call. RESULTS: In the COVIQuest_CV subtrial, 131 GPs and 1834 patients were included in the intervention group and 136 GPs and 1510 patients were allocated to the control group. Overall, 65 (3.54%) patients were hospitalised in the intervention group vs 69 (4.57%) in the control group (OR 0.82, 95% CI 0.56 to 1.20; risk difference -0.77, 95% CI -2.28 to 0.74). In the COVIQuest_MH subtrial, 136 GPs and 832 patients were included in the intervention group and 131 GPs and 548 patients were allocated to the control group. Overall, 27 (3.25%) patients were hospitalised in the intervention group vs 12 (2.19%) in the control group (OR 1.52, 95% CI 0.82 to 2.81; risk difference 1.38, 95% CI 0.06 to 2.70). CONCLUSION: A GP-initiated phone call may have been associated with more hospitalisations within 1 month for patients with MHD, but results lack robustness and significance depending on the statistical approach used. TRIAL REGISTRATION NUMBER: NCT04359875.

Integrating advanced practice nurses in ambulatory primary care: representations and expectations of general practitioners / Intégrer les infirmières en pratique avancée dans les soins premiers ambulatoires : représentations et attentes des médecins généralistes

Introduction: Advanced practice nursing has recently been introduced into the French health care system, eliciting a wide range of reactions from health care professionals. Many studies have focused on the benefits of advanced practice nursing (APN) and the steps to be taken to promote its implementation. Very few, however, have explored the feelings of general practitioners (GPs). The objective of this study was to explore the representations, feelings and expectations of GPs in a territorial professional health community (CPTS) with regard to the APN in ambulatory care. Method: A qualitative study with an approach inspired by grounded theory was conducted, based on individual or focus group semi-directive interviews with GPs of a CPTS. Results: 12 GPs were interviewed. The axial analysis allowed the construction and characterisation of two categories: "Being two" and "Defining the job". Discussion: The properties located at the intersection of these two categories related in particular to the question of "medical power".

Introduction: La pratique avancée infirmière a été récemment introduite dans le système de soins français, suscitant des réactions très variées des professionnels du soin. Beaucoup de travaux se sont intéressés aux bénéfices de l'infirmière en pratique avancée (IPA), aux étapes à suivre pour favoriser son implantation. Très peu, en revanche, ont exploré le ressenti des médecins généralistes (MG). L'objectif de ce travail était d'explorer les représentations, ressentis et attentes des MG d'une communauté professionnelle territoriale de santé (CPTS) vis-à-vis de la pratique avancée infirmière. Méthode: Une étude qualitative avec une approche inspirée de la théorisation ancrée a été conduite, à partir d'entretiens semi-directifs, individuels ou en focus groups, auprès des MG d'une CPTS. Résultats: 12 MG ont été interrogés. L'analyse axiale a permis de construire et caractériser deux catégories : « Être deux ¼ et « Définir le métier ¼. Discussion: Les propriétés situées à l'intersection de ces deux catégories avaient notamment trait à la question du « pouvoir médical ¼.

Impulsivity as a Risk Factor for Addictive Disorder Severity during the COVID-19 Lockdown: Results from a Mixed Quantitative and Qualitative Study.

Interindividual differences in personality traits, especially impulsivity traits, are robust risk factors for addictive disorders. However, their impact on addictive disorders during the COVID-19 lockdown remains unknown. This study assessed patients being followed for addictive disorders before the lockdown. We aimed to determine whether impulsivity traits (i.e., negative- and positive urgency) were associated with addictive disorders severity during the lockdowns. We also explored the patients' subjective experiences, focusing on high versus low impulsivity. The quantitative study assessed 44 outpatients consulting for addictive disorders, for impulsivity, emotion regulation, anxiety/depression, and their addictive disorder characteristics, using self-administered questionnaires. In the qualitative study, six patients from the quantitative study were assessed using guided interviews. We observed that higher negative and positive urgencies were associated with addictive disorder severity. The subjective experiences of patients during the lockdowns differed according to their emotion-related impulsivity: high versus low. Low impulsive patients used online technologies more effectively to maintain follow-up, with more positive reappraisal. In contrast, highly impulsive patients reverted more frequently to self-medication with substances and/or behaviors, more social isolation, and found coping with negative emotions more challenging. Overall, the patient's ability to cope with stressful events, like the COVID-19 lockdown, depended on their emotion-related impulsivity.

A Publication Rate Comparison of Oral Communications Presented at the 2010 and 2015 French General Practice Congresses and European General Practice Network Meetings.

BACKGROUND AND OBJECTIVES: We sought to assess and compare the publication rates of research presented at two French general practice congresses (Collège National des Généralistes Enseignants (CNGE, National College of General Practice Teachers) and Congrès de la Médecine Générale de France (CMGF [French General Practice Congress]) and the European General Practice Research Network (EGPRN) meetings held in 2010 and 2015. METHODS: We included all oral presentations from the 2010 and 2015 CNGE, CMGF and EGPRN meetings. We searched subsequent publications up to December 2018. We collected study themes, study designs, author qualifications, and journals for all published presentations. RESULTS: Overall, we included 701 oral presentations; 33% of the 2010 presentations, and 30% of the 2015 presentations were subsequently published (P=.40). For both years, the overall publication rate was higher for presentations from the EGPRN meetings compared with the French meetings (55.6% vs 27.1%; P<.05). Published articles mostly concerned clinical research and quantitative methods from academic authors. Seventeen percent of articles from the EGPRN meetings were published by BMC Family Practice and the European Journal of General Practice, whereas 32% of articles from the French meetings were published by Exercer, the French Journal of General Practice. CONCLUSIONS: More than half of the presentations at the 2010 and 2015 EGRPN meetings were published, whereas the publication rate from the French meetings remained under 30%. Further efforts are needed to increase the publication rate of general practice studies in peer-reviewed international journals.

Patients' adherence to optimal therapeutic, lifestyle and risk factors recommendations after myocardial infarction: Six years follow-up in primary care.

BACKGROUND: The 20% observed mortality within 5 years among survivors of myocardial infarction may be explained in part by non-adherence to the recommended treatment over the long term. MAIN OBJECTIVE: To investigate post-myocardial infarction patients' adherence to the therapeutic, lifestyle and risk factor control recommendations of the French health authority over 6 years. MATERIALS AND METHODS: A cohort of survivors of myocardial infarction established in Tours in 2009 was followed over 6 years. The general practitioner of the patients included in the first 1-year follow-up study was contacted to collect data on treatments, cardiovascular risk factors and lifestyle between January and June 2015. Data were described and compared with the recommendations and predictors of achieving all the recommended targets were determined. RESULTS: A total of 97 patients (52%) among the 185 patients who underwent a coronary angioplasty for MI were included at baseline. Treatment was adapted by the general practitioner on the advice on the cardiologist for 75% (73/97) patients, by both of them for 12% (12/97) and by the general practitioner alone for 7% (7/97) patients. Among the 97 initial patients, 62 were included in the final analysis at 6 years. Fatal events rate was 5% (5/97) at 1 year and 12% (11/91) at 6 years. Non-fatal events rate was 44% (43/97) at 6 months, 19% (17/91) at 1 year and 29% (18/62) at 6 years. Six years after the myocardial infarction, 6 (10%) patients achieved the recommended targets in terms of prescriptions of treatment, risk factors and lifestyle targets. Exposure to a cardiac rehabilitation program after a myocardial infarction was associated with long-term achievement of optimal therapeutic objectives (OR = 7.31 [95% CI 1.74; 44.88], p<0.002). CONCLUSION: Our data show suboptimal long-term adherence to secondary prevention treatment in this high-risk population of survivors of myocardial infarction, which seems to be improved in patients exposed to a cardiac rehabilitation program.

Consensus study to define appropriate inaction and inappropriate inertia in the management of patients with hypertension in primary care.

OBJECTIVES: To elaborate and validate operational definitions for appropriate inaction and for inappropriate inertia in the management of patients with hypertension in primary care. DESIGN: A two-step approach was used to reach a definition consensus. First, nominal groups provided practice-based information on the two concepts. Second, a Delphi procedure was used to modify and validate the two definitions created from the nominal groups results. PARTICIPANTS: 14 French practicing general practitioners participated in each of the two nominal groups, held in two different areas in France. For the Delphi procedure, 30 academics, international experts in the field, were contacted; 20 agreed to participate and 19 completed the procedure. RESULTS: Inappropriate inertia was defined as: to not initiate or intensify an antihypertensive treatment for a patient who is not at the blood pressure goals defined for this patient in the guidelines when all following conditions are fulfilled: (1) elevated blood pressure has been confirmed by self-measurement or ambulatory blood pressure monitoring, (2) there is no legitimate doubt on the reliability of the measurements, (3) there is no observance issue regarding pharmacological treatment, (4) there is no specific iatrogenic risk (which alters the risk-benefit balance of treatment for this patient), in particular orthostatic hypotension in the elderly, (5) there is no other medical priority more important and more urgent, and (6) access to treatment is not difficult. Appropriate inaction was defined as the exact mirror, that is, when at least one of the above conditions is not met. CONCLUSION: Definitions of appropriate inaction and inappropriate inertia in the management of patients with hypertension have been established from empirical practice-based data and validated by an international panel of academics as useful for practice and research.

General practitioners' justifications for therapeutic inertia in cardiovascular prevention: an empirically grounded typology.

OBJECTIVE: To construct a typology of general practitioners' (GPs) responses regarding their justification of therapeutic inertia in cardiovascular primary prevention for high-risk patients with hypertension. DESIGN: Empirically grounded construction of typology. Types were defined by attributes derived from the qualitative analysis of GPs' reported reasons for inaction. PARTICIPANTS: 256 GPs randomised in the intervention group of a cluster randomised controlled trial. SETTING: GPs members of 23 French Regional Colleges of Teachers in General Practice, included in the EffectS of a multifaceted intervention on CArdiovascular risk factors in high-risk hyPErtensive patients (ESCAPE) trial. DATA COLLECTION AND ANALYSIS: The database consisted of 2638 written responses given by the GPs to an open-ended question asking for the reasons why drug treatment was not changed as suggested by the national guidelines. All answers were coded using constant comparison analysis. A matrix analysis of codes per GP allowed the construction of a response typology, where types were defined by codes as attributes. Initial coding and definition of types were performed independently by two teams. RESULTS: Initial coding resulted in a list of 69 codes in the final codebook, representing 4764 coded references in the question responses. A typology including seven types was constructed. 100 GPs were allocated to one and only one of these types, while 25 GPs did not provide enough data to allow classification. Types (numbers of GPs allocated) were: 'optimists' (28), 'negotiators' (20), 'checkers' (15), 'contextualisers' (13), 'cautious' (11), 'rounders' (8) and 'scientists' (5). For the 36 GPs that provided 50 or more coded references, analysis of the code evolution over time and across patients showed a consistent belonging to the initial type for any given GP. CONCLUSION: This typology could provide GPs with some insight into their general ways of considering changes in the treatment/management of cardiovascular risk factors and guide design of specific physician-centred interventions to reduce inappropriate inaction. TRIAL REGISTRATION NUMBER: NCT00348855.

ESCAPE ancillary blood pressure measurement study 2: changes in end-digit preference after 2 years of a cluster randomized trial.

OBJECTIVE: The aim of the ESCAPE AMPA 2 trial was to describe the evolution of end-digit preference (EDP) practices in primary care after 2 years of trial. METHODS: A descriptive analysis of the EDP in the intervention group (IG) and in the electronic control group (ECG) of the ESCAPE trial and a comparative analysis of EDP changes in blood pressure (BP) measures of both groups were carried out between baseline and 2 years. In the ESCAPE trial, physicians in the IG were new users of electronic devices provided in the trial to measure their patients' BP and physicians in the ECG were former users of electronic devices. Hierarchical mixed-effects models were used for statistical analysis in a pragmatic cluster randomized-controlled trial. RESULTS: After 2 years, the proportion of BP measures ending with a 0 or a 5 was significantly higher in the ECG than in the IG (50.4 vs. 33.4%, P<0.0001). There was no significant change in EDP tendency between baseline and the end of the trial in the ECG (65.6-56.7%, P=0.39) and in the IG (29.6-38.2%, P=0.07), with a between-groups P value of 0.11. Over 2 years, there was no significant change in systematic EDP in the ECG (18.8-20.0%, P=0.29) and in the IG (4.8-10.6%, P=0.01), with a between-groups P value of 0.17. CONCLUSION: EDP is not eliminated by electronic devices and tends to increase with time for new users.

How do GP practices and patient characteristics influence the prescription of antidepressants? A cross-sectional study.

BACKGROUND: Under-prescription of antidepressants (ADs) among people meeting the criteria for major depressive episodes and excessive prescription in less symptomatic patients have been reported. The reasons influencing general practitioners' (GPs) prescription of ADs remain little explored. This study aimed at assessing the influence of GP and patient characteristics on AD prescription. METHODS: This cross-sectional study was based on a sample of 816 GPs working within the main health care insurance system in the Seine-Maritime district of France during 2010. Only GPs meeting the criteria for full-time GP practice were included. The ratio of AD prescription to overall prescription volume, a relative measure of AD prescription level, was calculated for each GP, using the defined daily dose (DDD) concept. Associations of this AD prescription ratio with GPs' age, gender, practice location, number of years of practice, number of days of sickness certificates prescribed, number of home visits and consultations, number and mean age of registered patients, mean patient income, and number of patients with a chronic condition were assessed using univariate and multivariate analysis. RESULTS: The high prescribers were middle-aged (40-59) urban GPs, with a moderate number of consultations and fewer low-income and chronic patients. GPs' workload (e.g., volume of prescribed drug reimbursement and number of consultations) had no influence on the AD prescription ratio. GPs with more patients with risk factors for depression prescribed fewer ADs, however, which could suggest the medications were under-prescribed among the at-risk population. CONCLUSIONS: Our study described a profile of the typical higher AD prescriber that did not include heavy workload. In future work, a more detailed assessment of all biopsychosocial components of the consultation and other influences on GP behavior such as prior training would be useful to explain AD prescription in GP's practice.

Patient education in chronic heart failure in primary care (ETIC) and its impact on patient quality of life: design of a cluster randomised trial.

BACKGROUND: Chronic heart failure, is increasing due to the aging population and improvements in heart disease detection and management. The prevalence is estimated at ~10% of the French general practice patient population over 59 years old. The primary objective of this study is to improve the quality of life for heart failure patients though a complex intervention involving patient and general practitioner (GP) education in primary care. METHODS: A randomised, cluster controlled trial, stratified over 4 areas of the Auvergne region in France comparing intervention and control groups. The inclusion criteria are: patients older than 50 years with New York Heart Association (NYHA) stage I, II, or III heart failure, with reduced ejection fraction or with preserved ejection fraction. Heart failure should be confirmed by the patient's cardiologist according to the European Society of Cardiology guidelines criteria. The exclusion criteria include: severe cognitive disorders, living in an institution, participating in another clinical trial, having NYHA stage IV heart failure, or a lack of French language skills. The complex intervention consists of training at the GP practice with an interactive 2-day workshop to provide a patient's education programme. GPs are trained to perform case management, lifestyle counselling and motivational interviewing, to educate patients on the main topics including clinical alarm signs, physical activity, diet and cardiovascular risk factors. The patients' education sessions are scheduled at 1, 4, 7, 10, 13 and 19 months following the start of the trial. The primary outcome to be assessed is the impact on the quality of life as determined using two questionnaires: the Minnesota Living with Heart Failure Questionnaire and SF-36. To detect a difference in the mean quality of life at 19 months, we anticipate studying a minimum of 400 patients from 80 GPs. DISCUSSION: This trial will provide insight into the effectiveness of a complex intervention to educate patients with heart failure including a 2-day GP workshop and patients' education programme in the setting of a GP consultation to improve the quality of life in patients with chronic heart failure. This complex intervention tool could be used during initial and further medical training. TRIAL REGISTRATION: ETIC is a cluster-randomised, controlled trial registered on ClinicalTrials.gov [ NCT01065142 , 2010, Feb 8] and the French drug agency [Agence Nationale de Sécurité du Médicament et des produits de santé; registration number: 2009-A01142-55, on March 5th, 2010].

Why do general practitioners prescribe antidepressants to their patients? A pilot study.

BACKGROUND: The frequency of antidepressant (ADs) prescription is high, with general practitioners (GPs) responsible for about 80% of the prescriptions. Some studies considered prescriptions meet DSM criteria, while others stress inadequate use. The importance of biological and psychosocial determinants of GP prescription behaviour remains little explored. We aimed to describe the importance of these biological and psychosocial determinants and their weight in the daily practice of GPs'. METHODS: During a week chosen at random, 28 GPs collected the AD prescriptions made within the previous six months, regardless of the reason for the patient contact. Bio psychosocial and AD treatment characteristics were recorded for all patients. In a random sample of 50 patients, patient characteristics were assessed via a structured face-to-face interview with the GP. RESULTS: The frequency of AD prescription was 8.90% [3.94 -17.02]. The GPs initiated 65.6% [60.1-70.8] of the prescriptions. The rate of AD prescription for non-psychiatric conditions was 18%. Patients had from 1 to 9 conditions, showing a high level of multi-morbidity. There was a strong influence of past medical history and contextual problems, such as work related problems. CONCLUSION: AD prescription is related to complex contextual situations and multi-morbid patients. GPs use a bio psycho social approach, rather than a purely biological assessment. Awareness of these influences could improve prescription by GPs.

The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review.

BACKGROUND: Therapeutic inertia has been defined as the failure of health-care provider to initiate or intensify therapy when therapeutic goals are not reached. It is regarded as a major cause of uncontrolled hypertension. The exploration of its causes and the interventions to reduce it are plagued by unclear conceptualizations and hypothesized mechanisms. We therefore systematically searched the literature for definitions and discussions on the concept of therapeutic inertia in hypertension in primary care, to try and form an operational definition. METHODS: A systematic review of all types of publications related to clinical inertia in hypertension was performed. Medline, EMbase, PsycInfo, the Cochrane library and databases, BDSP, CRD and NGC were searched from the start of their databases to June 2013. Articles were selected independently by two authors on the basis of their conceptual content, without other eligibility criteria or formal quality appraisal. Qualitative data were extracted independently by two teams of authors. Data were analyzed using a constant comparative qualitative method. RESULTS: The final selection included 89 articles. 112 codes were grouped in 4 categories: terms and definitions (semantics), "who" (physician, patient or system), "how and why" (mechanisms and reasons), and "appropriateness". Regarding each of these categories, a number of contradictory assertions were found, most of them relying on little or no empirical data. Overall, the limits of what should be considered as inertia were not clear. A number of authors insisted that what was considered deleterious inertia might in fact be appropriate care, depending on the situation. CONCLUSIONS: Our data analysis revealed a major lack of conceptualization of therapeutic inertia in hypertension and important discrepancies regarding its possible causes, mechanisms and outcomes. The concept should be split in two parts: appropriate inaction and inappropriate inertia. The development of consensual and operational definitions relying on empirical data and the exploration of the intimate mechanisms that underlie these behaviors are now needed.

Patient and professional attitudes towards research in general practice: the RepR qualitative study.

BACKGROUND: Since the 1990s, professional institutions worldwide have emphasised the need to develop research in general practice to improve the health of the population. The recent creation of professorships in general practice in French Universities should foster research in this field. Our aim was to explore the views of patients and relevant professionals on research in general practice. METHODS: Qualitative study, using the grounded theory approach according to Strauss and Corbin, conducted in 2010 in three French regions. Nine focus groups were run to data saturation, and included 57 participants in four different categories: patients, non-academic GPs, academic GPs, academics in other disciplines. RESULTS: Most of the participants in the four categories described research in general practice as specific to the population managed and relevant for health care. They considered that its grounding in day-to-day practice enabled pragmatic approaches. The influence of the pharmaceutical industry, rivalries between university disciplines and a possible gap between research and practice were considered as pitfalls. The barriers identified were representations of the medical researcher as a "laboratory worker", the lack of awareness of any research in the discipline, and lack of time and training. While the views of patients and non-academic GPs are mostly focused on professional issues and the views of academics other than GPs on technical issues, academic GPs are in a position to play a role of interface between the universities and general practices. CONCLUSIONS: Although the role of GPs in research is perceived differently by the various protagonists, research in general practice has an undisputed legitimacy in France. Solutions for overcoming the identified barriers include research networks with appropriate resources and training and scientifically sound collaborative research projects, as already implemented in leading countries.