Can physicians and schools mitigate social inequalities in human papillomavirus vaccine awareness, uptake and vaccination intention among adolescents? A cross-sectional study, France, 2021 to 2022.

BackgroundIn France, human papillomavirus (HPV) vaccination coverage varies across socioeconomic levels.AimWe aimed at assessing HPV vaccine awareness, uptake and vaccination intention among adolescents in France.MethodsIn a cluster-randomised study, 13-15-year-old students in 61 French middle schools completed a web-based questionnaire. We used multivariable logistic regression to evaluate determinants of HPV vaccine awareness, self-reported uptake and vaccination intention among unvaccinated students and interaction terms to explore effects of visits to family physician and remembering school lessons on vaccination. The French deprivation index of school municipalities served as proxy for socioeconomic levels.ResultsAmong 6,992 participants, awareness was significantly associated with parental education (odds ratio (OR) = 0.82; 95% confidence interval (CI): 0.71-0.95), language spoken at home (OR = 0.59; 95% CI: 0.52-0.66) and deprivation level (OR = 0.57; 95% CI: 0.44-0.71), regardless of physician visit or school lessons. Vaccine uptake was associated with parental education without a recent physician visit (OR = 0.31; 95% CI: 0.16-0.59, vs OR = 0.64; 95% CI: 0.52-0.78 with a visit, interaction p = 0.045). Vaccination intention among unvaccinated was associated with deprivation level (moderate-low vs low) among students not remembering school lessons on vaccination (OR = 0.17; 95% CI: 0.05-0.62, vs OR = 0.93; 95% CI: 0.51-1.67 remembering school lessons, interaction p = 0.022). Parental education was associated with vaccination intention among students reporting a physician visit (OR = 0.41; 95% CI: 0.26-0.64 vs OR = 1.05; 95% CI: 0.50-2.20 without a visit, interaction p = 0.034).ConclusionOur results suggest that healthcare and school could promote vaccination and mitigate social inequalities in HPV vaccination coverage.

Preventing autonomy loss with multicomponent geriatric interventions: A resource-saving strategy? Evidence from the SPRINT-T study.

Background: The objective of healthy aging strategies is to support interventions targeting autonomy loss prevention, with the assumption that these interventions are likely to be efficient by simultaneously improving clinical outcomes and saving costs. Methods: We compare the economic impact of two interventions targeting frailty prevention in older European populations: a multicomponent intervention including physical activity monitoring, nutrition management, information and communications technology use and a relatively simple healthy aging lifestyle education program based on a series of workshops. Our sample includes 1,519 male and female participants from 11 European countries aged 70 years or older. Our econometric model explores trends in several outcomes depending on intervention receipt and frailty status at baseline. Results: Implementing a multicomponent intervention among frail older people does not lead to a lower use of care and do not prevent quality of life losses associated with aging. However, it impacts older people's sense of priorities and interest in the future. We find no statistically significant differences between the two interventions, suggesting that the implementation of a multicomponent intervention may not be the most efficient strategy. The impact of the interventions does not differ by frailty status at baseline. Conclusions: Our results show the need to implement healthy aging strategies that are more focused on people's interests.

[Analyzing and comparing healthy aging in France and OECD countries based on a new physiological age measure]. / Le bien-vieillir en France et dans les pays de l'OCDE - Une analyse à partir d'une nouvelle mesure d'âge physiologique.

We introduce a new individual measure of healthy aging on a sample of more than 39,000 individuals and compare the results for France with 11 other European countries and the United States. Our healthy aging measure is based on the discrepancy between the calendar age of populations with their estimated physiological age, which corresponds to a measure of age adjusted for the effects of comorbidities and functional health. France is ranked in the lower middle of our healthy aging scale, with the Nordic countries (Denmark, Sweden, Netherlands), Switzerland and Greece being ahead. Economic capital has a strong impact on the estimated physiological age and on healthy aging trajectories. Socioeconomic inequalities are particularly marked in France as well as in Italy and the United States. The generosity of long-term care policies seems to be positively associated with the level of healthy aging of the populations. More work is required to identify the drivers of healthy aging among individuals living in OECD countries.

Title: Le bien-vieillir en France et dans les pays de l'OCDE - Une analyse à partir d'une nouvelle mesure d'âge physiologique. Abstract: Dans cette synthèse, nous relatons les résultats d'une étude utilisant une nouvelle mesure individuelle du bien-vieillir. À partir d'un échantillon de plus de 39 000 individus, nous avons comparé les résultats de la France avec ceux observés dans 11 autres pays européens et aux États-Unis. Le bien-vieillir a été estimé en comparant l'âge calendaire des populations et leur âge physiologique, qui correspond à une mesure de l'âge ajustée des effets liés à la présence de comorbidités et à la santé fonctionnelle. Sur notre échelle de bien-vieillir, la France se situe dans le milieu bas du classement des pays. Elle est devancée par les pays nordiques (Danemark, Suède, Pays-Bas), la Suisse et la Grèce. Le capital économique a un fort impact sur l'âge physiologique estimé et sur les trajectoires de bien-vieillir. Les inégalités socio-économiques sont particulièrement marquées en France, comme en Italie et aux États-Unis.

What motivates adults to accept influenza vaccine? An assessment of incentives, ease of access, messaging, and sources of information using a discrete choice experiment.

Seasonal influenza vaccination rates remain low, and contribute to preventable influenza cases, hospitalizations, and deaths in the US. While numerous interventions have been implemented to increase vaccine uptake, there is a need to determine which interventions contribute most to vaccine willingness, particularly among age groups with vaccination rates that have plateaued at suboptimal levels. This study aimed to quantify the relative effect of multiple interventions on vaccine willingness to receive influenza vaccine in three age groups using a series of hypothetical situations with different behavioral interventions. We assessed the relative impact of four categories of interventions: source of vaccine messages, type of vaccination messages, vaccination incentives, and ease of vaccine access using a discrete choice experiment. Within each category, we investigated the role of four different attributes to measure their relative contribution to willingness to be vaccinated by removing one option from each of the intervention categories. Among the 1,763 Minnesota residents who volunteered for our study, participants expressed vaccine willingness in over 80% of the scenarios presented. Easy access to drop-in vaccination sites had the greatest impact on vaccine willingness in all age groups. Among the younger age group, small financial incentives also contributed to high vaccine willingness. Our results suggest that public health programs and vaccination campaigns may improve their chances of successfully increasing vaccine willingness if they offer interventions preferred by adults, including facilitating convenient access to vaccination and offering small monetary incentives, particularly for young adults.

Where Are Populations Aging Better? A Global Comparison of Healthy Aging Across Organization for Economic Cooperation and Development Countries.

OBJECTIVES: Global comparisons and large samples are needed to inform policy makers about aging trends among people aged older than 60 years. Using harmonized data gathered from the Gateway to Global Aging data, we introduce a new framework to measure healthy aging across 13 OECD countries. METHODS: First, we developed an original measure of physiological age (PA), that is, a measure of age weighted for the influence of frailty, activities of daily living limitations, and comorbidities. Second, we compared healthy aging measures across 13 countries based on a ranking of the countries according to the discrepancy between estimated PA and chronological age (CA). Third, we explored the socioeconomic factors associated with healthy aging. RESULTS: We found a strong correlation between our PA measure and biological age. Italy, Israel, and the United States are the 3 countries where PA is the highest (independent of CA), thus indicating aging in poor health. In contrast, Switzerland, The Netherlands, Greece, Sweden, and Denmark have much lower PA than CA, thus indicating healthy aging. Finally, the PA-CA discrepancy is higher among poorer, less educated, and single older individuals. CONCLUSIONS: Countries with higher PA need to implement or reinforce healthy aging measures and target the disadvantaged populations.

Study protocol comparing the ethical, psychological and socio-economic impact of personalised breast cancer screening to that of standard screening in the "My Personal Breast Screening" (MyPeBS) randomised clinical trial.

BACKGROUND: The MyPeBS study is an ongoing randomised controlled trial testing whether a risk-stratified breast cancer screening strategy is non-inferior, or eventually superior, to standard age-based screening at reducing incidence of stage 2 or more cancers. This large European Commission-funded initiative aims to include 85,000 women aged 40 to 70 years, without prior breast cancer and not previously identified at high risk in six countries (Belgium, France, Italy, Israel, Spain, UK). A specific work package within MyPeBS examines psychological, socio-economic and ethical aspects of this new screening strategy. It compares women's reported data and outcomes in both trial arms on the following issues: general anxiety, cancer-related worry, understanding of breast cancer screening strategy and information-seeking behaviour, socio-demographic and economic characteristics, quality of life, risk perception, intention to change health-related behaviours, satisfaction with the trial. METHODS: At inclusion, 3-months, 1-year and 4-years, each woman participating in MyPeBS is asked to fill online questionnaires. Descriptive statistics, bivariate analyses, subgroup comparisons and analysis of variations over time will be performed with appropriate tests to assess differences between arms. Multivariate regression models will allow modelling of different patient reported data and outcomes such as comprehension of the information provided, general anxiety or cancer worry, and information seeking behaviour. In addition, a qualitative study (48 semi-structured interviews conducted in France and in the UK with women randomised in the risk-stratified arm), will help further understand participants' acceptability and comprehension of the trial, and their experience of risk assessment. DISCUSSION: Beyond the scientific and medical objectives of this clinical study, it is critical to acknowledge the consequences of such a paradigm shift for women. Indeed, introducing a risk-based screening relying on individual biological differences also implies addressing non-biological differences (e.g. social status or health literacy) from an ethical perspective, to ensure equal access to healthcare. The results of the present study will facilitate making recommendations on implementation at the end of the trial to accompany any potential change in screening strategy. TRIAL REGISTRATION: Study sponsor: UNICANCER. My personalised breast screening (MyPeBS). CLINICALTRIALS: gov (2018) available at: https://clinicaltrials.gov/ct2/show/NCT03672331 Contact: Cécile VISSAC SABATIER, PhD, + 33 (0)1 73 79 77 58 ext + 330,142,114,293, contact@mypebs.eu.

Frailty transitions and health care use in Europe.

OBJECTIVE: There is relative consensus that chronic conditions, disability, and time-to-death are key drivers of age-related health care expenditures. In this paper, we analyze the specific impact of frailty transitions on a wide range of health care outcomes comprising hospital, ambulatory care, and dental care use. DATA SOURCE: Five regular waves of the SHARE survey collected between 2004 and 2015. STUDY DESIGN: We estimate dynamic panel data models on the balanced panel (N = 6078; NT = 30 390 observations). Our models account for various sources of selection into frailty, that is, observed and unobserved time-varying and time-invariant characteristics. PRINCIPAL FINDINGS: We confirm previous evidence showing that frailty transitions have a statistically significant and positive impact on hospital use. We find new evidence on ambulatory and dental care use. Becoming frail has greater impact on specialist compared to GP visit, and frail elderly are less likely to access dental care. CONCLUSIONS: By preventing transitions toward frailty, policy planners could prevent hospital and ambulatory care uses. Further research is needed to investigate the relationship between frailty and dental care by controlling for reverse causation.

For better or worse? Investigating the validity of best-worst discrete choice experiments in health.

Discrete choice experiments (DCEs) are frequently used in health economics to measure preferences for nonmarket goods. Best-worst discrete choice experiment (BWDCE) has been proposed as a variant of the traditional "pick the best" approach. BWDCE, where participants choose the best and worst options, is argued to generate more precise preference estimates because of the additional information collected. However, the validity of the approach relies on two necessary conditions: (a) best and worst decisions provide similar information about preferences and (b) asking individuals to answer more than one choice question per task does not reduce data quality. Whether these conditions hold in empirical applications remains under researched. This is the first study to compare participants' choices across three experimental conditions: (a) BEST choices only, (b) WORST choices only, and (c) BEST and WORST choices (BWDCE). We find responses to worst choices are noisier. Implied preferences from the best only and worst only choices are qualitatively different, leading to different WTP values. Responses to BWDCE tasks have lower consistency, and respondents are more likely to use simplifying decision heuristics. We urge caution in using BWDCE as an alternative to the traditional "pick the best" DCE.

Drugs for Dementia and Excess of Hospitalization: A Longitudinal French Study.

BACKGROUND: The impact of adverse effects of drugs for dementia on the risk of hospitalization has not been much studied despite the impact of hospitalizations on cognitive decline. OBJECTIVE: To determine if the main adverse effects of cholinesterase inhibitors and memantine may be associated with excess of hospitalization and to quantify the subsequent impact on healthcare expenditures. METHODS: A representative sample of the French national health insurance beneficiaries aged 65 and older and suffering from dementia were included and followed from 2007 to 2014. Binary logit models for longitudinal data (GEE estimation technique) were used to estimate the excess of hospitalization events related to the adverse effects of anti-dementia drugs and then to derive the additional costs of hospitalizations for the public health insurance fund. RESULTS: In total, 7,668 patients were followed, generating 111,133 individual observations over the 8-year period. Treated patients were hospitalized significantly more than non-treated patients (adjusted Odd Ratio (OR) = 1.08, 95% confidence interval (95% CI) = [1.02 to 1.13], p = 0.004), mainly with cholinesterase inhibitors for cardiac (OR = 1.21, 95% CI = [1.01 to 1.46], p = 0.034) and gastrointestinal events (OR = 1.43, 95% CI = [1.01-2.05], p = 0.045), especially with rivastigmine. When extrapolated to the entire population, this corresponded to an annual additional cost of € 55,000. CONCLUSION: Prescription of antidementia drugs, more specifically rivastigmine, increases the risk of hospitalizations via their cardiac and gastrointestinal adverse effects and lead to additional health care expenditures. Even though these results must be confirmed, they may encourage cautious consideration of the balance between benefits and harms before a prescription is given.

Women's Benefits and Harms Trade-Offs in Breast Cancer Screening: Results from a Discrete-Choice Experiment.

BACKGROUND: Over the past decade, the benefits and harms balance of breast cancer (BC) screening has been widely debated. OBJECTIVES: To elicit women's trade-offs between the benefits and harms of BC screening and to analyze the main determinants of these trade-offs. METHODS: A discrete-choice experiment with seven attributes depicting BC screening programs including varying levels of BC mortality, overdiagnosis, and false-positive result was used. Eight hundred twelve women aged 40 to 74 years with no personal history of BC recruited by a survey institute and representative of the French general population (age, socioeconomic level, and geographical location) completed the discrete-choice experiment. Preference heterogeneity was investigated using generalized multinomial logit models from which individual trade-offs were derived, and their main determinants were assessed using generalized linear models. Screening acceptance rates under various benefits and harms ratios were simulated on the basis of the distribution of individual preferences. RESULTS: The women would be willing to accept on average 14.1 overdiagnosis cases (median = 9.6) and 47.8 false-positive results (median = 27.2) to avoid one BC-related death. After accounting for preference heterogeneity, less than 50% of women would be willing to accept 10 overdiagnosis cases for one BC-related death avoided. Screening acceptance rates were higher among women with higher socioeconomic level and lower among women with poor health. CONCLUSIONS: Women are sensitive to both the benefits and the harms of BC screening and their preferences are highly heterogeneous. Our study provides useful results for public health authorities and clinicians willing to improve their recommendations of BC screening on the basis of women's preferences.

Trends in Drug Prescription Rates for Dementia: An Observational Population-Based Study in France, 2006-2014.

BACKGROUND: Since the 2011 French guidance updates, cholinesterase inhibitors and memantine are considered optional in the management of dementia and leave physicians free to prescribe based on their clinical expertise. OBJECTIVES: The aims of this study were to analyze the influence of these recent guidance updates on the prescription rates of these drugs and to quantify the impact of potential changes on healthcare expenditures. METHODS: Patients over 65 years old from a representative sample of a national administrative claims database, the French national health insurance database, were retrospectively included from 2006 to 2014. Trends of annual prescription rates were tested using adjusted segmented regression analysis. Drug costs with and without prescribers' behavioral changes were estimated. RESULTS: A total of 119,731 individuals were included and followed during the study period. Among them, 5514 individuals were treated for dementia. According to the unadjusted segmented regression model, there was a significant increase in prescription rates between 2006 and 2010, from 2.23% (95% confidence interval 2.13-2.34) to 2.73% (95% confidence interval 2.62-2.84) of the study population. Since 2011, the trend has reversed with a significant decrease until 2014, from 2.64% (95% confidence interval 2.54-2.75) to 1.92% (95% confidence interval 1.84-2.01). In the multivariate analysis, we also found a gradual decline since 2011, particularly for patients aged 65-69 years and with one or more other chronic diseases. Cost savings associated with prescribers' behavioral changes were estimated at €108 million. CONCLUSION: Drugs prescribed for dementia are on a declining trend with important cost savings, and this was concomitant with guidance updates that left physicians to rely on their clinical expertise while managing dementia.

Impact assessment of a pay-for-performance program on breast cancer screening in France using micro data.

BACKGROUND: A voluntary-based pay-for-performance (P4P) program (the CAPI) aimed at general practitioners (GPs) was implemented in France in 2009. The program targeted prevention practices, including breast cancer screening, by offering a maximal amount of €245 for achieving a target screening rate among eligible women enrolled with the GP. OBJECTIVE: Our objective was to evaluate the impact of the French P4P program (CAPI) on the early detection of breast cancer among women between 50 and 74 years old. METHODS: Based on an administrative database of 50,752 women aged 50-74 years followed between 2007 and 2011, we estimated a difference-in-difference model of breast cancer screening uptake as a function of visit to a CAPI signatory referral GP, while controlling for both supply-side and demand-side determinants (e.g., sociodemographics, health and healthcare use). RESULTS: Breast cancer screening rates have not changed significantly since the P4P program implementation. Overall, visiting a CAPI signatory referral GP at least once in the pre-CAPI period increased the probability of undergoing breast cancer screening by 1.38 % [95 % CI (0.41-2.35 %)], but the effect was not significantly different following the implementation of the contract. CONCLUSION: The French P4P program had a nonsignificant impact on breast cancer screening uptake. This result may reflect the fact that the low-powered incentives implemented in France through the CAPI might not provide sufficient leverage to generate better practices, thus inviting regulators to seek additional tools beyond P4P in the field of prevention and screening.

Impact of a primary care national policy on HIV screening in France: a longitudinal analysis between 2006 and 2013.

BACKGROUND: Early diagnosis of HIV infection is a major public health issue worldwide. In 2009, the French National Authority for Health (Haute Autorité de Santé) developed specific guidelines and recommended mass screening of 15-70-year-olds across the general population. The guidelines were supported by communication directed at healthcare professionals, especially GPs. AIM: To assess the impact of the national mass screening policy on HIV testing. DESIGN AND SETTING: The study used data from the French National Health Insurance Fund database, from January 2006 to December 2013. Males and females aged 15-70 years, excluding HIV-positive individuals and pregnant females, were followed up throughout the 2006-2013 period. During the study period, 2 176 657 person-years and a total of 329 748 different individuals were followed up. METHOD: Standardised and non-standardised rates of HIV screening were calculated for each year; the impact of the policy was assessed using adjusted segmented regression analyses. RESULTS: Overall, annual HIV screening rates increased over the study period, from 4.2% (95% confidence interval [CI] = 4.2 to 4.3) in 2006 to 5.8% (95% CI = 5.7 to 5.9) in 2013 with a more pronounced trend after 2010 (P<0.0001). This increase was more significant for those who regularly consulted a GP. For these individuals, the policy led to a 20.4% increase (95% CI = 17.0 to 23.8) in HIV screening in 2013 compared with only a 4.5% increase (95% CI = 4.4 to 4.5) for those who did not consult a GP regularly in 2013. CONCLUSION: The results show that the mass screening policy coordinated by GPs had a significant impact on HIV testing in France, which could result in positive impacts on public and individual health outcomes.

What are GPs' preferences for financial and non-financial incentives in cancer screening? Evidence for breast, cervical, and colorectal cancers.

General practitioners (GPs) play a key role in the delivery of preventive and screening services for breast, cervical, and colorectal cancers. In practice, GPs' involvement varies considerably across types of cancer and among GPs, raising important questions about the determinants of GPs' implication in screening activities: what is the relative impact of financial and non-financial incentives? Are GPs' preferences for financial and non-financial incentives cancer-specific? Is there preference heterogeneity and how much does it differ according to the screening context? This study investigates the determinants of GPs' involvement in cancer screening activities using the discrete choice experiment (DCE) methodology. A representative sample of 402 GPs' was recruited in France between March and April 2014. Marginal rates of substitution were used to compare GPs' preferences for being involved in screening activities across three types of cancers: breast, cervical, and colorectal. Variability of preferences was investigated using Hierarchical Bayes mixed logit models. The results indicate that GPs are sensitive to both financial and non-financial incentives, such as a compensated training and systematic transmission of information about screened patients, aimed to facilitate communication between doctors and patients. There is also evidence that the level and variability of preferences differ across screening contexts, although the variations are not statistically significant on average. GPs appear to be relatively more sensitive to financial incentives for being involved in colorectal cancer screening, whereas they have higher and more heterogeneous preferences for non-financial incentives in breast and cervical cancers. Our study provides new findings for policymakers interested in prioritizing levers to increase the supply of cancer screening services in general practice.

Simultaneous effect of disabling conditions on primary health care use through a capability approach.

There is evidence of social disparities in the use of primary health services in most European countries, and these disparities particularly affect people with disabilities. Many determinants of disabilities interact to limit access to health care (e.g. impairments, functional limitations, educational level). However, these determinants have typically been examined separately. We adopted a capabilities perspective to define multidimensional disability. Capabilities refer to individuals' real opportunities to achieve possible outcomes. In this context, we aimed to assess disability through latent capabilities (shaped by personal, social and environmental variables) and to simultaneously analyze their effects on primary health care use (GP and nurse care; cervical, breast, and colorectal cancer screenings). We used a structural equation modeling framework, which allowed complete and simultaneous tests of relationships taking into account measurement errors. The data source was the 2008 French Health and Disability Survey (29,931 individuals). Potential disability-related determinants were selected to measure five latent variables: health condition and cognitive, physical, societal, and socioeconomic capabilities. All things being equal, we did not identify any specific barriers to GP care use. We found a lower likelihood of nursing care use among people with lower cognitive capabilities. Unlike usual findings, we did not observe a significant influence of either cognitive or physical capabilities for any type of cancer screening use. However, cancer screening participation was mainly affected by societal and socioeconomic capabilities. Considering the capability approach, which suggests public action oriented toward restoring capabilities of individuals, future programs should seek to increase societal support to compensate for disability. This approach could be helpful in reducing inequalities in health care access.

Impact of a pay for performance programme on French GPs' consultation length.

BACKGROUND: In 2009, a voluntary-based pay for performance scheme targeting general practitioners (GPs) was introduced in France through the 'Contract for Improving Individual Practices' (CAPI). OBJECTIVE: To study the impact of the CAPI on French GPs' consultation length. METHODS: Univariate analysis, and multilevel regression analyses were performed to disentangle the different sources of the consultation length variability (intra and inter physician). The dependant variable was the logarithm of the consultation length. Independent variables included patient's sociodemographics as well as the characteristics of GPs and their medical activity. RESULTS: Between November 2011 and April 2012, 128 physicians were recruited throughout France and generated 20,779 consultations timed by residents. The average consultation length in the sample was 16.8 min. After adjusting for patients' characteristics only, the consultation length of CAPI signatories was 14.1% lower than that observed for non signatories (p<0.001). After adjusting for GPs' characteristics and the case mix, the CAPI was no longer a significant predictor of the consultation length. The results did not change significantly from one type of consultation to another. CONCLUSION: Although the CAPI was extended to all GPs in 2012, our results provide a cautionary message to regulators about its ability to generate higher quality of care.

Why did most French GPs choose not to join the voluntary national pay-for-performance program?

BACKGROUND: In 2009, a voluntary pay for performance (P4P) scheme for primary care physicians was introduced in France through the 'Contract for Improving Individual Practice' (CAPI). Although the contract could be interrupted at any time and without any penalty, two-thirds of French general practitioners chose not to participate. We studied what factors motivated general practitioners not to subscribe to the P4P contract, and particularly their perception of the ethical risks that may be associated with adhering to a CAPI. METHOD: A cross-sectional survey among French general practitioners using an online questionnaire based on focus group discussion results. Descriptive and multivariate statistical analyses with logistic regression. RESULTS: A sample of 1,016 respondents, representative of French GPs. The variables that were associated with the probability of not signing a CAPI were "discomfort that patients were not informed of the signing of a P4P contract by their doctors" (OR = 8.24, 95% CI = 4.61-14.71), "the risk of conflicts of interest" (OR = 4.50, 95% CI = 2.42-8.35), "perceptions by patients that doctors may risk breaching professional ethics" (OR = 4. 35, 95% CI = 2.43-7.80) and "the risk of excluding the poorest patients" (OR = 2.66, 95% CI = 1.53-4.63). CONCLUSION: The perception of ethical risks associated with P4P may have hampered its success. Although the CAPI was extended to all GPs in 2012, our results question the relevance of the program itself by shedding light on potential adverse effects.

Intrinsic and extrinsic motivations in primary care: an explanatory study among French general practitioners.

BACKGROUND: Like many other OECD nations, France has implemented a pay-for-performance (P4P) model in primary care. However, the benefits have been debated, particularly regarding the possibly undesirable effects of extrinsic motivation (EM) on intrinsic motivation (IM). OBJECTIVE: To examine the relationship between French GPs' IM and EM based on an intrinsic motivation composite score (IMCS) developed for this purpose. If a negative relationship is found, P4P schemes could have side effects on GPs' IM that is a key determinant of quality of care. METHOD: From data on 423 GPs practicing in a region of France, IM indicators are selected using a multiple correspondence analysis and aggregated from a multilevel model. RESULTS: Several doctors' characteristics have significant impacts on IMCS variability, especially group practice and salaried practice. Qualitative EM variables are negatively correlated with the IMCS: GPs who report not being satisfied with their income or feeling "often" constrained by patients' requests in terms of consultations length and office appointments obtain a lower mean IMCS than other GPs. CONCLUSION: Our results provide a cautionary message to regulators who should take into account the potential side effects of increasing EM through policies such as P4P.