Scoring and psychometric validation of the 'Determinants of Intentions to Vaccinate' (DIVA©) questionnaire.

BACKGROUND: Primary care physicians (PCPs) play a key role regarding vaccination in France. The aims of the present study were to define the scoring rules and to assess the measurement properties of the 'Determinants of Intentions to Vaccinate' (DIVA©) questionnaire that aims to assess PCPs' attitudes and beliefs toward vaccination. METHODS: The DIVA questionnaire was derived from a literature review and PCPs focus groups. Scoring and early validation of the DIVA questionnaire were determined during a cross-sectional study conducted in France. During the study, PCPs had to complete the DIVA questionnaire for any of the six vaccine-preventable diseases (VPDs) to which they were randomly assigned (measles, pertussis, pneumococcus infection, seasonal influenza, human papillomavirus -HPV- infection and tetanus). Descriptive analyses of items and the analysis of the grouping of items into domains were conducted. Internal consistency reliability and construct validity was assessed according to each VPD. RESULTS: The DIVA questionnaire was completed by 1,069 PCPs and was well accepted. The 'Commitment of the PCP to the vaccination approach' score showed very good internal consistency reliability (Cronbach's alpha >0.70 overall and for each VPD). The construct validity of the DIVA questionnaire was confirmed. CONCLUSIONS: The DIVA questionnaire is a valid and reliable measure of PCPs' attitudes and beliefs toward vaccination.

The role of alcohol in the management of hypertension in patients in European primary health care practices - a survey in the largest European Union countries.

BACKGROUND: Even though addressing lifestyle problems is a major recommendation in most guidelines for the treatment of hypertension (HTN), alcohol problems are not routinely addressed in the management of hypertension in primary health care. METHODS: Internet based survey of 3081 primary care physicians, recruited via the mailing lists of associations for general practitioners (GPs) in France, Germany, Italy, Spain and the UK. Clinical practice, attitudes, knowledge, education and training were assessed. Logistic regression to predict screening, brief intervention and treatment for alcohol dependence in the management of hypertension were assessed. RESULTS: Overall, about one third of the interviewed GPs reported sufficient screening in cases with HTN (34.0 %, 95 % confidence interval (CI):32.1-35.8 %). One out of five GPs screened and delivered brief interventions in HTN patients with hazardous consumption (22.2 %, 95 % CI: 20.6-23.8 %) and about one in 13 GPs provided treatment for HTN patients with alcohol dependence other than advice or brief intervention (7.8 %, 95 % CI: 6.8-8.9 %). Post-graduate training and belief in their effectiveness predicted interventions. There were marked differences between countries. CONCLUSIONS: While current interventions were overall low, marked differences between countries indicate that current practices could be improved. Education and post-graduate training seems to be key in improving clinical practice of including interventions for problematic alcohol consumption and alcohol dependence in primary health care.

[The commitment of French general practitioners to vaccination: the DIVA study (Determinants of Vaccination Intentions)]. / L’engagement des médecins généralistes français dans la vaccination : l’étude DIVA (Déterminants des Intentions de Vaccination).

OBJECTIVES: Vaccination is an effective way to reduce morbidity and mortality related to infectious diseases. In France, primary care physicians are the main administrators of vaccines. Our objective was to conduct an exploratory qualitative study with primary care physicians to identify determinants of their commitment to vaccination. METHODS: A qualitative research study was conducted with 36 primary care physicians from different geographical regions in France. Six focus group discussions, following a semi-structured interview guide, were held. Qualitative analysis based on coding of the transcribed discussions was performed to identify the factors influencing primary care physicians' attitudes toward vaccination. These factors were then organized into themes. Saturation was also evaluated. RESULTS: Diphtheria, tetanus, poliomyelitis, measles, mumps, rubella, hepatitis B, tuberculosis, pneumococcal infections, meningococcus, human papillomavirus, rotavirus, pertussis, varicella and flu vaccinations were all discussed in each focus group. Saturation was reached from the fourth focus group. Forty identified determinants were divided into six themes: vaccine characteristics, disease characteristics, primary care physicians' past experience, practical aspects, expected benefits and primary care physician-patient relationship. CONCLUSIONS: This study identified the behavioural and organizational determinants influencing primary care physicians' attitudes toward vaccination. These attitudes and determinants varied according to diseases and vaccines. The identified determinants and themes were used as a basis for the development of a questionnaire evaluating the Determinant of Vaccination Intentions (DIVA) of primary care physicians.

[Restructuring of ambulatory care in France: proposals for the management of hypertensive patients]. / Restructuration des soins ambulatoires en France: propositions de gestion des patients hypertendus.

One of the factors responsible for the creation of multidisciplinary health centres is the growth of outpatient management of multiple chronic conditions. Based on a classification of hypertensive patients into eight groups, the authors discuss the interrelations between health care organization and modification of management. They discuss the effects of modification of health care structures and the need to create new job positions for the purposes of coordination, support of patients in the form of therapeutic education and support ofyoung professionals in multidisciplinary practice. External effects are improvement of office-hospital flows, especially with the development of second-line consultant roles and improved management of patient admissions and discharges. However, to ensure sustainable changes, there must be a change of mentalities with new modalities of remuneration of private practitioners and development of the health information system.

Attitudes toward preventive services and lifestyle: the views of primary care patients in Europe. the EUROPREVIEW patient study.

BACKGROUND: For preventive interventions in general practice to succeed, patients' points of view must be taken into account in addition to those of GPs. OBJECTIVE: To explore patients' views and beliefs about the importance of lifestyle and preventive interventions, to assess their readiness to make changes to their lifestyle and their willingness to receive support from GPs. METHODS: Cross-sectional survey conducted by EUROPREV in primary care practices in 22 European countries. Patients were consecutively selected and interviewed from September 2008 to September 2009. RESULTS: Seven thousand nine hundred and forty-seven participants, 52.2% females. Only 30.5% of risky drinkers think they need to change, as opposed to 64% of smokers, 73.5% of patients with unhealthy eating habits and 73% with lack of physical activity. Risky drinkers reported that GPs initiated a discussion on alcohol consumption less often (42%) than on smoking (63%), eating habits (59%) or physical activity (55%). Seventy-five per cent, 66% and 63% of patients without hypertension, diabetes or hypercholesterolaemia, respectively, think blood pressure, blood sugar and serum cholesterol should be checked yearly. Women (80%) think they should be screened with the cervical smear test and 72.8% of women aged 30-49 years with mammography, yearly or every 2 years. CONCLUSIONS: A high proportion of patients attending primary care with unhealthy lifestyles (especially risky drinkers) do not perceive the need to change their habits, and about half the patients reported not having had any discussion on healthy lifestyles with their GPs. Patients overestimate their need to be screened for cardiovascular risk factors and for cancer.

Attitudes & behaviors toward the management of tobacco smoking patients: qualitative study with French primary care physicians.

BACKGROUND: Smoking cessation is a major public health issue. In France, primary care physicians (PCP) are the first contact points for tobacco management. The objective of this study was to understand how PCPs are involved in the management of smoking cessation: ownership, commitment, barriers. METHODS: A qualitative study was conducted using group and individual semi-structured techniques with PCPs. A thematic analysis of verbatim transcripts was performed to identify concepts and sub-concepts of interest. Saturation was evaluated retrospectively to ensure adequate sample size. RESULTS: A sample of 35 PCPs were interviewed, 31 in four focus groups and four in individual interviews. PCPs discussed their roles in the management of tobacco smoking cessation, including the different strategies they are using (e.g., Minimal Intervention Strategy, Motivational Interviewing), the multiple barriers encountered (e.g., lack of time, patients' resistance to medical advice), the support resources and the treatment and intervention they prescribed (e.g. nicotine replacement therapy, supporting therapist). CONCLUSIONS: This study provides a better understanding of the beliefs, attitudes, and behaviors of PCPs in managing smoking cessation. Guiding and encouraging patients toward smoking cessation remains a major objective of PCPs. While PCPs reported that progress has been made in recent years in terms of tools, technology and general awareness, they still face major barriers, some of which could be overcome by appropriate training.

Pneumococcal and influenza vaccination coverage among at-risk adults: A 5-year French national observational study.

INTRODUCTION: The risk of developing pneumococcal infections increases with certain chronic conditions and in immunocompromised patients. We aimed to monitor pneumococcal vaccination coverage in at-risk patients and to examine factors associated with pneumococcal vaccination in France. MATERIAL AND METHODS: In this annual cross-sectional study, at-risk patients were extracted between 2014 and 2018 from the National Health Insurance's (NHI) General scheme's claims database with their vaccine reimbursements. Descriptive analyses and a logistic model were performed to assess the influence of healthcare use and medical and demographic factors on pneumococcal vaccination. RESULTS AND DISCUSSION: In 2018, 4.5% of 4,045,021 at-risk adults were up to date with their pneumococcal vaccination. During the study period, the number of patients with chronic medical conditions (86% of 4,045,021) increased by 10.1%, but vaccination coverage decreased from 12.9% to 2.9%. The population with immunocompromised status (14% of 4,045,021) increased by 16.2% and vaccination coverage from 10.3% to 18.8%. Influenza vaccination coverage was much higher and stable (around 45.0%). Factors associated with pneumococcal vaccination were: immunocompromised status vs. having a chronic medical condition (odds ratio [OR] 4.72), influenza vaccination (OR 2.36-3.42), hepatitis B vaccination (OR 2.82), DTPolio vaccination (OR 1.52), ≥5 specialist physicians' visits (OR 1.17), and age above 74 (OR 1.12). Pneumococcal vaccine dispensing was extremely low (median of 9per GP,1per specialist over 9 years) despite frequent healthcare visits. CONCLUSION: Pneumococcal and influenza vaccination coverage of adults at risk of pneumococcal disease fell well below public health expectations. Invitations for pneumococcal vaccination should be sent by the NHI to high-risk patients. Patient management protocols should include pneumococcal vaccination. Patients with multiple comorbidities are a high-priority population given the large potential health gains offered by pneumococcal vaccination. Commitment of both scientific societies and health authorities is urgently needed to increase vaccination coverage in at-risk populations.

[Feasibility, in general practice, to give to the patients clear, loyal and appropriate information about the undesirable side effects of the medicines prescribed. EICLAT study]. / Faisabilité en médecine générale d'une information claire, loyale et appropriée des patients sur les effets indésirables des médicaments prescrits. Etude EICLAT.

Drug prescription in general practice is present in 78 to 83% of consultations; practitioners must give to their patient clear loyal and appropriate information about the undesirable side effects of the medicines prescribed. The object of the EICLAT study was to give some light on the feasibility to respect this obligation. To that effect the study evaluates, for a normal prescription activity, the average number of potential undesirable side effects (USE) in relation with the number of lines of different medicines prescribed in each doctor's prescription. A total of 8,382 doctor's prescriptions, generating 34,427 lines of prescriptions given by 175 general practitioners, were analysed. Amongst these prescriptions, 11% included only one line, 55% from 2 to 4 lines and 34% 5 lines or more. The average doctor's prescription was of 4 lines of medicines generating 407 potential USE, of which 194 were different (the same undesirable effect may be present twice or more in the same doctor's prescription), and 293 frequent or serious potential USE, of which 166 were different. The patent medicines with a major or important added medical value (AMV), present in 7,840 doctor's prescriptions for a total of 24,127 lines exposed the patient, in the average, to 151 frequent or serious USE different. The patent medicines with an insufficient AMV, present in 2,292 prescriptions for a total of 3,887 lines, exposed the patient to 37 frequent and/or serious potential USE. Supposing that the information provided by the legal authority is sufficiently adequate, precise and exhaustive, the volume of information that must be given to the patient is not compatible with the present conditions of exercise of the profession.

[Do general practitioners identify iatrogenic in their medical records? Study of 2,380 cases of iatrogenic statements by French general practitioners]. / Les médecins identifient-ils la iatrogénie dans leurs dossiers médicaux? A partir d'une étude de 2380 cas de iatrogénie relevés par des médecins généralistes français.

OBJECTIVE: The only few data on non hospital iatrogeny stress its frequency and its scarce recording. We can wonder if general practioners identify it in their medical records and if the data collected are sufficient enough to describe it. METHODS: This transversal descriptive study was done on a 35-month period among a network of 112 GPs who steadily collected data. They used a thesaurus of diagnosis with definitions, the Dictionnaire des Résultats de Consultation. In addition to the diagnosis of iatrogeny, the 15 variables studied focused on the following characteristics: doctors, patients, consultations, adverse reactions and treatments. RESULTS: At least one diagnosis of iatrogeny was found for 42% GPs, which gives an average of 17 iatrogenic cases in a year (0.81%). The 1,899 patients concerned presented 2,380 cases of iatrogeny and are women in majority (sex ratio: 0.7). The most common age bracket is the 50 to 59 years old persons. The most frequent adverse reactions are: gastroenterology (26.9%), neurology (14.6%) and finally dermatology (14.2%). The 1,762 treatments recorded concern the cardiovascular system (14.2%), the neurologic system (23.3%), and anti-infectious treatments (2.3%). The physicians are the ones who prescribed the suspicious treatments for two thirds of the cases and automedication counts for 1.7%. CONCLUSION: One GP out of two collects iatrogeny. Thanks to the information contained in the structured computerized medical record, we are able to analyse it accurately. The final results match the data found in literature. The interdoctor variability opens the way to optimise the recording of iatrogeny with drug-monotoring centres.

[Acute fever: has the media coverage of the swine flu generated a medical overconsumption in primary care in France?]. / Etat fébrile: la médiatisation de la grippe A(H1N1)v a-t-elle généré une surconsommation médicale en médecine générale? Etude prospective utilisant un questionnaire informatisé accessible en ligne.

OBJECTIVE: Based on patient's declarations, evaluate if the media coverage of the pandemic flu (H1N1) has lead to an overconsumption of primary care. Identify the opinions of the general practionners (GP) concerning this media coverage and the health crisis. METHODS: A prospective study, based on an electronic questionnaire, was conducted during the main period of the pandemic flu. Each GP was invited to include one patient who presented fever since less than 2 days, associated to two of four following clinical signs: cough, headache, coat throat and ache. RESULTS: 730 questionnaires were fully completed and analyzed. 96 patients (12,9%) have declared to the GP an overconsumption, and two thirds of them because of their concern about the swine flu and a quarter because the social control. This concern was noted by 80% of the GP from the beginning of the flu 77% of the GP have considered the media coverage of the flu alarming, while 69% of them have declared to feel serene concerning the pandemic. No statistic link has been noticed between the GP opinions and the overconsumption of their patients. DISCUSSION: Media coverage of the swine flu and the state organization of the crisis have lead to an overconsumption estimated to 13%. Many efforts must be done in the future to reassure patients about flu and its vaccination.

Initiation and continuation of oral anticoagulant prescriptions for stroke prevention in non-valvular atrial fibrillation: A cohort study in primary care in France.

BACKGROUND: Oral anticoagulants are prescribed in non-valvular atrial fibrillation for stroke prevention; however, little is known about the current management of anticoagulation in France, particularly given the availability of non-vitamin K antagonist oral anticoagulants in recent years. AIMS: To describe the characteristics of patients prescribed oral anticoagulants, and assess treatment persistence in French primary care. METHODS: We conducted a cohort study of patients with non-valvular atrial fibrillation, who were newly prescribed oral anticoagulants between 1 January 2014 and 31 January 2016, using French primary care data (IMS Longitudinal Patient Database). Adjusting for baseline characteristics, risk of non-persistence (switch or discontinuation) was compared using Cox regression. RESULTS: Of 4111 patients, 1710 were newly prescribed vitamin K antagonists, 1257 rivaroxaban, 744 apixaban and 400 dabigatran. The median age was 76 years, and 57.5% were male. History of hypertension was the most common co-morbidity (68.1%). Compared with vitamin K antagonists, non-persistence was higher with rivaroxaban (hazard ratio: 1.28; 95% confidence interval: 1.13-1.45) and dabigatran (hazard ratio: 1.42; 95% confidence interval: 1.20-1.69) and similar with apixaban (hazard ratio: 1.12; 95% confidence interval: 0.96-1.32). CONCLUSIONS: Non-persistence (treatment discontinuation or switch) with vitamin K antagonists was lower than with rivaroxaban and dabigatran in French primary care; however, non-persistence with the newest drug, apixaban, was similar to vitamin K antagonists. Larger studies with longer follow-up are needed to support these findings. This study is registered on ClinicalTrials.gov (NCT02488421).

Internet use for information seeking in clinical practice: a cross-sectional survey among French general practitioners.

BACKGROUND: Medical information needs regarding patient care are particularly large for general practitioners (GPs). The Internet seems to be a relevant but underused tool to seek medical information. OBJECTIVE: We aimed to describe the characteristics of the French GPs using the Internet for information seeking, to identify the barriers to its use and the factors that could facilitate it. METHOD: We conducted a cross-sectional survey among GPs currently practicing in France, using an online questionnaire, in July 2009. We analysed the answers of 721 respondents. RESULTS: Most of the respondents used the Internet to seek information. They were significantly younger, worked in group practice, had Internet training and had Internet access at the practice. The main barriers were related to the physician (lack of knowledge or specific skills), to the practice conditions (lack of time, concerns about relationship with patient, financial non-recognition) and to the information (information overload, quality concerns, low relevance, language barrier). Practitioners wanted more reliable and more relevant documents for daily practice. Websites with already selected resources could increase the GPs use of the Internet for medical information seeking. CONCLUSION: The reported obstacles were largely common with those previously described in other countries, except the language barrier and the financial non-recognition. Even if the generalization of our results to all French GPs should be cautious, the study provided better insights into the obstacles to the Internet use to seek clinical information in family practice and the factors that could facilitate it.

Performance scores in general practice: a comparison between the clinical versus medication-based approach to identify target populations.

CONTEXT: From one country to another, the pay-for-performance mechanisms differ on one significant point: the identification of target populations, that is, populations which serve as a basis for calculating the indicators. The aim of this study was to compare clinical versus medication-based identification of populations of patients with diabetes and hypertension over the age of 50 (for men) or 60 (for women), and any consequences this may have on the calculation of P4P indicators. METHODS: A comparative, retrospective, observational study was carried out with clinical and prescription data from a panel of general practitioners (GPs), the Observatory of General Medicine (OMG) for the year 2007. Two indicators regarding the prescription for statins and aspirin in these populations were calculated. RESULTS: We analyzed data from 21.690 patients collected by 61 GPs via electronic medical files. Following the clinical-based approach, 2.278 patients were diabetic, 8,271 had hypertension and 1.539 had both against respectively 1.730, 8.511 and 1.304 following the medication-based approach (% agreement = 96%, kappa = 0.69). The main reasons for these differences were: forgetting to code the morbidities in the clinical approach, not taking into account the population of patients who were given life style and diet rules only or taking into account patients for whom morbidities other than hypertension could justify the use of antihypertensive drugs in the medication-based approach. The mean (confidence interval) per doctor was 33.7% (31.5-35.9) for statin indicator and 38.4% (35.4-41.4) for aspirin indicator when the target populations were identified on the basis of clinical criteria whereas they were 37.9% (36.3-39.4) and 43.8% (41.4-46.3) on the basis of treatment criteria. CONCLUSION: The two approaches yield very "similar" scores but these scores cover different realities and offer food for thought on the possible usage of these indicators in the framework of P4P programmes.

A culture of care: the French approach to cardiovascular risk factor management.

OBJECTIVE: The objective of this study was to describe French primary care physicians' beliefs about cardiovascular disease (CVD) risk factors and best practices for managing CVD. METHODS: This study comprised a purposive convenience sample of 656 primary care physicians in France, recruited from contacts made through the French Society of General Medicine. We compiled the physicians' responses to free text questions taken from an Internet-based survey and analyzed them using a qualitative approach. Physician's responses were inductively analyzed using content analysis. Responses were thematically coded, tabulated, and computed for frequencies. Overall themes and verbatim examples are presented in this article. RESULTS: The French physicians in our study are generally happy with their country's health care system and cite equity as the primary reason. Interestingly, along with food and lifestyle differences, they also cite equity of their health system as the reason for the lower CVD death rate in France, Japan, and Israel compared with the United States. The physicians believe that they are successful at managing CVD risk factors by emphasizing aspects of the doctor-patient relationship, including spending more time with patients and focusing on education. CONCLUSIONS: Physicians who are on the front line of care and management offer a fresh perspective on best practices for CVD prevention and management. The equity of the French health care system supports a "culture of care" in France that might lead to better outcomes for CVD risk factor patients than in the United States.

Physician cardiovascular disease risk factor management: practices in France vs the United States.

Cardiovascular risk factor management by French vs US primary care physicians was studied. A survey was conducted that found that French physicians spend >20 minutes while US physicians spend five to 10 minutes (P<.001) addressing cardiovascular risk with patients. Fifty-three percent of French (vs 33% of US) physicians focus more on lifestyle modification and less on medication management (P<.0001). Sixty-nine percent of French physicians spend 0% to 20% of their time on administration while 65% of US physicians spend 10% to 30% (P=.0028). Fifty-one percent of French physicians see patients in one to three months for follow-up, while 51% of US physicians see patients in three to six months (P<.0001). Eighty-seven percent of French (vs 39% of US) physicians have guidelines available in the examination room either frequently or very frequently. US physicians report disparities in care more frequently than do French physicians (P<.0001). Forty-nine percent of French (vs 10% of US) physicians believe that they have relative freedom to practice medicine (P<.001). US physicians report greater administrative efforts, frustration, and disparities in their practice. French physicians focus more of their efforts on lifestyle management and see their patients more frequently and for a longer visit time.

Health problems in returning travelers consulting general practitioners.

Over a 2-month period, 43 of 143 participating general practitioners included 97 patients with 113 health impairments, mainly gastrointestinal problems (35%), respiratory tract infections (30%), and skin diseases (11%). Systemic febrile illness or imported tropical disease accounted for less than 4% of cases.