Link between the referring physician and breast and cervical cancers screening: a cross-sectional study in France.

BACKGROUND: The aims of the "médecin traitant" or referring physician (RP) reform, introduced in France in 2004, were to improve the organisation and quality of care and to allow for greater equity, particularly in terms of prevention. The objective of our study was to evaluate the effect of having a declared RP on the uptake of screening for breast and cervical cancers, and to explore the mechanisms involved. METHODS: We used an existing dataset of 1,072,289 women, which combines data from the Health Insurance information systems, with census data. We built multivariable logistic regression models to study the effect of having a RP on the uptake of mammography and pap smear, adjusted for age, socio-economic level, health status and healthcare provision. We secondarily added to this model the variable "having consulted a General Practitioner (GP) within the year". Finally, we evaluated the interaction between the effect of having a referring physician and the area of residence (metropolitan/urban/rural). RESULTS: Patients who had a declared RP had a significantly higher uptake of mammography and pap smear than those who did not. The strength of the association was particularly important in very urban areas. The effect of having visited a GP seemed to explain a part of the correlation between having a RP and uptake of screening. CONCLUSIONS: Lower rates of gynaecological screening among women without an RP compared to those with an RP may partly reflect a specific behaviour pattern in women less adherent to the health care system. However, this result also shows the importance of the RP, who assumes the key role of relaying public health information in a more personalised and adapted way.

Study protocol of the CREDO randomised controlled trial: evaluation of a structured return home consultation for patients suffering from metastaticcancer.

INTRODUCTION: Patients suffering from cancer are often managed by multiple health professionals. General practitioners with specific skills in oncology could facilitate care coordination between hospital and general practice in the management of these patients. To explore this hypothesis, we run a randomised clinical trial, called 'Concertation de REtour à DOmicile, CREDO'. The main objective is to explore the effectiveness of a 'return home' consultation compared with standard care. The number of unscheduled visits to care centres is used to evaluate the effectiveness of the treatment. METHODS AND ANALYSIS: CREDO is a multicentre, randomised, open-label, prospective trial. It takes place in two specialised cancer care centres in southern France (Occitania region). Patient inclusion criteria are: be over 18 years old; be treated with a first cycle of metastatic chemotherapy in a specialised cancer care centre; have a metastatic solid cancer and be returning home after treatment. Patients are randomised in two arms: standard-arm (conventional management) or intervention-arm (CREDO management). In the intervention arm, a 'return home' consultation is carried out in three steps. First, the investigating GP (GP with specific skills in oncology) from the specialised care centre collects information about the patient and patient's management choices. Then, the investigating GP conducts an interview with the patient's referring GP to quickly communicate and discuss information about the patient. Finally, the investigating GP summarises these exchanges and transmits this information to the care centres chosen by the patient.All the patients are followed for 1 year.Statistical and medicoeconomic analysis are planned. ETHICS AND DISSEMINATION: This clinical trial is registered under ClinicalTrials.gov identifier and was approved by the ethics committee of South-Western French Committee for the Protection of Persons (number: 2016-A01587-44) and from the French National Drug Safety Agency (ANSM, number: 2016111500034).An international publication of the final results and conference presentations will be planned. TRIAL REGISTRATION NUMBER: NCT02857400.

Experimental system of care coordination for the home return of patients with metastatic cancer: a survey of general practitioners.

BACKGROUND: To promote improved coordination between general practice and hospital, the French clinical trial CREDO ("Concertation de REtour à DOmicile") is testing an innovative experimental consultation for patients with metastatic cancer who are returning home. This consultation involves the patient, the patient's referring GP (GPref) and a GP with specific skills in oncology (GPonc) in a specialized care center. The objective of our study is to explore the satisfaction of GPsref about this consultation, in the phase of interaction between GPonc and GPref. METHODS: This observational, cross-sectional, multicenter study explored the satisfaction of GPsref who had participated in this type of consultation, via a telephone survey. RESULTS: One Hundred GPsref responded to the questionnaire between April and September 2019 (overall response rate: 55%). 84.5% were satisfied with the consultation, and the majority were satisfied with its methods. Half of the GPsref learned new information during the consultation, three-quarters noted an impact on their practice, and 94.4% thought that this type of coordination between the GPref and the oncology specialist could improve general practice - hospital coordination. CONCLUSIONS: For GPs, the CREDO consultation seems to be practical and effective in improving the coordination between general medicine and hospital. GPs would benefit from such coordination for all patients with cancer, several times during follow-up and at each occurrence of a medically significant event.

Adapting patients' oncological treatment through remote participation of general practitioners in multi-disciplinary consultation meetings: A feasibility study.

BACKGROUND: The general practitioner (GP) is central to managing patients with cancer, whose numbers are increasing worldwide. The GP's involvement requires better coordination between involved partners, in particular oncologists and GPs. OBJECTIVES: To conduct a feasibility study of remote participation of GPs in multi-disciplinary consultation meetings (MCMs). We analysed participation, participants' satisfaction, and their impact on therapeutic decisions. METHODS: We conducted a feasibility study in the regional cancer centre of Toulouse, France. All patient cases discussed in the MCMs for myelodysplasia from 1 January to 31 March 2016 were included. Cases of patients aged over 18 years, with a diagnosis of myelodysplasia and registered with a GP were included if patients gave informed consent. One investigator collected the data provided by GPs during three telephone or video calls: before, during, and after the MCM, respectively. RESULTS: Of 86 patient cases discussed during three months of MCMs, 44 were eligible for GP participation; 27 GPs participated in discussions of 27 patient cases. The GP's participation in the MCM led to a change in management in five cases, with four times treatment intensifications and once de-intensification. Medical, social, family-related, and psychological domains were discussed with input from the GPs. Overall, all participants were satisfied with the MCMs. CONCLUSION: Remote participation of GPs in MCMs is feasible and may result in adapting oncological and haematological management for patients. This patient-centred approach requires a specific organisation that, when implemented, satisfies the needs of all participants.

Social and territorial inequalities in breast and cervical cancers screening uptake: a cross-sectional study in France.

OBJECTIVE: The objective of this cross-sectional study was to investigate the impact of socio-territorial characteristics on mammography and pap smear uptake according to the place of residence in the recommended age groups, and second outside the recommended age groups. SETTING AND PARTICIPANTS: We used an existing dataset of 1 027 039 women which combines data from the Health Insurance information systems, with census data from Midi-Pyrénées, France. PRIMARY AND SECONDARY OUTCOME MEASURES: Our outcome was, for each woman, the uptake of the pap smear and the uptake of the mammography during the year. RESULTS: A social gradient of screening uptake was found in the recommended age groups. This gradient was stronger in large urban areas:(1) For mammography: decile 10 (the most deprived) vs 1 (the least deprived), adjusted OR 0.777, 95% CI (0.748 to 0.808) in large urban area; adjusted OR= 0.808 for decile 1 to 0.726 for decile 10 in other areas vs decile 1 in urban areas;(2) For pap smear: decile 10 vs 1 adjusted OR 0.66, 95%CI (0.642 to 0.679) in large urban areas; adjusted OR= 0.747 for decile 1 to 0.562 for decile 10 in other areas vs decile 1 in urban areas).Screening rates were globally higher in large urban areas.For mammography, the social and territorial disparities were higher outside the recommended age group. CONCLUSIONS: Offering a universal approach to every woman, as it is often the case in nationally organised screening programmes, is likely to be insufficient to ensure real equity in access. Developing global dataset combining health data and diverse socioeconomic data, at individual and contextual levels, could enable a better understanding of the mechanisms involved in this social gradient, and therefore, the development of targeted territorial actions to improve equity of access to healthcare.

Inventory of tools for care coordination between general practice and hospital system for patients suffering from cancer in active phase of treatment: A scoping review.

INTRODUCTION: During the active phase of treatment, major difficulties appear in the transmission and quality of the information communicated to the General Practitioner (GP). Our objective was to carry out an inventory of the coordination tools used to improve exchanges between the hospital and the GP in the management of the patient suffering from cancer during this phase. MATERIAL AND METHOD: A scoping review was conducted using MEDLINE databases via PubMed, The Cochrane Library, Web of Science. Articles published between 1998 and 2018, in English and French, were analysed. RESULTS: Over 4,863 articles were extracted, and 11 studies were included. They highlight an increase in the quality of patient care after the introduction of information sheets or training by video vignettes with GPs. They demonstrate the importance of using standardised letters between health professionals. The role of a "leader physician" is discussed, and its first evaluations are positive. An increase in information transmitted to GPs leads to a better satisfaction of patients and GPs. CONCLUSION: Communication tools are essential for the transmission of information, but direct and oral communication between all health professionals seems to be a point to be further developed.

Improving communication between the general practitioner and the oncologist: a key role in coordinating care for patients suffering from cancer.

BACKGROUND: Patients suffering from cancers are increasingly numerous in general practice consultations. The General Practitioner (GP) should be at the heart of the management of patients. Several studies have examined the perceptions of GPs confronted with the patient suffering from cancer and the relationships of GPs with oncologists, but few studies have focused on the patients' perspective. We studied the three-way relationship between the oncologist, the GP, and the patient, from the patient's point of view. METHODS: A questionnaire validated by a group consisting of GPs, oncologists, nurses, an epidemiologist and quality analyst, was administered over a three-week period to patients suffering from cancer receiving chemotherapy in a day hospital. RESULTS: The analysis was based on 403 questionnaires. Patients had confidence in the GP's knowledge of oncology in 88% of cases; 49% consulted their GP for pain, 15% for cancer-related advice, and 44% in emergencies. Perceived good GP/oncologist communication led patients to turn increasingly to their GP for cancer-related consultations (RR = 1.14; p = 0.01) and gave patients confidence in the GP's ability to manage cancer-related problems (RR = 1.30; p < 0.01). Mention by the oncologist of the GP's role increased the consultations for complications (RR = 1.82; p < 0.01) as well as recourse to the GP in an emergency (RR = 1.35; p < 0.01). CONCLUSION: Patients suffering from cancer considered that the GP was competent, but did not often consult their GP for cancer-related problems. There is a discrepancy between patients' beliefs and their behaviour. When the oncologist spoke to patients of the GP's role, patients had recourse to their GP more often. Systematically integrating a GP consultation to conclude cancer diagnosis disclosure, could improve management and care coordination.

Assessment of cancers' diagnostic stage in a Deaf community - survey about 4363 Deaf patients recorded in French units.

BACKGROUND: Deaf people represent 0.1% of the French population and their access to public health campaigns is limited due to their frequent illiteracy and the infrequent use of sign language in campaigns. There is also a lack of general health knowledge in spite of the existence of French Deaf Care Units (UASS). The aim of this study is to assess the average diagnostic stage of cancer in the Deaf Community and discuss deafness as a contributing factor. METHODS: Four thousand three hundred sixty-three Deaf patients recorded in five UASS, 80 diagnosed between 2005/01/01 and 2014/12/31 were selected from medical records and/or ICD-10 coding. Data regarding cancers were extracted, grouped by stage and compared to literature. Statistical significance was tested with Fisher's Exact Test. RESULTS: Eighty patients were selected. Most cancers were diagnosed at advanced stages: of 11 prostate cancers, 46% were locally advanced and 18% were metastatic. (In the general population, this was respectively 3% and 10.4% (p < 0.01)). Of six colorectal cancers, 67% were diagnosed at stage III and 33% at stage IV. (Respectively 20.6% and 26.6% (p = 0.03) in the general population). In contrast, of the 15 breast cancers, 93% were diagnosed at stages T1-T3 that was earlier than in the general population (p = 0.43). CONCLUSION: In this study, we observed a delay cancer diagnosis among Deaf people. Complicated and/or non-systematic screening procedures for cancers would be involved. Which is most likely the result of many factors (communication, medical knowledge). Increasing UASS coverage and health information campaigns in sign language could assist in earlier cancer diagnosis.

Pre-treatment choroidal thickness is not predictive of susceptibility to form-deprivation myopia in chickens.

PURPOSE: Chicks developing experimentally-induced myopia show profound thinning of the choroid. We observed a wide range of choroidal thicknesses in a sample of normal chicks prior to their use in a pedigree-based study of form-deprivation myopia. Hence, we tested whether pre-treatment choroidal thickness predicted susceptibility to myopia. METHODS: Retinal, choroidal and scleral thickness were measured using A-scan ultrasonography in normal White Leghorn chicks (n= 891) aged 4 days old, and again (n=498) after 4 days of monocular form-deprivation at age 8 days of age. Refractive error was assessed by retinoscopy. Relationships between pre-treatment choroidal thickness and other variables were investigated using general linear models and variance components analysis. RESULTS: Untreated 4 day-old male chicks had choroids approximately 10% thinner than females (p<0.001), but sex explained <2% of the overall variability in choroidal thickness. Axial eye length in these untreated chicks was not significantly associated with choroidal thickness (p=0.25). Moreover, pre-treatment choroidal thickness was not predictive of susceptibility to form-deprivation myopia (p=0.89). Heritability analysis suggested that at least 50% of the variation in pre-treatment choroidal thickness was determined by additive genetic effects (p<0.001). CONCLUSIONS: Parental choroidal thickness is the major determinant of choroidal thickness in untreated 4-day old chicks. Despite choroidal thickness potentially being indicative of ongoing emmetropisation to innate refractive errors, in this study it was not predictive of subsequent susceptibility to form-deprivation myopia.