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.

Continuity of care in general practice at cancer diagnosis (COOC-GP study): a national cohort study of 2853 patients.

BACKGROUND: At cancer diagnosis, it is unclear whether continuity of care (COC) between the patient and GP is safeguarded. AIM: To identify patient-GP loss of COC around the time of, and in the year after, a cancer diagnosis, together with its determinants. DESIGN AND SETTING: A post-hoc analysis of data from a prospective cohort of GPs in France, taken from a survey by the Observatoire de la Médecine Générale. METHOD: A prospective GP cohort (n = 96) filed data on patients who were diagnosed with incident cancer between 1 January 2000 and 31 December 2010. COC was assessed by ascertaining the frequency of consultations and the maximal interval between them. (In France, patients see their referring/named GP in most cases.) A loss of COC was measured during the trimester before and the year after the cancer diagnosis, and the results compared with those from a 1-year baseline period before cancer had been diagnosed. A loss of COC was defined as a longer interval (that is, the maximum number of days) between consultations in the measurement periods than at baseline. Determinants of the loss in COC were assessed with univariate and multivariate logistic regression models. RESULTS: In total, 2853 patients were included; the mean age was 66.1 years. Of these, 1440 (50.5%) were women, 389 (13.6%) had metastatic cancer, and 769 (27.0%) had a comorbidity. The mean number of consultations increased up to, and including, the first trimester after diagnosis. Overall, 26.9% (95% confidence interval [CI] = 25.3 to 28.6) of patients had a loss of COC in the trimester before the diagnosis, and 22.3% (95% CI = 20.7 to 23.9) in the year after. Increasing comorbidity score was independently associated with a reduction in the loss of COC during the year after diagnosis (adjusted odds ratio [OR] comorbidity versus no comorbidity 0.61, 95% CI = 0.48 to 0.79); the same was true for metastatic status (adjusted OR metastasis versus no metastasis 0.49, 95% CI = 0.35 to 0.70). CONCLUSION: As COC is a core value for GPs and for most patients, special care should be taken to prevent a loss of COC around the time of a cancer diagnosis, and in the year after.

Non-steroids anti-inflammatory drugs and risk of peritonsillar abscess in pharyngitis: a French longitudinal study in primary care†.

BACKGROUND: The safety of non-steroids anti-inflammatory drugs (NSAIDs) in the context of pharyngitis is doubtful with contradictory results in the literature. OBJECTIVE: To evaluate the risk of peritonsillar abscess (PTA) associated to NSAIDs consumption during a pharyngitis episode observed in primary care. METHOD: A retrospective cohort study using Observatory of General Medicine Datalink from 1995 to 2010. All patients consulting a GP from the Datalink network for pharyngitis have been included. The occurrence of a PTA in the 15 days following the consultation for pharyngitis was matched. The association between PTA and prescriptions of NSAIDs was studied via an adjusted logistic regression model. RESULTS: During the study period, 105 802 cases of pharyngitis and 48 cases of PTA following a pharyngitis were reported, concerning respectively 67 765 and 47 patients. In the multivariate analysis, the risk of PTA was associated positively with a NSAIDs prescription (OR = 2.9, 95% CI = 1.6-5.2). Other factors associated with PTA occurrence were the prescription of corticosteroids (OR = 3.1, 95% CI = 1.3-7.6) and an age between 20 and 40 years (OR = 5.7, 95% CI = 2.5-13.0). The prescription of antibiotics was not significantly associated with PTA (P = 0.7). CONCLUSION: Prescription of NSAIDs in pharyngitis may increase the risk of PTA. This study encourages considering cautiously the balance between benefits and harms before prescription of NSAIDs for pharyngitis.

[Feasibility and practical value of statistical matching of a general practice database and a health insurance database applied to diabetes and hypertension]. / Faisabilité et intérét de l'appariement de données individuelles en médecine générale et de données de remboursement appliqué au diabète et a l'hypertension artérielle.

OBJECTIVES: Public Health actors in France are striving to improve the use of national databases for public health and research. The main objective of this project was to develop a research tool in ambulatory care by matching medical data and reimbursement data. METHODS: Data sources were the health insurance database (SNIIRAM) and the General Practice Observatory (OMG) database. The SNIIRAM is a national medical and administrative database comprising data used in healthcare reimbursement. The OMG is a medical database on ambulatory care recording presenting complaints called "Results of Consultation" (RC). Based on data for patients who consulted one of the 30 general practitioners selected in 2008, we performed a probabilistic matching of the two databases. RESULTS: The linkage procedure allowed matching of 89,211 consultations or doctor visits and 29,088 patients. Comparison of long-term diseases (ALD) and RC showed that 94% of patients with diabetes as ALD had at least one RC coded as diabetes during the year, but only 65% of patients with one RC coded as diabetes were reported as ALD for this disease. Matching of the databases identified 12% of diabetic patients without antidiabetic treatment and without ALD for this affection; these patients were therefore not identifiable in the SNIIRAM database. CONCLUSION: This study describes an innovative database matching methodology. It also illustrates the contribution of this model of matched data in terms of targeting populations at risk. Other approaches to analysis of comorbidities, medical practices and care pathways could be proposed.

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.

Determinants of preventive services in general practice. A multilevel approach in cardiovascular domain and vaccination in France.

BACKGROUND: France is in Europe, the country in which the mortality due to potentially preventable causes is the highest. At the same time, French doctors receive no incentives to undertake prevention activities. This article examined the general practitioners' (GPs) determinants (characteristics, patient list and contextual factors) of cardiovascular prevention and vaccination carried out by GPs in their offices. METHODS: Data were collected from 105,726 patients followed by 86 GPs (observational study). A multilevel analysis with two levels: GP and patient (HLM) was performed. RESULTS: A high between-GP variability of the prevention activity is underlined in both domains. After controlling for patient characteristics, we observed a positive effect of the GP's workload (ORa=1.03) and of an elderly GP's patient list (ORa=1.04) on cardiovascular prevention, a positive effect of a patient list with a high level of health care consumption on vaccination activity (ORa=1.04). The significant influence of contextual factors is ever more demonstrative: the ORa is 1.3 times lower in cardiovascular prevention and 1.6 in vaccination when the density of GPs in the local community of the doctor's practice grows of one-point (1/1000); the ORa is two times lower in both cardiovascular prevention and vaccination for GPs having an urban practice. CONCLUSION: These results emphasize the need for taking into account contextual factors to implement prevention policies in primary care. But further studies of this type should be conducted by taking other variables into account in order to improve the proportion of variance explained in our models.