Triage of patients and remote consultations in primary care facilities during the COVID-19 pandemic in France (PRICOV-19 study) / Triage des patients et consultations à distance dans les structures de soins primaires pendant la pandémie de Covid-19 en France (étude PRICOV-19)

Introduction: PRICOV-19 is a European cross-sectional study based on an online questionnaire, describing the impact of the pandemic on primary care structures (PCS). In France, PCS are solo practices (SP), single or multi-professional group practices (GP), coordinated practice structures (CPS): health houses and health centers. Triage, whether it is digital (TD), by telephone (TT) or at the reception (TR), is essential to reduce the risk of infection, and is part of recommended organizational practices. Purpose of research: Based on French data from the PRICOV-19 study, the objective is to describe the frequency and factors associated with triage in PCSs during the COVID 19 pandemic. Results: 1100 structures responded to the survey. The TD was implemented in 64% of PCSs (53.3% of SPs, 64.9% of GPs, 73.2% of CPSs). The TT was implemented in 76% of structures (72.7% of SPs, 75.4% of GPs and 81% of CPSs). Finally, TR was implemented in 52% of structures (37.7% of SPs, 52% of GPs and 67% of CPSs). The other positively associated factors are the urban territory and the lower workload for the TD, and the presence of a receptionist for the TR. Conclusions: Triage practices seem to be clearly associated with the organization and working conditions in the PCSs, and first and foremost with the type of structure.

Introduction: PRICOV-19 est une étude transversale européenne basée sur un questionnaire en ligne, décrivant l'impact de la pandémie sur les structures de soins primaires (SSP). En France, les SSP sont les cabinets solo (CS), les cabinets de groupe mono ou pluriprofessionnels (CG), les structures d'exercice coordonné (SEC) : maisons de santé et centres de santé. Le triage, qu'il soit numérique (TN), téléphonique (TT) ou à l'arrivée (TA) est indispensable pour réduire le risque infectieux, et fait partie des pratiques d'organisation recommandées. But de l'étude: En s'appuyant sur les données françaises de l'étude PRICOV-19, l'objectif est de décrire la fréquence et les facteurs associés au triage dans les SSP pendant la pandémie de COVID 19. Résultats: 1 100 structures ont répondu au questionnaire. Le TN a été mis en œuvre dans 64 % des SSP (53,3 % des CS, 64,9 % des CG, 73,2 % des SEC). Le TT a été mis en œuvre dans 76 % des structures (72,7 % des CS, 75,4 % des CG et 81 % des SEC). Enfin, le TA a été mis en œuvre dans 52 % des structures (37,7 % des CS, 52 % des CG et 67 % des SEC). Les autres facteurs positivement associés sont le territoire urbain et la charge de travail moins importante pour le TN, et la présence d'une réceptionniste pour le TA. Conclusion: Les pratiques de triage semblent clairement associés à l'organisation et aux conditions d'exercice dans les SSP, et en premier lieu au type de structure.

Impact of a patient reminder letter from their general practitioners on influenza vaccination: A quasi-experimental study in Paris, France.

BACKGROUND: Seasonal influenza vaccination coverage levels remain too low in many countries. OBJECTIVES: This study aimed to evaluate the impact of a reminder letter from their general practitioner (GP) on patients' influenza vaccination. METHODS: Eligible patients for this controlled non-randomised study were the vulnerable categories targeted by the 2019-2020 national health insurance fund (NHIF) vaccination campaign, on the lists of 14 GPs from three practices in Paris (France) and unvaccinated on January 2, 2020 (mid-campaign). The choice of practices and assigning five GPs to the intervention arm were made for convenience. At mid-campaign, GPs in the intervention arm sent a standardised letter reminding each eligible patient to be vaccinated. In the control arm, GPs worked as usual. The intervention effect, calculated from the NHIF databases, was estimated by the difference between the groups in their vaccination coverage at the end of the campaign, with a linear mixed model adjusted for age, sex, chronic disease (at the patient level) and medical practice (at the GP level). RESULTS: The vaccination coverage at the end of the campaign was 14.7% in the intervention group (n = 317) and 1.7% in the control group (n = 493): a difference of 13.1% points (95% confidence interval [9.0-17.2], number needed to send 7.7). At the campaign's end, vaccination coverage among patients from the lists of GPs in the intervention arm was 62.7%, and 46.2% among patients from the control-arm GP lists. CONCLUSION: Reminder letters could help increase influenza vaccination coverage.

How to Better Integrate Social Determinants of Health into Primary Healthcare: Various Stakeholders' Perspectives.

This paper aims to identify challenges and opportunities related to the integration of social determinants of health (SDH) into primary healthcare at an international symposium in Orford, Quebec, Canada. A descriptive qualitative approach was conducted. Three focus groups on different topics were led by international facilitators. Two research team members took notes during the focus groups. All the material was analyzed using a thematic analysis according to an inductive method. Many challenges were identified, leading to the identification of potential opportunities: integrate the concept of SDH in all phases of the training curriculum for health professionals to foster interprofessional and intersectoral collaboration and sociocultural skills; organize healthcare for better outreach to vulnerable populations; organize local and regional committees to develop management frameworks to produce and use territory-specific data; develop dashboards for primary healthcare providers describing the composition of their territory's population; work collaboratively, rallying primary healthcare providers, community organization delegates, patient partners, citizens, and municipality representatives around common projects. Discussions prompted new directions for further primary healthcare research, among which are building on best practices in the literature and in the field, and engaging various stakeholders in research, including vulnerable populations, while focusing on patient experience.

ABiMed: Towards an Innovative Clinical Decision Support System for Medication Reviews and Polypharmacy Management.

Polypharmacy in elderly is a public health problem with both clinical (increase of adverse drug events) and economic issues. One solution is medication review, a structured assessment of patients' drug orders by the pharmacist for optimizing the therapy. However, this task is tedious, cognitively complex and error-prone, and only a few clinical decision support systems have been proposed for supporting it. Existing systems are either rule-based systems implementing guidelines, or documentary systems presenting drug knowledge. In this paper, we present the ABiMed research project, and, through literature reviews and brainstorming, we identified five candidate innovations for a decision support system for medication review: patient data transfer from GP to pharmacists, use of semantic technologies, association of rule-based and documentary approaches, use of machine learning, and a two-way discussion between pharmacist and GP after the medication review.

Evaluation of a guidelines website capitalizing on Finnish content and Belgium interface: A pilot study in French general practice.

No reference point-of-care, web-based medical compendium is available in general practice in France. We have then conducted the experimentation of EBMPracticeNet, a Belgian website of guidelines translated and adapted from the Finnish EBM Guidelines. We collected data from three sources: (i) the website logbook; (ii) a search-specific assessment questionnaire; (iii) a global assessment questionnaire. A cumulative number of 262 (62.8%) physicians performed at least one search on the website and clicked on average 5.9 times per month. Physicians globally got an accurate answer (74.2%). They found the information provided by the website reliable (92.2%) and useful for practice (78.6%). They perceived the website ergonomics as good. The main reported barriers were the time and effort required to find an accurate answer and the uneven relevance of the information retrieved. Improvements should focus on guidelines indexing and their adaptation to the French context, and training physicians to search medical databases.

Differences based on patient gender in the management of hypertension: a multilevel analysis.

The objective of our study was to investigate differences in the management of men and women treated for hypertension while considering the gender of their physicians. We used the data from the cross-sectional Paris Prevention in General Practice survey, where 59 randomly recruited general practitioners (42 men and 19 women) from the Paris metropolitan area enroled every patient aged 25-79 years taking antihypertensive medication and seen during a 2-week period (520 men and 666 women) in 2005-6. The presence in the medical files of six items recommended for hypertension management (blood pressure measurement, smoking status, cholesterol, creatinine, fasting blood glucose and electrocardiogram) was analysed with mixed models with random intercepts and adjusted for patient and physician characteristics. We found that the presence of all items was lower in the records of female than male patients (3.9 vs. 6.9%, p = 0.01), as was the percentage of items present (58.5 vs. 64.2%, p = 0.003). The latter gender difference was substantially more marked when the physician was a man (69.3 vs. 63.4%, p = 0.0002) rather than a woman (63.5 vs. 61.0%, p = 0.46). Although all guidelines recommend the same management for both genders, the practices of male physicians in hypertension management appear to differ according to patient gender although those of women doctors do not. Male physicians must be made aware of how their gender influences their practices.

Physicians' preventive practices: more frequently performed for male patients and by female physicians.

BACKGROUND: We sought to analyze gender differences in General Practitioners' (GP) preventive practices: variations according to the GP's and the patient's genders, separately and combined, and the homogeneity of GPs' practices according to gender. METHODS: Fifty-two general practitioners volunteered to participate in a cross-sectional study. A sample of 70 patients (stratified by gender) aged 40-70 years was randomly chosen from each GP's patient panel. Information extracted from the medical files was used to describe the GPs' preventive practices for each patient: measurements of weight, waist circumference, glucose, and cholesterol; inquiry and counseling about smoking, alcohol consumption, diet, and physical activity, and dates of cervical smears and mammographies. An aggregate preventive score was calculated to assess the percentage of these practices performed by each GP for patients overall and by gender. Mixed models were used to test for gender differences. RESULTS: Questionnaires were collected in 2008-2009 for 71% of the 3640 patients and analyzed in June 2017. Male patients and female GPs were associated with the most frequent performance of many types of preventive care. The aggregate preventive score was higher for male patients (OR = 1.60, 95% CI 1.47-1.75) and female GPs (OR = 1.35, 95% CI 1.05-1.73). There was no combined effect of the genders of the two protagonists. Female patients of male GPs appeared to receive preventive care least frequently and female GPs to deliver preventive care more consistently than their male colleagues. CONCLUSION: Physicians need to be aware of these differences, for both patient gender and their own.

Helping GPs to extrapolate guideline recommendations to patients for whom there are no explicit recommendations, through the visualization of drug properties. The example of AntibioHelp® in bacterial diseases.

INTRODUCTION: Clinical decision support systems (CDSS) implementing clinical practice guidelines (CPGs) have 2 main limitations: they target only patients for whom CPGs provide explicit recommendations, and their rationale may be difficult to understand. These 2 limitations result in poor CDSS adoption. We designed AntibioHelp® as a CDSS for antibiotic treatment. It displays the recommended and nonrecommended antibiotics, together with their properties, weighted by degree of importance as outlined in the CPGs. The aim of this study was to determine whether AntibioHelp® could increase the confidence of general practitioners (GPs) in CPG recommendations and help them to extrapolate guidelines to patients for whom CPGs provide no explicit recommendations. MATERIALS AND METHODS: We carried out a 2-stage crossover study in which GPs responded to clinical cases using CPG recommendations either alone or with explanations displayed through AntibioHelp®. We compared error rates, confidence levels, and response times. RESULTS: We included 64 GPs. When no explicit recommendation existed for a particular situation, AntibioHelp® significantly decreased the error rate (-41%, P value = 6x10-13), and significantly increased GP confidence (+8%, P value = .02). This CDSS was considered to be usable by GPs (SUS score = 64), despite a longer interaction time (+9-22 seconds). By contrast, AntibioHelp® had no significant effect if there was an explicit recommendation. DISCUSSION/CONCLUSION: The visualization of weighted antibiotic properties helps GPs to extrapolate recommendations to patients for whom CPGs provide no explicit recommendations. It also increases GP confidence in their prescriptions for these patients. Further evaluations are required to determine the impact of AntibioHelp® on antibiotic prescriptions in real clinical practice.

[The "Wellbeing" project: To more reliably identify and support pregnant women with psychological or social vulnerabilities]. / Projet Bien-être : vers un meilleur repérage et accompagnement des femmes présentant des vulnérabilités psychologiques ou sociales.

The perinatal period is one of the most critical periods in the life cycle. The health of the mother and child are strongly and permanently influenced by events occurring during pregnancy, delivery or early infancy. In psychological terms, nearly 10% of women reported poor self-rated mental health during pregnancy. Moreover, sociodemographic characteristics indicative of social disadvantage are associated with a higher risk of poor self-rated mental health. 81.3% of these women did not consult a healthcare professional for psychological problems. The well-being project is designed to optimise the care of pregnant women with psychological or socioeconomic vulnerabilities and to assess the value of an early prenatal interview.

Modular Knowledge-Based Decision Support System Dedicated to a Cooperative Decision to Prevent Cardiovascular Diseases.

Despite the success of artificial intelligence solutions in the recent years, physicians are still reticent to use integrated functionalities to support their decision. Methods used to create these functionalities can be divided into two groups, each being associated to different questions. Data-based methods are seen as black boxes for which it is impossible to understand how the decision is taken; knowledge-based methods need to rely on formalized knowledge sources on the basis of evidence, which can be discussed and criticized by physicians for their use in real life. This paper presents a new modular decision support system for the prevention of cardiovascular diseases, based on knowledge and on cooperative decision between the patient and the physician. The decision support system is based on two layers: (i) the first layer is a knowledge-based module which generates automatically patient profile, and prevention strategies associated to the profile; (ii) the second layer is a dynamic collaborative graphic user interface which displayed information about the risks of treatment adherence failure, personalized motivation and follow-up strategies. In the future, we aim at assessing the platform in real life.

Accumulation of unhealthy behaviors: Marked social inequalities in men and women.

The objective of this study was to compare the accumulation of unhealthy behaviors at the bottom of the social scale in men and women and, secondarily, to compare social and gender-based inequalities. Fifty-two general practitioners from the Paris area volunteered to participate. A sample of 70 patients (stratified by gender) aged 40-74 years was randomly chosen from each physician's patient panel and asked to complete a questionnaire about their social position and health behaviors: tobacco and alcohol use, unhealthy diet, and physical inactivity. Mixed Poisson models were used to describe, with relative risks (RRs) and relative inequality indexes (RIIs), the social inequalities in the accumulation of these four unhealthy behaviors. In 2008-2009, 71% of the 3640 patients returned their questionnaires. Men had an average of 1.59 of the 4 unhealthy behaviors we studied, and women 1.35 (RR = 1.18; 95% CI [1.11-1.25]). The mean number of unhealthy behaviors increased significantly for both genders from the top to the bottom of the social scale. The order of magnitude of RIIs was similar among men and women, ranging from 1.33 (occupational RII among women, 95% CI [1.11-1.60]) through 1.69 (financial RII among women, 95% CI [1.43-1.99]). None of the interaction tests between gender and social position was significant. The social inequalities had significantly wider amplitudes than those between genders for two of the three indicators of social position. The amplitude of social gradients related to unhealthy behaviors was similar between men and women and exceeded the gender inequality between them.

Building a Knowledge-Based Tool for Auto-Assessing the Cardiovascular Risk.

The prevention of cardiovascular diseases needs first to quantify the cardiovascular risk. To estimate this risk, French national health authorities provided clinical practice guidelines extending the existing European SCORE, which doesn't include all the cardiovascular risk factors (e.g. diabetes). Hence, French national clinical practice guidelines to quantify the cardiovascular risk is able to deal with more clinical situations than the SCORE. The goal of this paper is to formalize knowledge extracted from these guidelines and implement the rules so that they can be used into an auto-assessing tool of cardiovascular risk. Formalization followed five steps and was conducted under the guidance of medical experts. It resulted into a decision tree fed by eight decision variables. Evaluation of the accuracy of the decision tree showed 80% of agreement with an expert in medical informatics in predicting the cardiovascular risk level for 15 different clinical situations. Discrepancies correspond to the knowledge gaps within Clinical Practice Guidelines. We intend to extend the implementation of the decision tree to a complete tool, for allowing patient to auto-assess their cardiovascular risk. This tool will be integrated into a platform providing recommendations adapted to the calculated level of cardiovascular risk.

Using visual demonstrations in young adults to promote smoking cessation: Preliminary findings from a French pilot study.

BACKGROUND: A personalised, smoking cessation message was successfully delivered in Australian community pharmacies to motivate behavioural change in young smoking adults. OBJECTIVE: The purpose of this pilot study was to test the acceptability and effectiveness of the innovative, proven smoking cessation intervention to another population of young adults with a higher prevalence of smoking and associated morbidities. METHODS: Ninety eight university students in Paris, France were recruited to a pilot study (50 intervention: 48 control). All students received smoking cessation counselling sessions and half also received a visual demonstration of themselves, both as a lifelong smoker and non-smoker. RESULTS: There was no statistical significant difference between the groups in smoking dependence at recruitment. At the three month follow-up, the proportion who had attempted to quit smoking were 37% (control) vs 46% (intervention). These percentages suggested a positive result for the intervention, although the difference was not statistically significant (p = 0.39). CONCLUSION: This is one of the first studies conducted in France using visual demonstrations combined with healthcare counselling to promote smoking cessation amongst young adult smokers. Further research, recruiting from the general French public, is needed to better understand if the innovative personalised health message can motivate young French adult smokers to quit.

Are primary-care physician practices related to health behaviors likely to reduce social inequalities in health?

Our objective was to examine patients' health behaviors and the related practices of their primary-care physicians to determine whether physicians' actions might help to reduce the social inequalities in health behaviors among their patients. Fifty-two general practitioners, who were also medical school instructors in the Parisian area, volunteered to participate. A sample of 70 patients (stratified by sex) aged 40-70years was randomly chosen from each physician's patient panel and asked to complete a questionnaire about their social position and health behaviors: tobacco and alcohol use, diet, physical activity, and participation in breast and cervical cancer screening. Each physician reported their practices related to each such behavior of each patient. Mixed models were used to test for social differences. Questionnaires were collected in 2008-2009 from both patient and physician for 71% of the 3640 patients. Our results showed social inequalities disfavored those at the bottom of the social scale for all but one of the health behaviors studied among both men and women (exception: excessive alcohol consumption among women). Physicians' practices related to these health behaviors also appeared to be socially differentiated. Among men, this differentiation favored those with the lowest social position for all behaviors except physical activity. Among women, however, practices favored the most disadvantaged only for breast cancer screening. In all other cases, they were either socially neutral or unfavorable to the most disadvantaged. Physicians' practices related to their patients' health behaviors should focus more on those lowest in the social hierarchy, especially among women.

Time and feasibility of prevention in primary care.

BACKGROUND: Prevention is an essential task in primary care. According to primary care physicians (PCPs),lack of time is one of the principal obstacles to its performance. OBJECTIVE: To assess the feasibility of prevention in terms of time by estimating the time necessary to perform all of the preventive care recommended, separately from the PCPs and patient's perspectives, and to compare them to the amount of time available. METHODS: A review of the literature identified the prevention procedures recommended in France, the duration of each procedure and its recommended frequency, as well as PCPs' consultation time. A hypothetical patient panel size of 1000 patients, representative of the French population, served as the basis for our calculations of the annual time necessary for prevention for a PCP. The prevention time from the patient's perspective was estimated from data collected from a previous study of a panel of 3556 patients. RESULTS: For PCPs, the annual time necessary for all of the required preventive care was 250 hours, or 20% of their total patient time. For a patient, the annual time required for prevention during encounters with a PCP ranged from 9.7 to 26.4 minutes per year. The mean total encounter time was 75.9 minutes per year. Nearly 73% of patients had a prevention-to-care time ratio exceeding 15%. CONCLUSION: Feasibility thus differs substantially between patients. These differences correspond especially to disparities in the annual care time used by each patient. Specific solutions should be developed according to the patients' utilization of care.

Primary prevention of cardiovascular disease: More patient gender-based differences in risk evaluation among male general practitioners.

OBJECTIVE: Our objective was to analyse general practitioner (GP) cardiovascular risk assessment of patients for primary prevention while considering the gender of both the GP and the patient. METHODS: This study consisted of an observational survey of GPs who were internship supervisors in the Paris metropolitan area. Each of 52 volunteer GPs completed a self-administered questionnaire regarding their own characteristics and randomly selected 70 patients from their patient list. Dependent variables from the patient files included the presence of information about risk factors necessary to assess the patient's cardiovascular risk according to the French scale and the Systematic COronary Risk Evaluation (SCORE) scale. Analyses used mixed logistic models with a random intercept and adjusted for patient and physician characteristics. RESULTS: Both cardiovascular risk scales could be assessed less frequently in women than in men (odds ratio (OR) = 0.64 (95% confidence interval (CI): 0.5-0.8) for the French scale and OR = 0.63 (95% CI: 0.5-0.8) for the SCORE scale). These gender differences were less substantial when the patients were seen by female (for the SCORE scale OR = 0.72 (95% CI: 0.5-1.01)) compared with male physicians (OR = 0.56 (95% CI: 0.4-0.7)). The patients who were least well assessed for cardiovascular risk were women seen by male physicians. CONCLUSION: Even before the onset of cardiovascular disease, women patients receive less satisfactory preventative management than men do, and these differences are even more marked when the physician is a man. More attention to the influence of gender stereotypes is needed in medical training in order to combat the inequalities that they cause.

Factors associated with GPs' knowledge of their patients' socio-economic circumstances: a multilevel analysis.

BACKGROUND: To determine appropriate management for individual patients, GPs are supposed to use their knowledge of the patient's socio-economic circumstances. OBJECTIVE: To analyse factors associated with GPs' knowledge of these circumstances. METHODS: Observational survey of GPs who were internship supervisors in the Paris metropolitan area. Each of 52 volunteer GPs completed a self-administered questionnaire about their own characteristics and randomly selected 70 patients from their patient list. Their knowledge was analysed as the agreement between the patients' and GPs' responses to questions about the patients' socio-economic characteristics in questionnaires completed by both groups. The association between agreement and the GPs' characteristics was analysed with a multilevel model adjusted for age, sex and the duration of the GP-patient relationship. RESULTS: Agreement varied according to the socio-economic characteristics considered (from 51% to 90%) and between GPs. Globally, the GPs overestimated their patients' socio-economic level. GP characteristics associated with better agreement were sex (female), long consultations, the use of paper records or an automatic reminder system and participation in continuing medical education and in meetings to discuss difficult cases. CONCLUSION: Knowledge of some patient characteristics, such as their complementary health insurance coverage or perceived financial situation, should be improved because their overestimation may lead to care that is too expensive and thus result in the patients' abandonment of the treatment. Besides determining ways to help GPs to organize their work more effectively, it is important to study methods to help doctors identify their patients' social-economic circumstances more accurately in daily practice.

Acute low back pain management in primary care: a simulated patient approach.

BACKGROUND: Recent medical guidelines for acute low back pain (aLBP) are unevenly followed. Based on financial criteria or associated with a desirability bias, studies incompletely describe the actual management provided by general practitioners (GPs) in terms of diagnosis, treatment and prevention of progression towards chronicity. OBJECTIVE: To compare actual practices of French GPs for aLBP management with clinical guidelines. METHODS: A young simulated patient (SP) consulted, using a single scenario of aLBP, in 30 primary care practices in the Paris region. RESULTS: Heterogeneous data were collected according to the grid items: during the questioning, 29 GPs (97%) asked for age and 1 GP (3%) for pregnancy; during the clinical examination, 21 GPs (70%) asked for spinal stiffness and 3 GPs (10%) for cauda equina syndrome. Non-steroidal anti-inflammatory drugs were prescribed by 27 GPs (90%). Imaging (2 GPs or 7%) and physiotherapy (3 GPs or 10%) was rarely prescribed. A sick leave was prescribed by 22 GPs (73%). Twenty-seven GPs (90%) reassured the patient. CONCLUSION: aLBP management was in line with international guidelines in terms of clinical examination, physiotherapy and imaging prescriptions and some risk factors for chronicity were taken into account. However, patient questioning was brief, and drug and sick leave prescriptions did not meet international guidelines. The SP approach seems to be a useful tool for assessing actual GP practices.