Evaluation of the Belgian Guidelines Website EBMPracticeNet in French General Practice.

EBMPracticeNet is a Belgian website of guidelines translated and adapted from the Finnish EBM guidelines. During the experimentation of the EBMPracticeNet website in France, physicians globally got an accurate answer and found the information provided by the website reliable and useful for practice. They perceived its ergonomics as good and wished to continue using it. Improvements should focus on the indexation and adaptation of the guidelines, and on physicians' training.

Interventions Developed with the Intervention Mapping Protocol in Work Disability Prevention: A Systematic Review of the Literature.

Purposes Intervention mapping (IM) is a protocol for developing effective behavior change interventions. It has been used for 10 years to develop work disability prevention (WDP) interventions, but it is not known to what extent and with what success. The main objective of this study was to review the effectiveness of these interventions. Secondary objectives were to review their fidelity to the IM protocol, their theoretical frameworks and their content. Methods A search strategy was conducted in MEDLINE, Web of Science, PsycINFO, Pascal, Francis, and BDSP. All titles and abstracts were reviewed. A standardized extraction form was developed. All included studies were reviewed by two reviewers blinded to each other. Results Eight WDP interventions were identified aimed at return to work (RTW; n = 6) and self-management at work (n = 2). RTW interventions targeted workers with stress-related mental disorders (n = 1), low back pain (n = 1), musculoskeletal disorders (n = 1), cancer (n = 2) and gynecological surgery (n = 1). The fidelity to the IM protocol was weaker for the participatory planning group. Matrices of change, change methods, and applications were systematically reported. The main theoretical frameworks used were the attitude-social influence-self efficacy model (n = 4) and the theory of planned behavior (n = 2). Half of the interventions included a workplace component (n = 4). Two interventions were reported as effective, and one partially effective. Conclusion The IM protocol is used in WDP since 2007. The participative dimension appears underused. Few theoretical frameworks were used. Implications are to better consider the stakeholders involvement, and mobilize theoretical frameworks with greater attempts to intervene on the work environment.

Diagnostic strategies for urinary tract infections in French general practice.

OBJECTIVES: We aimed to describe the diagnostic management procedures for detection of urinary tract infections in general practice and their correlated factors. PATIENTS AND METHODS: We analyzed data from the ECOGEN study on urinary tract infections, collected in France between November 2011 and April 2012. This national cross-sectional study was carried out in general practices. Data was coded according to the International Classification of Primary Care. RESULTS: A total of 340 consultations or home visits were held for urinary tract infections. The five most frequent diagnostic procedures were (in descending order) clinical examination (67.6%), urine cytobacteriological examination (UCBE) (47.9%), urine dipstick test (15.6%), blood test (8.5%), and imaging (6.5%). No urine dipstick test or UCBE was performed in 43% of cases. Factors correlated with diagnostic procedures were age and gender of patients, annual number of consultations held by family physicians, and duration of consultation. CONCLUSION: Family physicians did not comply with guidelines on diagnostic management for detection of urinary tract infections. We hypothesized that this non-compliance could be due to the family physicians' environment and characteristics, and to clinical practice guidelines.

[Therapeutic adherence in asthma in France: A general review]. / L'adhésion thérapeutique dans l'asthme en France : revue générale.

INTRODUCTION: Adherence in asthma is a paramount issue of disease management. A general review of the French publications on this topic has been conducted. METHODS: Research equations used for bibliographic databases (MEDLINE, Science Direct, Banque de données en santé publique, Cochrane and Cairn.info) comprised the following keywords: "asthma", "therapeutic adherence" and "France". These publications unrelated to asthma, focused on asthma management without exploring adherence, or those conducted in populations without French patients were excluded. RESULTS: A total of 82 articles have been selected (36 surveys, 4 randomized trials and 42 reviews/syntheses). Whatever the methodology used and publication year, the inadequate therapeutic adherence in asthma was steadily reported, notably for controllers and the quality of use of inhaled devices. CONCLUSION: The present review highlights the sustainability of adherence-related issues in asthma and the need to improve patients' knowledge on asthma and the finality of therapy. It also highlights the need of an improved communication between patients and physicians is also advocated. Further studies with more recent data are desirable to assess changes in disease management of asthma and the impact of potential future corrective interventions.

What are the therapeutic alternatives to dextropropoxyphene in France? A prescribers' survey.

About a year after dextropropoxyphene (DXP) withdrawal from the French market, we conducted a survey among members of the French Society of Anesthesia & Intensive Care Medicine (Sfar) and of the French Society of the Study and Treatment of Pain (SFETD) to identify the indications for which this WHO level II analgesic had been prescribed, the prescriber's feedback following withdrawal, and the substitutive analgesics prescribed. DXP had been prescribed by more than 75% of the 430 anaesthesiologists and 230 pain specialists interviewed, mainly for acute and chronic non-cancer pain of moderate intensity. While two thirds of pain specialists were not satisfied with DXP withdrawal, this decision did not affect the majority of anaesthesiologists. In both groups, the main substitutive analgesic was tramadol combined with acetaminophen, while only 24% of prescribers considered acetaminophen alone as a substitute.

[Medical homes and poles including pharmacists: An inventory]. / Maisons et pôles de santé pluriprofessionnels incluant des pharmaciens : un état des lieux.

INTRODUCTION: The current restructuring of primary healthcare aims toward the creation of coordinated practices, which involves new roles for pharmacists. The objectives of this study were to identify all the French multidisciplinary medical homes and poles (MMHs and MMPs) with pharmacists currently active, and to describe how they are organized and operate. METHODS: This study focused on metropolitan MMHs and MMPs, active during the second semester of 2013, which include one or several pharmacists. These centers were identified through information provided by French regional health authorities (Agences régionales de santé, ARS) and the French medical homes medical poles federation (Fédération française des maisons et pôles de santé). Data were collected via an electronic questionnaire. RESULTS: Pharmacists were active in 60 centers in total, namely 35 MMHs and 25 MMPs. These were mostly set up as sociétés interprofessionnelles de soins ambulatoires (SISA, a type of company), with the help of government funding, typically from the ARS, in buildings owned by local government agencies. Pharmacists were systematically invited to attend interprofessional meetings held in the MMHs and MMPs, and multimodal treatment protocols were often in place. Pharmacists had no access to shared clerical services in MMHs, and rarely in MMPs, and their access to medical records was inconsistent in the two types of structures. CONCLUSION: Pharmacists are currently active in nearly one in four MMHs and MMPs but are still only partially integrated therein.

[The intervention mapping protocol: A structured process to develop, implement and evaluate health promotion programs]. / Le protocole de l'intervention mapping : un processus méthodique pour élaborer, implanter et évaluer des programmes en promotion de la santé.

BACKGROUND: Health promotion programs are expected to improve population health and reduce social inequalities in health. However, their theoretical foundations are frequently ill-defined, and their implementation faces many obstacles. The aim of this article is to describe the intervention mapping protocol in health promotion programs planning, used recently in several countries. METHODS: The challenges of planning health promotion programs are presented, and the six steps of the intervention mapping protocol are described with an example. Based on a literature review, the use of this protocol, its requirements and potential limitations are discussed. RESULTS: The intervention mapping protocol has four essential characteristics: an ecological perspective (person-environment), a participative approach, the use of theoretical models in human and social sciences and the use of scientific evidence. It comprises six steps: conduct a health needs assessment, define change objectives, select theory-based change techniques and practical applications, organize techniques and applications into an intervention program (logic model), plan for program adoption, implementation, and sustainability, and generate an evaluation plan. This protocol was used in different countries and domains such as obesity, tobacco, physical activity, cancer and occupational health. Although its utilization requires resources and a critical stance, this protocol was used to develop interventions which efficacy was demonstrated. CONCLUSION: The intervention mapping protocol is an integrated process that fits the scientific and practical challenges of health promotion. It could be tested in France as it was used in other countries, in particular to reduce social inequalities in health.

Interprofessional collaboration in primary health care: a review of facilitators and barriers perceived by involved actors.

BACKGROUND: The epidemiological transition calls for redefining the roles of the various professionals involved in primary health care towards greater collaboration. We aimed to identify facilitators of, and barriers to, interprofessional collaboration in primary health care as perceived by the actors involved, other than nurses. METHODS: Systematic review using synthetic thematic analysis of qualitative research. Articles were retrieved from Medline, Web of science, Psychinfo and The Cochrane library up to July 2013. Quality and relevance of the studies were assessed according to the Dixon-Woods criteria. The following stakeholders were targeted: general practitioners, pharmacists, mental health workers, midwives, physiotherapists, social workers and receptionists. RESULTS: Forty-four articles were included. The principal facilitator of interprofessional collaboration in primary care was the different actors' common interest in collaboration, perceiving opportunities to improve quality of care and to develop new professional fields. The main barriers were the challenges of definition and awareness of one another's roles and competences, shared information, confidentiality and responsibility, team building and interprofessional training, long-term funding and joint monitoring. CONCLUSIONS: Interprofessional organization and training based on appropriate models should support collaboration development. The active participation of the patient is required to go beyond professional boundaries and hierarchies. Multidisciplinary research projects are recommended.

[Nosological and functional justifications for sick leave: a cross-sectional study in the Rhône district]. / Justifications nosologiques et fonctionnelles des arrêts maladie: une étude transversale dans le Rhône.

BACKGROUND: Although sick leave has significant medical and economic stakes, justifications for sick leave are poorly known in France. Our objective was to describe the medical justifications for sick leave, in nosological, functional and contextual terms. METHODS: Cross-sectional study, based on 1,143 sick leave certificates collected by the Health Insurance Fund of the Rhône district in February 2011. The medical justifications for sick leave were classified and coded in nosological terms according to the International Classification of Primary Care (ICPC-2) and in functional and contextual terms according to the "AT-CIF questionnaire", derived from the International Classification of Functioning (ICF). RESULTS: Among the 1,073 sick leaves containing a medical justification (93.9%), 757 (70.5%) could be classified only according to the ICPC-2 and 316 (29.5%) according to both the ICPC-2 and the AT-CIF questionnaires. The health problems most frequently reported in sick leave justifications concerned, in order of decreasing frequency: respiratory (26.9%), psychological (13.7%), or digestive (12.1%) systems; general problems (10.7%); pregnancy (3.5%); the neurological system (2.9%). Furthermore, 346 functional deficiencies, five restrictions of activity and one environmental barrier were identified. CONCLUSION: Sick leave certificates almost always provide justifications for sick leave in nosological terms, but in less than one third of certificates provide information in functional or contextual terms. Training practitioners to make functional and contextual assessments may allow them to more optimally decide on the indication and the duration of sick leave, and facilitate communication around the patient.

Building a shared patient record for breast cancer management: a French Delphi study.

Before electronic records become operational, patient-held records provide an opportunity to improve communication between patients and healthcare professionals. Our aim was to design the appropriate organization, layout and content for such a shared record for breast cancer management, based on a consensus between the various stakeholders. We therefore conducted a Delphi study within a working group of 48 members, including patients, oncologists, general practitioners, nurses and other professionals. The procedure featured three rounds during which participants' judgements were collected via mailed questionnaires and quantitative and qualitative feedback was provided on a regular basis. These three rounds were followed by an evaluation phase. Forty members (83%) participated in the three rounds. According to the agreement reached, the shared record was expected to include a front summary card, four sections for groups of users authorized to write down or insert information in the record (patient, physicians, medical auxiliaries and other healthcare professionals), and one section for medical imaging files. In addition, the record was to include specific categories of information as subsections within each of the various user sections. The participant satisfaction rate was over 90% for all aspects of the procedure, with the exception of interaction within the working group (79%).

[Patient-held health records: impact on breast cancer follow-up in the Rhône-Alpes region. Project Archimed]. / Le dossier de santé détenu par le patient : impact sur le suivi du cancer du sein dans la région Rhône-Alpes. Projet Archimed.

BACKGROUND: The conditions of use and access to medical records have become an important source of interest in the last decade. In this context, our main objective was to assess the impact of a paper patient-held records, shared with healthcare professionals. METHODS: In the particular case of breast cancer management, we identified the expectations of practitioners and patients. Secondly and according to a Delphi method, we defined the content and size of a medical record, which could be held by the patient. Following these preliminary studies, we conducted a randomized controlled trial, comparing patients with usual follow-up to others holding the new record containing essential information for coordination of care. RESULTS: The patient-held record favoured membership and satisfaction of both patients and health professionals. It was used as a communication tool between physicians and patients, but could also cause anxiety to some patients. Patient quality of life, data confidentiality and costs of care remained identical in the two arms. With its benefits for both patients and healthcare professionals, a new concept of medical records was revealed by this study. CONCLUSION: New models for healthcare organization deeply modify the roles and relationships of all the actors in the healthcare system. Further research on patient-held records is needed to evaluate the full range of its benefits and limits.

[Role of gynecologists in the care of women with breast cancer]. / La place des médecins gynécologues libéraux dans la prise en charge des femmes atteintes de cancer du sein.

OBJECTIVES: To describe the role of gynecologists in the care of women with breast cancer, their relationship with hospital specialists and with patients, and their expectations in terms of the quality of this relationship. MATERIALS AND METHODS: A descriptive cross-sectional study was performed in 2002. Two hundred and fifty gynecologists from Rhone Alpes region were randomly selected and received a questionnaire. RESULTS: Sixty-four percent of the polled practitioners answered. Forty-two percent of gynecologists had about 25-50 patients with breast cancer. Their participation in the care principally concerned the phases of diagnosis (99%) and remission (98.5%). Eight percent took part in therapeutic decision making. Ninety-two percent of the gynecologists wanted to receive systematically feedback concerning any consultation or hospitalization and 98% wanted to know the name and address details of the care coordinator. CONCLUSION: Gynecologists are willing to participate in the care of breast cancer patients. This for, they want to have more details about therapy, follow-up and the level of information given to the patients.

Lyme disease in France: a primary care-based prospective study.

To estimate the incidence of Lyme borreliosis in France, describe its clinical presentations, and assess its potential risk factors, we conducted a nationwide prospective study in the French Sentinelles Network, consisting of 1178 general practitioners (GPs). Of these, 875 (74%), i.e. 1.6% of all French GPs, participated in the study from May 1999 to April 2000. Eighty-six cases of Lyme disease were reported and validated, of which 77 (90%) consisted of erythema migrans. At national level, the incidence was estimated at 9.4/100,000 inhabitants. Compared to the French general population, Lyme disease patients were older (P<10(-4)), more were living in rural areas (P<10(-3)), and amongst the working population, more were farmers (P<10(-3)) and fewer, salaried workers (P<0.005). Cervidae density correlated strongly with the estimated regional incidence of Lyme disease (r=0.82). Both incidence data and identified risk factors can help to target measures for its prevention and treatment.

Postdischarge nosocomial infections in primary care.

OBJECTIVE: To study both surgical and nonsurgical nosocomial infections (NIs) seen by primary-care physicians (general practitioners [GPs]) in France. DESIGN: Ongoing surveillance of postdischarge NIs by an organized group of GPs, from August 1997 to July 1999. Both the GP who personally examined the case spontaneously presenting with NI and the responsible hospital physician or surgeon were interviewed by telephone. SETTING: 305 general practices from all French regions. RESULTS: 2,199 (29%) of 7,540 patients referred for hospitalization reconsulted the GP within 30 days of discharge. In 21 (1%) of the 2,199 cases, an NI was diagnosed by the GP and confirmed as plausible by the responsible hospital physician. We diagnosed an NI in 8 (1.3%) of the post-surgical patients and in 13 (0.8%) of the non-surgical cases within the cohort. We saw eight urinary tract infections, seven surgical-site infections, three soft-tissue infections, two respiratory tract infections, and one primary bloodstream infection. In 19 patients (90%), clinical signs of NI appeared within 7 days of discharge. Assuming that all 5,431 patients who were missed for follow-up did not experience any NI, an attack rate of 0.3 per 100 admissions may be estimated for the whole group. CONCLUSION: We diagnosed 1% of NIs following discharge from a hospital in a cohort of 2,199 patients, of which 1.3% were seen post-surgery and 0.8% following nonsurgical admissions. The percentage of postdischarge visits that were for an NI in nonsurgical patients warrants a major effort with feedback to the hospital physician to reduce infection rates.

Postdischarge adverse drug reactions in primary care originating from hospital care in France: a nationwide prospective study.

OBJECTIVE: To describe and estimate the incidence and preventability of postdischarge adverse drug reactions (ADRs) detected in primary care in France. DESIGN: Prospective study of patients referred to hospital by participating general practitioners (GPs). These GPs reported all cases of an adverse reaction to a drug instituted in hospital among patients who consulted them within 30 days of discharge. SETTING: 305 general practices from all French regions. PATIENTS: 7540 patients referred by GPs to private or public hospitals. MAIN OUTCOME MEASURES: The incidence for postdischarge ADRs in primary care, and their preventability. RESULTS: 30 cases of postdischarge ADR were detected in 29 re-consulting patients, yielding a minimal incidence for France of 0.4 per 100 admissions (95% confidence interval 0.3 to 0.6). The ADRs were assessed as serious in 60% of cases. The main drug classes implicated were cardiovascular drugs (8 ADRs), oral anticoagulants (6), psychoactive drugs (4), antidiabetics (3), and opioid analgesics (3). Patients experiencing a postdischarge ADR were older than patients not experiencing one (median age: 77 vs 68 years; p = 0.004). Detected ADRs were considered preventable in 59% of cases. CONCLUSIONS: Physicians and patients should be aware of the possible occurrence of postdischarge ADRs. Patient information in hospital, close postdischarge follow-up of patients at risk, and appropriate transmission of information between hospital physicians and GPs can help to prevent them.

Reliability of report coding of hospital referrals in primary care versus practice-based coding.

Coding of medical data according to a suitable classification is useful to epidemiological research in primary care but its implementation at practice-based level may be considered as extra work by participating practitioners. Secondary coding from reported data can be considered as a possible alternative to practice-based coding. The purpose of this study was to assess the inter-rater reliability of report coding versus practice-based coding of morbidity data. Via teleinformatics, 300 French general practitioners from the French Sentinel epidemiological network transmitted in free text, on a continuous real-time basis, the health problems generating each hospital referral they made since August 1997. All these reports were centrally coded according to the International Classification of Primary Care (ICPC). A subsample of 120 reports were coded in local practices for comparison. Codes resulting from blind centralized free-text coding were compared with practice-based codes. For the 120 referrals reported, the K measure of agreement for the number of codes was 0.65 (95% confidence interval [CI], CI: 0.52-0.77), and for the chapters selected, 0.84 (95% CI: 0.78-0.91). Discrepancies attributable to the centralized coding only occurred for 7.5% of the referrals, and were due to the lack of specificity of the information transmitted as free text. A thesaurus of correspondences between problem(s) generating referrals and ICPC codes was built from 5000 referrals, and has been used routinely for the automated report coding of an additional sample of 1691 referrals. We conclude that centralized coding is a reliable alternative to practice-based coding in primary care, provided that physicians give sufficiently specific information.

Automatic coding of reasons for hospital referral from general medicine free-text reports.

Although the coding of medical data is expected to benefit both patients and the health care system, its implementation as a manual process often represents a poorly attractive workload for the physician. For epidemiological purpose, we developed a simple automatic coding system based on string matching, which was designed to process free-text sentences stating reasons for hospital referral, as collected from general practitioners (GPs). This system relied on a look-up table, built up from 2590 reports giving a single reason for referral, which were coded manually according to the International Classification of Primary Care (ICPC). We tested the system by entering 797 new reasons for referral. The match rate was estimated at 77%, and the accuracy rate, at 80% at code level and 92% at chapter level. This simple system is now routinely used by a national epidemiological network of sentinel physicians.

Risk factors of acute diarrhoea in summer--a nation-wide French case-control study.

The aim of this study was to identify risk factors for acute diarrhoea (AD) during the summer in France. A matched case-control study was conducted at a national level among patients of 500 general practitioners (GPs). From July to September 1996, 468 case-control pairs were included. Cases were more likely than controls (i) to live away from their main residence (OR 3.0; 95% CI 1.6-5.7), (ii) to have returned from a country at high risk of AD (OR 4.6; CI 0.9-23.1), and (iii) to have been in contact with a case of AD (OR 2.0; CI 1.3-3.1). A significantly decreased risk of AD was found for consumption of well-cooked chicken (OR 0.5; CI 0.3-0.8) and raw or undercooked home-made egg-containing products (OR 0.6; CI 0.4-0.8). These findings suggest that travel to high-risk areas, or travel within France, and being in contact with a case of AD, are risk factors for the occurrence of AD in summer in France.