How does the quality of care for type 2 diabetic patients benefit from GPs-nurses' teamwork? A staggered difference-in-differences design based on a French pilot program.

In many countries, policies have explicitly encouraged primary care teams and inter-professional cooperation and skill mix, as a way to improve both productive efficiency gains and quality improvement. France faces barriers to developing team working as well as new and more advanced roles for health care professionals including nurses. We aim to estimate the impact of a national pilot experiment of teamwork between general practitioners (GPs) and advance practitioners nurses (APN)-who substitute and complement GPs-on yearly quality of care process indicators for type two diabetes patients (T2DP). Implemented by a not-for-profit meso-tier organisation and supported by the Ministry of Health, the pilot relied on the voluntary enrolment of newly GPs from 2012 to 2015; the staffing and training of APNs; skill mixing and new remuneration schemes. We use latent-response formulation models, control for endogeneity and selection bias by using controlled before-after and quasi-experimental design combining coarsened exact matching-prior to the treatment, at both GPs (435 treated vs 973 control) and T2DP levels -, with intention to treat (ITT; 18,310 in each group) and per protocol (PP, 2943 in each group) perspectives, as well as difference-in-differences estimates on balanced panel claims data from the National Health Insurance Fund linked to clinical data over the period 2010-2017. We show evidence of a positive and significant positive impact for T2DP followed-up by newly enrolled GPs in the pilot compared to the pretreatment period and the control group. The effect magnitudes were larger for PP than for ITT subsamples.

Do gender differences affect the doctor-patient interaction during consultations in general practice? Results from the INTERMEDE study.

OBJECTIVE: The aim of the study was to ascertain whether disagreement between GPs and patients on advice given on nutrition, exercise and weight loss is related to patient-doctor gender discordance. Our hypothesis is that a patient interacting with a physician of the same gender may perceive more social proximity, notably on health care beliefs and may be more inclined to trust them. METHODS: The analysis used the Intermede project's quantitative data collected via mirrored questionnaires at the end of the consultation. Multilevel logistic regressions were carried out to explore associations between patient-doctor gender discordance and their disagreement on advice given during the consultation adjusted on patients' and physicians' characteristics. The sample consists of 585 eligible patients and 27 GPs. RESULTS: Disagreement on advice given on nutrition was observed less often for female concordant dyads: OR = 0.25 (95% CI = 0.08-0.78), and for female doctors-male patients dyads: OR = 0.24 (95% CI = 0.07-0.84), taking the male concordant dyads as reference. For advice given on exercise, disagreement was found less often for female concordant dyads OR = 0.38 (95% CI = 0.15-0.98) and an interdoctor effect was found (P < 0.05). For advice given on weight loss, the probability of disagreement was significantly increased (OR: 2.87 95% CI = 1.29-6.41) when consultations consisted of female patient and male GP. CONCLUSION: Patient-doctor gender concordance/discordance is associated with their agreement/disagreement on advice given during the consultation. Physicians need to be conscious that their own demographic characteristics and perceptions might influence the quality of prevention counseling delivered to their patients.

Is perceived social distance between the patient and the general practitioner related to their disagreement on patient's health status?

OBJECTIVE: To ascertain whether disagreement between patients and general practitioners (GP) on the patient's health status varies according to their respective perceived social distance (PSD). METHODS: The analysis used the Intermede project's quantitative data collected from 585 patients and 27 doctors via mirrored questionnaires. GPs and patients ranked their own perceived social position (PSP) in society, and their patients' and their GP respectively. PSD was calculated as the PSP's subtraction from the patients' and GPs' assessments. RESULTS: Disagreement between GPs and patients regarding the patient's health status was associated with PSD by the GP whereas it was not associated with PSD by the patient. In the multilevel analysis, disagreement whereby GPs overestimate patient's health status increased within PSD by the GP: OR:2.9 (95%CI = 1.0-8.6, p = 0.055) for low PSD, OR:3.4 (95%CI = 1.1-10.2, p < 0.05) for moderate PSD and OR:3.8 (95%CI = 1.1-13.1, p < 0.05) for high PSD (reference: no distance). CONCLUSIONS: Patients perceived with a lower social position by their GP and who consider themselves to have poor health are less likely to be identified in the primary care system. PRACTICE IMPLICATIONS: Physicians need to be conscious that their own perception influences the quality of the interaction with their patients, potentially resulting in unequal health care trajectories.

Do general practitioners overestimate the health of their patients with lower education?

This study sought to ascertain whether disagreement between patients and physicians on the patients' health status varies according to patients' education level. INTERMEDE is a cross-sectional multicentre study. Data were collected from both patients and doctors via pre- and post consultation questionnaires at the GP's office over a two-week period in October 2007 in 3 regions of France. The sample consists of 585 eligible patients (61% women) and 27 GPs. A significant association between agreement/disagreement between GP and patient on the patient's health status and patient's education level was observed: 75% of patients with a high education level agreed with their GP compared to 50% of patients with a low level of education. Patients and GPs disagreed where patients with the lowest education level said that their health was worse relative to their doctor's evaluation 37% of the time, versus 16% and 14% for those with a medium or high education level respectively. A multilevel multivariate analysis revealed that patients with a low educational level and medium educational level respectively were at higher risk of being overestimated by GP's in respect of self-reported health even if controlling for confounders. These findings suggest that people with a lower education level who consider themselves to have poor health are less reliably identified as such in the primary care system. This could potentially result in lack of advice and treatment for these patients and ultimately the maintenance of health inequalities.

Do doctors and patients agree on cardiovascular-risk management recommendations post-consultation? The INTERMEDE study.

BACKGROUND: Understanding interactions between patients and GPs may be important for optimising communication during consultations and improving health promotion, notably in the management of cardiovascular risk factors. AIM: To explore the agreement between physicians and patients on the management of cardiovascular risk factors, and whether potential disagreement is linked to the patient's educational level. DESIGN OF STUDY: INTERMEDE is a cross-sectional study with data collection occurring at GPs' offices over a 2-week period in October 2007 in France. METHOD: Data were collected from both patients and doctors respectively via pre- and post-consultation questionnaires that were 'mirrored', meaning that GPs and patients were presented with the same questions. RESULTS: The sample consisted of 585 eligible patients (61% females) and 27 GPs. Agreement between patients and GPs was better for tangible aspects of the consultation, such as measuring blood pressure (κ = 0.84, standard deviation [SD] = 0.04), compared to abstract elements, like advising the patient on nutrition (κ = 0.36, SD = 0.04), and on exercise (κ = 0.56, SD = 0.04). Patients' age was closely related to level of education: half of those without any qualification were older than 65 years. The statistical association between education and agreement between physicians and patients disappeared after adjustment for age, but a trend remained. CONCLUSION: This study reveals misunderstandings between patients and GPs on the content of the consultation, especially for health-promotion outcomes. Taking patients' social characteristics into account, notably age and educational level, could improve mutual understanding between patients and GPs, and therefore, the quality of care.

Patient-physician interaction in general practice and health inequalities in a multidisciplinary study: design, methods and feasibility in the French INTERMEDE study.

BACKGROUND: The way in which patients and their doctors interact is a potentially important factor in optimal communication during consultations as well as treatment, compliance and follow-up care. The aim of this multidisciplinary study is to use both qualitative and quantitative methods to explore the 'black box' that is the interaction between the two parties during a general practice consultation, and to identify factors therein that may contribute to producing health inequalities. This paper outlines the original multidisciplinary methodology used, and the feasibility of this type of study. METHODS AND DESIGN: The study design combines methodologies on two separate samples in two phases. Firstly, a qualitative phase collected ethnographical and sociological data during consultation, followed by in-depth interviews with both patients and doctors independently. Secondly, a quantitative phase on a different sample of patients and physicians collected data via several questionnaires given to patients and doctors consisting of specific 'mirrored' questions asked post-consultation, as well as collecting information on patient and physician characteristics. DISCUSSION: The design and methodology used in this study were both successfully implemented, and readily accepted by doctors and patients alike. This type of multidisciplinary study shows great potential in providing further knowledge into the role of patient/physician interaction and its influence on maintaining or producing health inequalities. The next challenge in this study will be implementing the multidisciplinary approach during the data analysis.