Prescription-free consultation: A cross-sectional study in general practice.

PURPOSE: In 2005, 10% of consultations in France ended without a prescription. In 2019, a review of the literature found 30 to 70% of prescription-free consultations in Northern Europe and 10 to 22% in Southern Europe and underlined the scarcity of quantitative data. Different factors contribute to this heterogeneity, such as product availability and status, modes of management, distribution channels, clinical practice recommendations, public policies targeting certain classes, etc. The main objective of our study was to quantify the rate of prescription-free consultations in general practice in France in 2021. The secondary objective was to characterize prescription-free consultations and analyze their determinants. METHODS: This was a quantitative observational study conducted using self-questionnaires among patients in medical practices in Auvergne. RESULTS: Out of 540 questionnaires, the rate of prescription-free consultations was 24% (95% CI [20.11-27.41]). Prescription-free consultations were for prevention, administrative problems, and gestures. The limiting factors are "feeling a need for a medication" (OR=0,006), "not knowing if a medication is needed" (OR=0.11) and "consultations for acute reasons" (OR=0.33). CONCLUSION: Acute consultations limit prescription-free consultations. General practitioners (GPs) probably overestimate patients' expectation of drug prescription. The French GP must be supported in their decision to not prescribe drugs. This is a long-term investment of time, to educate patients and avoid new consultations for acute reasons. A tool to help doctors manage non-prescription during acute consultations will be created in a future study in France.

Project rebuild the evidence base (REB): A method to interpret randomised clinical trials and their meta-analysis to present solid benefit-risk assessments to patients.

Evidence-based medicine is the cornerstone of shared-decision making in healthcare today. The public deserves clear, transparent and trust-worthy information on drug efficacy. Yet today, many drugs are prescribed and used without solid evidence of efficacy. Clinical trials and randomised clinical trials (RCTs) are the best method to evaluate drug efficacy and side effects. In a shared medical decision-making approach, general practitioners need drug assessment based on patient-important outcomes. The aim of project rebuild the evidence base (REB) is to bridge the gap between the data needed in clinical practice and the data available from clinical research. The drugs will be assessed on clinical patient important outcomes and for a population. Using the Cochrane tools, we propose to analyse for each population and outcome: 1) a meta-analysis based on RCTs with a low risk of bias overall; 2) an evaluation of results of confirmatory RCTs; 3) a statistical analysis of heterrogeneity between RCTs and 4) an analysis of publication bias. Depending on the results of these analyses, the evidence will be categorized in 4 different levels: firm evidence, evidence (to be confirmed), signal or absence of evidence. Project REB proposes a method for reading and interpreting RCTs and their meta-analysis to produce quality data for general practitioners to focus on risk-benefit assessment in the interest of patients. If this data does not exist, it could enable clinical research to better its aim.

Implementation of shared decision-making and patient-centered care in France: Towards a wider uptake in 2022.

We present the evolution of patient-centered care (PCC) and shared decision-making (SDM) in France since 2017, highlighting advantages and drawbacks of their implementation at the macro level. We then focus on several key policy and legislative milestones that are aimed to develop PCC and SDM. These milestones underline the importance of patient movements to support and fund the development of research and practice in the field. We shall conclude by presenting the growing research agenda and selected key topics. These key topics notably include the increase in both patient and healthcare professional trainings on PCC and SDM provided by healthcare users' and patients' representatives. PCC and SDM continue to be central preoccupations at the macro level, supported by public health policies and patients/healthcare users' actions. This overview, however, suggests that although implementation initiatives have increased since 2017, implementation remains scarce in routine clinical practice. Funding, not only for research projects, but for the implementation of PCC and SDM in real-life settings (e-decision aids, clinical guidelines integrating PCC/SDM, human resources dedicated to PCC/SDM, etc.) are needed to promote sustained adoption. More systematic training for both healthcare professionals and patients is also warranted for a true acculturation to occur.

[Comparative study in primary care of the stability of INR in patients treated with warfarin or fluindione for atrial fibrillation. The FLOWER study (FLuindione Or WarfarinE - Result INR)]. / Étude comparative en soins primaires du taux d'INR dans la cible thérapeutique chez des patients traités par warfarine ou fluindione pour une fibrillation atriale. L'étude FLOWER (FLuindione Or WarfarinE ­ Result INR).

INTRODUCTION: The aim of our study was to compare the time spent within the target INR or Time in Therapeutic Range (TTR) of patients treated with fluindione to that of patients treated with warfarin for non-valvular atrial fibrillation (NVAF) and followed in general practice, with the hypothesis of a better TTR with warfarin, which is the VKA most commonly prescribed in France. METHOD: Liberal nurses and general practitioners working in the Auvergne region recruited patients treated with fluindione or warfarin for NVAF. Patients' INRs (International Normalized Ratios) were recorded by medical analysis laboratories for 6 months. The primary endpoint was TTR, the secondary endpoint the number of hemorrhagic and/or thromboembolic events. RESULTS: Of the 342 participants with a mean age of 75.3 ± 9.8 years, 239 (70%) were treated with fluindione and 103 (30%) with warfarin. The mean number of INRs achieved per patient was 9.2 ± 4.0 in the fluindione group and 9.3 ± 4.0 in the warfarin group (p=0.73). The median TTR of fluindione was 81.9% [63.5; 94.1] and that of warfarin was 81.3% [65.6; 92.6] (p=0.98). Twenty-eight of 263 patients reported hemorrhage (10.6%) and 4 reported thromboembolic events (0.8%), with no significant difference between the groups. CONCLUSION: The TTRs of patients treated for NVAF with fluindione versus warfarin do not differ significantly over an observation period of 6 consecutive months in a patient population comparable to that of the publications in this field. However, these TTRs are significantly higher than those reported in the literature, with no difference between the two treatments. The TTRs of patients treated for VANF with fluindione versus warfarin do not differ significantly over a 6-month observation period in a patient population comparable to that of the publications in this indication.

"I Can't Go Far": Perceptions and Experiences of Heart Failure Patients Regarding Physical Activity: A Qualitative Study Using Semistructured Face-to-Face Interviews.

BACKGROUND: Participation in regular physical activity (RPA) is beneficial to the quality of life and life expectancy of patients with chronic heart failure (CHF). However, it is inadequate in many patients. AIMS: To determine the factors that influence the practice of RPA in patients with CHF managed in general practice. METHOD: This was a qualitative study using semistructured, individual face-to-face interviews. Patients with CHF (New York Heart Association Stages 1-3) capable of participating in RPA were enrolled by their general practitioner. A longitudinal and transversal inductive thematic analysis was performed by two researchers. RESULTS: Five themes emerged from the 19 interviews that were conducted. Poor knowledge of the disease and the benefits of participating in RPA, as well as the lack of motivation or enjoyment, in particular due to the absence of previous participation, were considered significant obstacles. Fear associated with CHF or other comorbidities was also an obstacle. Attendance at a rehabilitation center, family and social circles, and having a pet all appeared to be beneficial. Family and friends were important for motivating the patient to participate in an activity but could also be an obstacle when they were overprotective. CONCLUSION: This study helps highlight the difficulties for patients with CHF associated with participation in RPA. Despite the obstacles, there are enabling factors on which the general practitioner may rely to motivate their patients.

Benefits and adverse effects of sacubitril/valsartan in patients with chronic heart failure: A systematic review and meta-analysis.

This review aims to assess the benefits and adverse effects of sacubitril/valsartan in heart failure, with a focus on important patient outcomes. A systematic review was conducted of double-blind randomized controlled trials (RCTs) comparing sacubitril/valsartan versus a reference drug, in heart failure patients with reduced (HFrEF) and preserved (HFpEF) ejection fraction, published in French or English. Searches were undertaken of Medline, Cochrane Central, and Embase. The primary outcomes were all-cause mortality and adverse events. From 2 082 articles analyzed, 5 were included. For all-cause mortality, the absolute numbers for HFrEF (2 RCTs, 4627 patients) were 16% on sacubitril/valsartan and 18% on enalapril, with a risk ratio (RR) of 0.85 [CI = 0.78, 0.93], and 13% vs 14% in with HFpEF (2 RCTs, 5097 patients), with no statistical difference. Under the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, the evidence for HFrEF patients was of moderate quality. For HFrEF patients, an increased risk of symptomatic hypotension and angioedema (low quality of evidence) was shown. There was no statistical difference for the risk of hyperkalemia or worsening renal function. There was a protective RR (0.50 [0.34, 0.75]) for worsening renal function for patients with HFpEF, with a high quality of evidence despite similar absolute numbers (1.4% vs. 2.8%). To keep in mind for shared decision-making, sacubitril/valsartan reduces all-cause mortality in HFrEF patients but for HFpEF further data are needed. Take into consideration the small number of studies to date to assess the risks.