Interprofessional follow-up of patients with cancer in France (the SINPATIC study): a preliminary, qualitative study of the patient's perspective.

BACKGROUND: In 2020, 19.2 million people were diagnosed with cancer, and nearly 10 million cancer patients died worldwide. An effective cancer care pathway must be based on coordination, multidisciplinarity, a personalized approach, and collaboration between stakeholders. Follow-up can be improved by good collaboration and communication between GPs and the cancer care team at a common level of organization. OBJECTIVES: To study patients with solid cancers and assess their perceptions of the care pathway, the roles of the healthcare professionals involved, and interprofessional collaboration. METHODS: In a preliminary, qualitative study (part of the SINPATIC study of general practitioners, oncologists, nurses, and patients), adult patients with cancer in the Paris area of France were interviewed between January and April 2018. Using purposive sampling, 10 patients were recruited from hospital departments and primary care. An interview guide explored 3 themes: the care pathway, the stakeholders' roles in follow-up, and interprofessional collaboration. RESULTS: For patients, dealing with cancer is a complex process of awareness, care provision, decision-making, task assignment, a lack of clarification of professional roles, a piecemeal announcement of the diagnosis of cancer by several stakeholders, organizational and administrative difficulties, non-formal collaboration in inertia (tending towards collaboration under construction), and with cancer follow-up that was usually parallel, sometimes shared, rarely sequential. CONCLUSION: This SINPATIC substudy provided us a better understanding of the complexity of the patient care pathway. Looking forward, the present findings might stimulate thoughts on the design and development of interventional studies.

Changes over time in attitudes towards the management of older patients with heart failure by general practitioners: a qualitative study.

BACKGROUND: Underdiagnosis and undertreatment of chronic heart failure (CHF) are common in older patients, who are usually treated by general practitioners (GPs). In 2007, the French ICAGE study explored GPs' attitudes to the management of this condition in older patients. OBJECTIVES: To explore changes over time in GPs' attitudes towards the management of CHF in patients aged ≥75 and to identify barriers to optimal management. METHODS: In 2015, we performed a qualitative study of 20 French GPs via semi-structured interviews and a thematic content analysis. The results were compared with the findings of a 2007 study. RESULTS: In 2015, the perceived barriers to diagnosis were the same as in 2007. Echocardiography was still the preferred diagnostic method but the GPs relied on the cardiologist to confirm the diagnosis. Many GPs were still unaware of the different types of CHF. In contrast, they reported greater knowledge of decompensation factors and the ultrasound criteria for CHF. They also prescribed a brain natriuretic peptide assay more frequently. Angiotensin-converting enzyme inhibitors and beta blockers were more strongly perceived to be core treatments. Few GPs initiated drug treatments and optimized dosages. Although patient education was never mentioned, the importance of multidisciplinary care was emphasized. CONCLUSION: Our results evidenced a small recent improvement in the management of older patients with CHF. Appropriate guidelines and training for GPs, patient education and multidisciplinary collaboration might further improve the care given to this population.

Self-medication in pain management: The state of the art of pharmacists' role for optimal Over-The-Counter analgesic use.

BACKGROUND AND OBJECTIVE: Self-medication is associated with an important utilization of Over-The-Counter (OTC) analgesics. The medical outcome resulting from therapeutic options bypassing the physician prescription is a major issue. In that context, pharmacists are expected to play a crucial role. The main objective of this review was to analyse the state-of-the art of pharmacists' role in pain management self-medication. DATABASES AND DATA TREATMENT: An expert multidisciplinary group dedicated to self-medication in pain was established. Selection of publications was performed from PubMedand EMBASE databases which was based on the use of "pain" and/or "self-medication" and/or "self-care" and/or "analgesics" and/or "painkillers" keywords, restricted to the past 10 years. RESULTS: A total of 480 papers were identified, 49 of which papers were considered relevant and finally kept for final discussion, on OTC pain management and pharmacist's role. Literature analysis demonstrates that OTC analgesics are generally safe when appropriately used. Risks associated with misuse or inappropriateness depend on patients' vulnerability (elderly, pregnancy) or behaviour. Social cognitive theory-based intervention and multimedia applications improve self-medication but do not replace health care professional advice Pharmacists' interventions may improve the benefits and safety of OTC analgesic medication, with a better management of pain. CONCLUSIONS: Considering the heterogeneity of patients' knowledge and behaviour reported worldwide, inappropriate use of OTC pain medication should not be underestimated. Community pharmacists are ideally placed to guide self-medication or recommend a medical advice when needed. Embedding pharmacists in primary care pain management is essential and pharmacist-led medication coupled with an appropriate training of pharmacy staffs should be encouraged. SIGNIFICANCE: Analgesics are widely used without prescription, all over the world. They represent the largest market of OTC drugs, with an overall benefit/risk ratio favourable when appropriately used. Because of potential individual risks associated to the ailment or to the patient's behaviour, pharmacists' interventions have proven to optimize analgesic self-medication, provided that pharmacy staffs are both available and more specifically trained. In the future, in pain management, especially self-medication, pharmacists should play an increasing role and should be included in educational programmes and pain management guidelines.

[Improving the complementarity of patient education proposals: Experience feedback and recommendations]. / Améliorer la complémentarité des offres d'éducation thérapeutique du patient : retour d'expérience et recommandations.

INTRODUCTION: Implementing patient education (PE) in a defined geographic area, based on a population-based approach, implies using community resources according to a logic of complementarity, in order to mitigate the risk of rupture in patient care. METHODS: The PE Resource Centre for the Ile-de-France Region convened a multidisciplinary and multi-setting meeting attended by 45 participants in order to define the ways to improve the complementarity of all available PE resources, while taking into account the diversity of patients' needs. Three working groups successively explored three dimensions: structure, processes and outcomes, in order to assess this complementarity. RESULTS: Each group worked on three aspects: PE resources; patient's health trajectory in a defined geographic area, and a multidisciplinary team approach.Participants identified various deficits: clustering and lack of visibility for PE resources, programme framing constraints and difficulties of access for patients. Nevertheless, they highlighted several positive elements emerging from their shared experience. They recommend: 1) sharing of the available resources by developing communication and multidisciplinary training and more flexible programme formats; 2) building links between stakeholders, by promoting local PE programmes, and by encouraging coordination and practice analysis; 3) using and articulating a diversity of evaluation approaches, while reinforcing the multidimensional nature of PE contributions, not only for patients but also for professionals and the healthcare system. DISCUSSION: PE Resource Centres may facilitate implementation of these recommendations by supporting a collective and dynamic approach, contributing to a reduction of social inequalities in PE access.

[COPD patient care pathways: points of view of hospital personnel]. / Trajectoires de soins des patients ayant une bronchopneumopathie chronique obstructive: points de vue des acteurs hospitaliers.

INTRODUCTION: The aim of this study was to identify, from an hospital point of view, the care pathways of patients with chronic obstructive pulmonary disease (COPD) between the ambulatory and in-hospital settings in two regions to the East of Paris (Val-de-Marne and Seine-et-Marne). METHODS: A qualitative multisite case study was conducted from January to October 2012 with hospital doctors managing patients with COPD. Semi-structured individual interviews were carried out with 46 hospital practitioners from the 25 main hospitals of this area. RESULTS: A marked variability in care pathways was observed between the 25sites studied, but no typology could be established. The care pathways depended on the configuration of the available local medical facilities. The main finding of this study was the global lack of coordination between ambulatory care and in-hospital care of patients before and after hospitalization. DISCUSSION: The care pathways identified concerned the probably most severely ill patients who frequently attend hospital emergency rooms. The lack of pre-hospital coordination for the management of acute exacerbations resulted in a very high hospitalization rate. However, international studies have showed that a better management in an ambulatory care setting reduced significantly the hospitalization rates. The problem ofcoordination between ambulatory and in-hospital carefor optimizing of the care pathways remains unsolved in the territories studied here. This example of COPD care shows that a better management of patients with chronic diseases requires a restructuring of the local health care systems in France.

[Frequency, modes, and determinants of patients' nutritional education in family medicine: the Nutrimege study]. / Fréquence, modalités et déterminants de l'éducation nutritionnelle des patients en médecine générale: l'étude Nutrimège.

BACKGROUND: Nutritional education is one of the tasks of the family physicians. The aims of the Nutrimege study were to describe the frequency and modes of patients' nutritional education in family medicine, the characteristics of family physicians and patients involved, and its impact on the consultation length. METHODS: Cross-sectional study, performed with questionnaires mailed to sixty family physicians from the Val-de-Marne in December 2007. Each physician had to include the first ten patients seen during a given day. RESULTS: 45 family physicians participated, allowing the inclusion of 410 patients. The sample of family physicians was representative of the physicians in Val-de-Marne and in France. Nutritional counseling was delivered in 42.4% of consultations (95% CI: 37.6-47.2%). It mainly consisted in a dietary advice (90.2%), delivered orally (80.5%), at the initiative of the physician (81.6%). Collaborating with other healthcare professionals for nutritional purposes was rare (5.4%). Nutritional counseling was especially delivered for secondary prevention, to patients either aged 40 or older, obese, having one or more chronic conditions. The physicians who delivered nutritional counseling most were aged 45 and over, were practicing with free fees agreement, and had a specific practice. When nutritional counseling was delivered, the consultation lasted one minute more on average. CONCLUSION: The use of written tailored media (edited with appropriate computer tools), a better collaboration with other healthcare professionals, and the strengthening of the medical training on preventive medicine may help to improve the quality of patients' nutritional education process.