Participation rate in cervical cancer screening in general practice related to the proximity of gynecology care facilities: A 3 year follow-up cohort study.

Cervical cancer screening (CCS) by Pap tests is mainly performed by gynecologists in France, but also by general practitioners (GPs) and midwives. The screening uptake is insufficient to reduce the incidence of cervical neoplasms. Our aim was to investigate the association between screening rates in patients listed with GPs and the distance between GPs' offices and gynecology facilities. The population of 345 GPs, and their 93,918 female patients eligible for screening over 3 years (2013-2015), were derived from the Health Insurance claim database. We estimated the socioeconomic level of the geographical area of GPs' offices using the European Deprivation Index (EDI). The proximity of gynecology facilities was calculated by computing their distance from GPs' offices (in order to adjust the proximity of gynecology facilities with EDI and performance of smears by the GP). The number of gynecologists within 5 km of a GP's office was associated with the CCS rate increasing by 0.31% for every unit increase in the density of gynecologists within 5 km (p < 0.0001). The close proximity of gynecology facilities was not significantly associated with screening uptake among female patients when the office of the GP where they were registered was settled in a deprived area.

Defining and evaluating the Hawthorne effect in primary care, a systematic review and meta-analysis.

In 2015, we conducted a randomized controlled trial (RCT) in primary care to evaluate if posters and pamphlets dispensed in general practice waiting rooms enhanced vaccination uptake for seasonal influenza. Unexpectedly, vaccination uptake rose in both arms of the RCT whereas public health data indicated a decrease. We wondered if the design of the trial had led to a Hawthorne effect (HE). Searching the literature, we noticed that the definition of the HE was unclear if stated. Our objectives were to refine a definition of the HE for primary care, to evaluate its size, and to draw consequences for primary care research. We designed a Preferred Reporting Items for Systematic reviews and Meta-Analyses review and meta-analysis between January 2012 and March 2022. We included original reports defining the HE and reports measuring it without setting limitations. Definitions of the HE were collected and summarized. Main published outcomes were extracted and measures were analyzed to evaluate odds ratios (ORs) in primary care. The search led to 180 records, reduced on review to 74 for definition and 15 for quantification. Our definition of HE is "an aware or unconscious complex behavior change in a study environment, related to the complex interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias and observation and measurement bias." Its size varies in time and depends on the education and professional position of the investigators and subjects, the study environment, and the outcome. There are overlap areas between the HE, placebo effect, and regression to the mean. In binary outcomes, the overall OR of the HE computed in primary care was 1.41 (95% CI: [1.13; 1.75]; I 2 = 97%), but the significance of the HE disappears in well-designed studies. We conclude that the HE results from a complex system of interacting phenomena and appears to some degree in all experimental research, but its size can considerably be reduced by refining study designs.

Does hip or knee joint replacement decrease chances to complete an ultra-trail race? Study in participants at the Ultra-Trail du Mont Blanc®.

INTRODUCTION: The number of patients with hip or knee joint replacements is increasing. Some of these patients want to practice sport, including in high-impact sports such as ultra-trails. Is the proportion of drop-out higher among runners after a hip or knee replacement? What are the symptoms of these patients? HYPOTHESIS: Hip or knee joint replacements are associated with a higher drop-out rate during an ultra-trail. MATERIAL AND METHODS: We conducted a monocentric retrospective epidemiological study. A questionnaire translated into French, English and Spanish were sent to all runners registered for one or more of the 5 races of the 2015 to 2017 Ultra-Trail du Mont-Blanc® (UTMB®) editions. There were no exclusion criteria. The drop-out rate of patients who responded to the questionnaire was calculated among patients with and without hip or knee joint replacement. Specific symptoms related to these joint replacements were identified before, during and after the race. RESULTS: Out of the 24,855 participants having run at least one of the 3 editions, 2,469 responded. Some of them ran several races: these 2469 runners were on 3171 start lines and 2548 finish lines (drop-out rate of 19.6%). Among these 2469 runners, 18 had hip and/or knee replacement and were on 27 start lines and 17 finish lines (drop-out rate of 37%). The race was finished by 3 of the 6 runners with a total hip arthroplasty (THA), all of the 8 runners with a hip resurfacing arthroplasty (HRA) and 3 of the 4 runners with a total knee arthroplasty (TKA). Among runners with THA, pubalgia or groin pain was described by one of them before the race, 3 during the race and 2 after the race. Among runners with HRA, pygalgia or groin pain was described by 2 of them during the race. As for the TKA, there was no specific symptom. No answering runner had a unicompartmental knee prosthesis. DISCUSSION: Running ultra-trail is possible after a hip or knee joint replacement. All of the 8 runners with HRA finished the race. We may remain cautious about the long-term survival of prostheses. LEVEL OF PROOF: IV; monocentric retrospective epidemiological study.

The association between cervical cancer screening participation and the deprivation index of the location of the family doctor's office.

BACKGROUND: Cervical cancer screening rates are known to be strongly associated with socioeconomic status. Our objective was to assess whether the rate is also associated with an aggregated deprivation marker, defined by the location of family doctors' offices. METHODS: To access this association, we 1) collected data from the claim database of the French Health Insurance Fund about the registered family doctors and their enlisted female patients eligible for cervical screening; 2) carried out a telephone survey with all registered doctors to establish if they were carrying out Pap-smears in their practices; 3) geotracked all the doctors' offices in the smallest existing blocks of socioeconomic homogenous populations (IRIS census units) that were assigned a census derived marker of deprivation, the European Deprivation Index (EDI), and a binary variable of urbanization; and 4) we used a multivariable linear mixed model with IRIS as a random effect. RESULTS: Of 348 eligible doctors, 343 responded to the telephone survey (98.6%) and were included in the analysis, encompassing 88,152 female enlisted patients aged 25-65 years old. In the multivariable analysis (adjusted by the gender of the family doctor, the practice of Pap-smears by the doctor and the urbanization of the office location), the EDI of the doctor's office was strongly associated with the cervical cancer screening participation rate of eligible patients (p<0.001). CONCLUSION: The EDI linked to the location of the family doctor's office seems to be a robust marker to predict female patients' participation in cervical cancer screening.

Audiovisual aids in primary healthcare settings' waiting rooms. A systematic review.

BACKGROUND: Health promotion is part of GPs' commitments. Some waiting rooms have therefore been implemented with audiovisual aids (posters, pamphlets or screens) for health promotion purposes. Few studies have assessed the effect of audiovisual aids in primary care. OBJECTIVES: To identify, describe and appraise studies that have investigated the effects of audiovisual aids on health promotion in primary healthcare waiting rooms. To determine which factors influence this impact through literature review. METHODS: Systematic review. Two independent researchers using predefined keywords searched databases. Additional publications were extracted from the reference lists of the selected articles. The selection of the articles was performed on the title and abstract, followed by complete reading and assessment. Bias and level of evidence were analysed. RESULTS: A total of 909 articles were collected. Most of them were not in primary care settings. Fourteen peer-reviewed articles fully meeting inclusion criteria were included and analysed. Good quality studies were scarce. Eight of these articles using videos or slideshows on TV screens or tablets indicated effects: three of them were significant on patient knowledge with acceptable evidence and three on health behaviour on surrogate endpoints. Audiovisual aids seem to be used or noticed by patients and can induce conversations with physicians. The relevant factors that might influence these effects (duration of exposure, conception quality, theme, target population and time spent in the waiting room) are insufficiently investigated. CONCLUSION: Audiovisual aids broadcasting messages using screens (TVs, computers, tablets, and smartphones with Bluetooth® pairing) probably enhance patients' knowledge. A change in health behaviour remains controversial.

The Effect of Cervical Smears Performed by General Practitioners on the Cervical Cancer Screening Rate of their Female Patients: A Claim Database Analysis and Cross-Sectional Survey.

PURPOSE: Cervical cancer screening reduces the incidence and specific mortality rate of cervical neoplasms. In most cases screening by means of Pap smears is performed in France by gynecologists. The primary objective of this study was to confirm whether the participation rate is increased when general practitioners (GPs) carry out the smears themselves. The secondary objective was to evaluate other independent characteristics of GPs predicting participation rates in women. METHODS: The population of 347 GPs, including their relevant characteristics and their 90,094 female patients eligible for screening over 2 years (2013-2014), was derived from the SIAM claim database of the Flanders Healthcare Insurance Fund (CPAM). A telephone survey among all GPs was carried out to know whether they were performing smears in their surgeries. RESULTS: A total of 343 GPs were included for analysis (98.8% participation rate). The mean cervical cancer screening participation rate over 2 years among all the women in the recommended age group (25-65 years) was 43.3% (±6.9). Bivariate analysis showed that participation rate was higher when the GP performed smears (adjusted difference of mean: 2.06 [95% CI: 0.67-3.45], p = 0.037) and whether the GP was female (2.08 [0.42-3.74], p = 0.0144). After multivariate analysis the only significant characteristic of the GP was the performance of smears (1.71 [0.27-3.16], p = 0.0204). CONCLUSIONS: Cervical smears performed by GPs led to increased screening participation rates within the recommended age group of women. However, the size of this increase is insufficient to reach the expected participation rates.

Randomized controlled trial on promoting influenza vaccination in general practice waiting rooms.

BACKGROUND: Most of general practitioners (GPs) use advertising in their waiting rooms for patient's education purposes. Patients vaccinated against seasonal influenza have been gradually lessening. The objective of this trial was to assess the effect of an advertising campaign for influenza vaccination using posters and pamphlets in GPs' waiting rooms. METHODS AND FINDINGS: Registry based 2/1 cluster randomized controlled trial, a cluster gathering the enlisted patients of 75 GPs aged over 16 years. The trial, run during the 2014-2015 influenza vaccination campaign, compared patient's awareness from being in 50 GPs' standard waiting rooms (control group) versus that of waiting in 25 rooms from GPs who had received and exposed pamphlets and one poster on influenza vaccine (intervention group), in addition to standard mandatory information. The main outcome was the number of vaccination units delivered in pharmacies. Data were extracted from the SIAM-ERASME claim database of the Health Insurance Fund of Lille-Douai (France). The association between the intervention (yes/no) and the main outcome was assessed through a generalized estimating equation. Seventy-five GPs enrolled 10,597 patients over 65 years or suffering from long lasting diseases (intervention/control as of 3781/6816 patients) from October 15, 2014 to February 28, 2015. No difference was found regarding the number of influenza vaccination units delivered (Relative Risk (RR) = 1.01; 95% Confidence interval: 0.97 to 1.05; p = 0.561). CONCLUSION: Effects of the monothematic campaign promoting vaccination against influenza using a poster and pamphlets exposed in GPs' waiting rooms could not be demonstrated.

Factors associated with the achievement of cervical smears by general practitioners.

OBJECTIVE: Reliable data about general practitioners performing pap-tests are insufficient. A claim code for the achievement of pap-smears exists in France, but its use by general practitioners is not known. The main purpose of this study was to highlight independent factors associated with the achievement of pap-smears by the general practitioner (GP). We carried out a descriptive and analytic epidemiologic study in 347 GPs and their 244,889 patients, registered at the Health Care Insurance Fund of Flanders. The European Deprivation Index (EDI) in the area of GP's surgeries was specified. All GPs were questioned by telephone about their performance of pap-tests. The claim database of the insurance fund was analyzed to describe characteristics of GPs. RESULTS: The answer rate among questioned GPs was 98.8%. Pap-smears were performed in their surgeries by 182 GPs (53.1%). Among males, 45.7% performed pap-smears versus 78.4% of the female (adjusted odds-ratio = 4.5, p < 0.001). The mean rate of screened women in the target population was 44% when GPs were performing smears versus 42% when they were not (adjusted odds-ratio = 1.04, p = 0.03). Only 19.5% of GPs used the claim code. The number of patients, and the EDI were not associated with pap-smears. Trial registration ClinicalTrials.gov NCT02749110 (April 22, 2016).

[Investigation of the medical and social situation of patients managed by opiate replacement regimens for over 10 years by their GP]. / Enquête sur la situation médico-sociale de patients suivis pour un traitement substitutif aux opiacés depuis plus de 10ans par leur médecin généraliste.

OBJECTIVE: Management with opiate replacement regimens (ORRs) of patients presenting to primary care settings with opiate addiction has become a long-term follow-up. The aim of this survey study was to describe patients who had been prescribed ORRs for at least 10 years by their general practitioner (GP). METHOD: In 2011, two questionnaires were sent to a sample of 38 GPs prescribing ORRs in Northern France. Doctors' questionnaires collected their typology and opinions on their patients receiving opiate substitution treatments for over 10 years. Patients' questionnaires were completed in the presence of the patient. RESULTS: Twenty-three doctors' and 83 patients' questionnaires were suitable for analysis. The average number of listed ORR patients was 14.2 and 3.6 had been managed for 10 years or more. Misuse persisted: 30.5% of GPs considered that it was carried out by at least by 15% of patients. Average dosages were 60.3 mg for methadone and 7.0 mg for buprenorphine. Employment (46.3% of patients had a salary), dwelling and family live (46.3% of patients were in charge of children) were favored. Nevertheless, precariousness persisted: 32% of patients were indebted and help of social workers was not systematically searched. One third of the patients were alcohol and cannabis misusers, 70% were smoking and 34.5% multiple drug misusers. An important number of patients were taking anxiolytics (37.8%) and hypnotics (30.5%). CONCLUSION: After 10 years of follow-up for an ORR by a GP, the social situation of patients seems to have stabilized, but psychoactive drugs consumption remains important.

Off-Label Prescribing of Antipsychotics in Adults, Children and Elderly Individuals: A Systematic Review of Recent Prescription Trends.

INTRODUCTION: New antipsychotics continuously arrive on the market, which thereby influences the approved and off-label prescribing (OLP) schemes. We aimed to identify the recent trends in the OLP of antipsychotics. We conducted a literature review based on three different populations: adult, pediatric, and elderly patients. METHODS: A literature search was performed in the PubMed and ScienceDirect databases using the following keyword algorithm: "offlabel" AND ("antipsychotic*" OR "neuroleptic*"). The period investigated ranged from January 2000 to January 2015. Only Englishwritten pharmacoepidemiological studies were included. RESULTS: Seventy-seven relevant results were identified. Among adults, OLP consisted of 40 to 75% of all antipsychotic prescriptions. The main indications were mood disorders, anxiety disorders, insomnia and agitation. Quetiapine was the most frequently prescribed offlabel antipsychotic, especially for anxiety and insomnia. Among children, OLP was estimated between 36 and 93.2% of all antipsychotic prescriptions. Risperidone and aripiprazole were primarily used and were most often prescribed for attention deficit hyperactivity disorder, anxiety, or mood disorders. Among elderly individuals, OLP consisted of 22 to 86% of all antipsychotic prescriptions. Antipsychotic OLP was particularly frequent for agitation; however, a recent decrease in this OLP was identified. DISCUSSION: Antipsychotics have largely been prescribed off-label in recent years. The types of antipsychotic OLP practices differ according to the age category of patients. OLP is often used in cases of therapeutic dead-ends or for specific disorders with few or no currently approved medications. However, other OLP practices only reflect temporary prescription trends for mild symptoms, which may induce safety concerns.