Perception of barriers and facilitators in the continuity of care for precarious migrants in general practice / Perception des freins et facilitateurs de la continuité des soins délivrés aux migrants précaires en médecine générale

Introduction: Continuity of care is essential for the diagnosis and treatment of somatic and mental conditions in precarious migrants. This study explored the barriers and facilitators in the continuity of care provided to precarious migrants in general practice. Methods: A qualitative study was carried out based on semi-directed interviews with twenty precarious migrants. The term "medical follow-up" was used in the interview grid to represent the concept of continuity of care. The verbatims were analyzed using the grounded theory approach, with data analysis triangulation. Results: Precarious migrants described the medical follow-up as repeated access to the same doctor for all their health problems. This follow-up was limited by difficulties in accessing health insurance and guidance in the health system, and by language and cultural barriers. Conversely, the physician's clinical and interpersonal skills, the presence of a translator, the support from the migrants' family circle and associations, and some organizations of the care structure facilitated their medical follow-up. Conclusions: Relational, managerial, and informational continuities of care provided to precarious migrants should be optimized in a synergistic manner. To achieve this, it is necessary to improve doctors' training in communication with migrants, medical information sharing and migrants' education to the appropriate use of the healthcare system, in order to encourage their gradual empowerment in their care pathway.

Introduction: La continuité des soins est essentielle pour le diagnostic et le traitement des pathologies somatiques et psychiques des migrants précaires. Cette étude a exploré les freins et les facilitateurs de la continuité des soins délivrés aux migrants précaires en médecine générale. Méthodes: Étude qualitative par entretiens semi-dirigés, conduits auprès de 20 migrants précaires. Le terme « suivi médical ¼ a été utilisé dans la grille d'entretien pour représenter le concept de continuité des soins. Les verbatims ont été analysés selon l'approche par théorisation ancrée, avec une triangulation de l'analyse des données. Résultats: Les migrants précaires décrivaient le suivi médical comme un accès répété chez un même médecin pour tous leurs problèmes de santé. Ce suivi était limité par les difficultés d'accès à la couverture maladie et d'orientation dans le système de santé, et par les barrières linguistique et culturelle. En revanche, le savoir-faire et le savoir-être du médecin, la présence d'un traducteur, le soutien de l'entourage familial et associatif des migrants et certaines organisations de la structure de soins facilitaient leur suivi médical. Conclusions: Les continuités relationnelle, organisationnelle et informationnelle des soins délivrés aux migrants précaires méritent d'être optimisées de façon synergique. Pour cela, il conviendrait d'améliorer la formation des médecins à la communication avec les migrants, le partage des informations médicales et l'éducation des migrants au bon usage du système de santé, afin de favoriser leur autonomisation progressive dans leur parcours de soins.

Frequency and determinants of technical procedures in French general practice: a cross-sectional study.

INTRODUCTION: Technical skills have many areas of application in general practice and are a dimension of medical competence. Several studies have attempted to describe the technical procedures performed in general practice but most had limitations in the data collection process, the scope of the procedures addressed, or the healthcare actors involved. No French comparable data have been published. The aim of the present study was therefore to describe the frequency and type of technical procedures in French general practice, and to assess their determinants, in particular rurality. METHODS: The present study was ancillary to the ECOGEN (Eléments de la COnsultation en médecine GENérale) study, which was an observational cross-sectional, multicentre, nationwide study conducted in 128 French general practices. Data were collected on 20 613 patient-GP encounters, including the characteristics of GPs and encounters, as well as the health problems managed during the encounter and their associated processes of care; the latter two variables were coded according to the International Classification of Primary Care classification. The GPs' practice location was first classified as rural area, urban cluster, or urban area; the former two categories were combined for analysis. The various technical procedures were classified according to the framework of the International Classification of Process in Primary Care. The frequency of each technical procedure was compared according to GP practice location. The dependent variable analysed was the performance of at least one technical procedure per each health problem managed. Bivariate analysis was performed for all independent variables followed by multivariate analysis for key variables, using a hierarchical model including three levels: the physician, the encounter, the health problem managed. RESULTS: The data included 2202 technical procedures performed. At least one technical procedure was performed in 9.9% of encounters and for 4.6% of health problems managed. The two most frequent groups of technical procedures performed were injections (44.2% of all procedures) and clinical laboratory procedures (17.0%). The following procedures were more often performed by GPs practicing in a rural area or an urban cluster than those practicing in an urban area: injection of joints, bursae, tendons and tendon sheaths (4.1% v 1.2% of all procedures), manipulation and osteopathy (10.3% v 0.4%), excision/biopsy of superficial lesions (1.7% v 0.5%), and cryotherapy (1.7% v 0.3%). Conversely, the following procedures were more often performed by GPs practicing in urban areas: vaccine injection (46.6% v 32.1%), point-of-care testing for group A streptococci (11.8% v 7.6%), and ECG (7.6% v 4.3%). GPs practicing in a rural area or an urban cluster performed more often technical procedures than those practising in an urban area (odds ratio=1.31, 95% confidence interval 1.04-1.65), according to the multivariate model. CONCLUSION: Technical procedures were more frequently performed and more complex when they were performed in French rural and urban cluster areas. More studies are required to assess patients' needs regarding technical procedures.

Barriers and Facilitators to the Use of Clinical Decision Support Systems in Primary Care: A Mixed-Methods Systematic Review.

PURPOSE: To identify and quantify the barriers and facilitators to the use of clinical decision support systems (CDSSs) by primary care professionals (PCPs). METHODS: A mixed-methods systematic review was conducted using a sequential synthesis design. PubMed/MEDLINE, PsycInfo, Embase, CINAHL, and the Cochrane library were searched in July 2021. Studies that evaluated CDSSs providing recommendations to PCPs and intended for use during a consultation were included. We excluded CDSSs used only by patients, described as concepts or prototypes, used with simulated cases, and decision supports not considered as CDSSs. A framework synthesis was performed according to the HOT-fit framework (Human, Organizational, Technology, Net Benefits), then a quantitative synthesis evaluated the impact of the HOT-fit categories on CDSS use. RESULTS: A total of 48 studies evaluating 45 CDSSs were included, and 186 main barriers or facilitators were identified. Qualitatively, barriers and facilitators were classified as human (eg, perceived usefulness), organizational (eg, disruption of usual workflow), and technological (eg, CDSS user-friendliness), with explanatory elements. The greatest barrier to using CDSSs was an increased workload. Quantitatively, the human and organizational factors had negative impacts on CDSS use, whereas the technological factor had a neutral impact and the net benefits dimension a positive impact. CONCLUSIONS: Our findings emphasize the need for CDSS developers to better address human and organizational issues, in addition to technological challenges. We inferred core CDSS features covering these 3 factors, expected to improve their usability in primary care.

Barriers and Facilitators to Participation in Health Screening: an Umbrella Review Across Conditions.

Screening is an essential prevention practice for a number of health conditions. However, screening coverage remains generally low. Studies that investigate determinants of screening participation are becoming more common, but oftentimes investigate screening for health conditions in an individualized rather than integrated fashion. In routine clinical practice, however, healthcare professionals are often confronted with situations in which several screening procedures are recommended for the same patient. The consideration of their common determinants may support a more integrated screening approach. The objectives of this umbrella review were therefore to examine: 1) the determinants (barriers and facilitators) that have been identified in relation to recommended health screening procedures; and 2) the modifiable determinants (in primary care) common across health conditions or specific to individual procedures. Results were presented through a narrative synthesis. PubMed, PsycInfo and Cochrane were searched up to January 2022. Systematic reviews reporting determinants of participation in health screening procedures with grade A or B recommendation according to the US Preventive Services Task Force were included. A total of 85 systematic reviews were included, most which contained both qualitative and quantitative studies on determinants that describe individual factors (961 occurrences), social factors (113 occurrences, healthcare professional factors (149 occurrences), health system factors (105 occurrences) and screening procedure factors (99 occurrences). The most studied screening procedures concerned cervical cancer/human papillomavirus (n = 33), breast cancer (n = 28), colorectal cancer (n = 25) and the human immunodeficiency virus (n = 12). Other conditions have been under-studied (e.g. cardiovascular problems, lung cancer, syphilis). The individual domain, including determinants such as knowledge, beliefs and emotions, was the most covered across health conditions. Healthcare professional's recommendations and the quality of patient-provider communication were identified to have a strong influence on screening participation in most conditions. The other three domains included determinants which were more specific to a condition or a population. Various determinants modifiable in primary care were found in the individual domain and in the health system, healthcare professional and screening procedure domains. Quality was assessed as low for most systematic reviews included. The identification of various modifiable determinants common across conditions highlights the potential of an integrated screening participation approach. Interventions may address common determinants in a broader person-centred framework within which tailoring to specific procedures or populations can be considered. This approach needs to be explored in intervention studies. The systematic review registration is PROSPERO CRD42019126709.

General practitioner gender and use of diagnostic procedures: a French cross-sectional study in training practices.

OBJECTIVES: The acceleration in the number of female doctors has led to questions about differences in how men and women practice medicine. The aim of this study was to assess the influence of general practitioner (GP) gender on the use of the three main categories of diagnostic procedures-clinical examinations, laboratory tests and imaging investigations. DESIGN: Cross-sectional nationwide multicentre study. SETTING: French training general practices. PARTICIPANTS: The patient sample included all the voluntary patients over a cumulative period of 5 days per office between November 2011 and April 2012. The GP sample included 85 males and 43 females. METHODS: 54 interns in general practice, observing their GP supervisors, collected data about the characteristics of GPs and consultations, as well as the health problems managed during the visit and the processes of care associated with them. Using hierarchical multilevel mixed-effect logistic regression models, we performed multivariable analyses to assess differences in each of the three main categories of diagnostic procedures, and two specific multivariable analyses for each category, distinguishing screening from diagnostic or follow-up procedures. We searched for interactions between GP gender and patient gender or type of health problem managed. RESULTS: This analysis of 45 582 health problems managed in 20 613 consultations showed that female GPs performed more clinical examinations than male GPs, both for screening (OR 1.75; 95% CI 1.19 to 2.58) and for diagnostic or follow-up purposes (OR 1.41; 95% CI 1.08 to 1.84). Female GPs also ordered laboratory tests for diagnostic or follow-up purposes more frequently (OR 1.21; 95% CI 1.03 to 1.43). Female GPs performed even more clinical examinations than male GPs to diagnose or follow-up injuries (OR 1.69; 95% CI 1.19 to 2.40). CONCLUSION: Further research on the appropriateness of diagnostic procedures is required to determine to what extent these differences are related to underuse or overuse.

General practice and associated health conditions in patients aged 65 years or over.

We aimed at identifying associations of health conditions addressed during general practice consultations involving patients aged 65 years or over, according to sex. This is an ancillary study of the ECOGEN study on the consultation practices of French general practitioners. We studied the 15 most frequent health issues addressed in patients aged 65 years or over and identified the pairs most frequently and strongly associated. The sample included 5,782 consultations corresponding to 17,182 health issues addressed. Each consultation involved an average of 3.0 [2.9-3.0] health issues. The strongest associations mainly included cardio-metabolic conditions. The most frequent and strong pair (OR: 3.8 [3.3-4.4]) associated non-complicated arterial hypertension with a lipid disorder. Some associations were specific to the patient's sex. Significant associations identified may improve the management of elderly patients with multiple morbidities by encouraging synergic treatments.

[Health issues of patients aged 65 years or over managed in general practice: which associations are remarkable?] / Résultats de consultation des patients âgés de 65 ans et plus pris en charge en médecine générale : quelles sont les associations remarquables ?

INTRODUCTION: We aimed at identifying the associations of health issues managed in general practice encounters with patients aged 65 years or over, according to their sex. METHODS: Ancillary study of the ECOGEN study on the consultation practice of French general practitioners. We have studied the 15 most frequent health issues managed in patients aged 65 years or over and identified the pairs most frequently and strongly associated. RESULTS: The sample included 5,782 encounters corresponding to 17,182 health issues managed. Each encounter involved an average of 3.0 [2.9-3.0] health issues. The strongest associations mainly included cardio-metabolic conditions. The most frequent and strong pair (OR: 3.8 [3.3-4.4]) associated non-complicated arterial hypertension with lipid disorder. Some associations were specific to patient sex. CONCLUSION: The remarkable associations identified may enable to improve the management of elderly patients with multimorbidity by favouring synergic treatments.

Comparison of rural and urban French GPs' activity: a cross-sectional study.

INTRODUCTION: In various countries, a shortage of general practitioners (GPs) and worrying health statistics on risk factors, morbidity and mortality have been observed in rural areas. However, few comparative data are available on GP activities according to their location. The aim of this study was to analyse French GP activities according to their rural or urban practice location. METHODS: This study was ancillary to the Eléments de la COnsultation en médecine GENérale (ECOGEN) study, which was a cross-sectional, multicentre, national study conducted in 128 French general practices in 2012. Data were collected by 54 interns in training during a period of 20 working days from December 2011 to April 2012. GP practice location was classified as rural area, urban cluster or urban area. The International Classification of Primary Care (ICPC-2) was used to classify reasons for encounter, health problem assessments, and processes of care. Univariate analyses were performed for all dependent variables, then multivariable analyses for key variables, using hierarchical mixed-effect models. RESULTS: The database included 20 613 consultations. The mean yearly number of consultations per GP was higher in rural areas (p<0.0001), with a shorter consultation length (p<0.0001). No difference was found for GP sex (p=0.41), age (p=0.87), type of fees agreement (p=0.43), and type of practice (p=0.19) according to their practice location. Urban patients were younger, and there was a lower percentage of patients over 75 years (p<0.001). GPs more frequently consulted at patients' homes in rural areas (p<0.0001). The mean number of chronic conditions managed was higher in rural areas and urban clusters than in urban areas (p<0001). Hypertension (p<0.0001), type 2 diabetes (p=0.003), and acute bronchitis/bronchiolitis (p=0.01) were more frequently managed in rural areas than in urban clusters and areas. Health maintenance/prevention (p<0.0001) and no disease situations (p<0.0001) were less frequent in rural areas. Drug prescription was more frequent in rural areas than in urban clusters and areas (p<0.0001). Multivariable analysis confirmed the influence of a GP's rural practice location on the consultation length (p<0.0001), the number of chronic conditions per consultation (p<0.0001) and the number of health maintenance/prevention situations (p<0.0001), and a trend towards a higher yearly number of consultations per GP (p=0.09). CONCLUSION: French rural GPs tend to have a higher workload than urban GPs. Rural patients have more chronic conditions to be managed but are offered fewer preventive services during consultations. It is necessary to increase the GP workforce and develop cooperation with allied health professionals in rural areas.

Health Profile of Precarious Migrants Attending the Médecins Du Monde's Health and Social Care Centres in France: a Cross-Sectional Study.

Objective: The present study aimed to compare the precarious migrants' health problems managed in Médecins du Monde's health and social care centres (CASO) with those of patients attending general practice in France. Methods: We compared the most frequent health problems managed in the 19 CASO in metropolitan France with those of a national sample of usual general practice consultations, after standardisation for age and sex. Results: Precarious migrants had fewer health problems managed per consultation than other patients (mean: 1.31 vs. 2.16), and these corresponded less frequently to chronic conditions (21.3% vs. 46.8%). The overrepresented health problems among CASO consultations were mainly headache (1.11% vs. 0.45%), viral hepatitis (1.05% vs. 0.20%), type 1 diabetes (1.01% vs. 0.50%) and teeth/gum disease (1.01% vs. 0.23%). Their underrepresented health problems were mainly lipid disorder (0.39% vs. 8.20%), depressive disorder (1.36% vs. 5.28%) and hypothyroidism (0.50% vs. 3.08%). Prevention issues were nominal in precarious migrants (0.16%). Conclusion: Both chronic somatic and mental conditions of precarious migrants are presumably underdiagnosed. Their screening should be improved in primary care.

[General practitioners' views on cognitive disorders diagnosis: a qualitative study]. / Représentations des médecins généralistes à propos du diagnostic des troubles cognitifs.

Diagnosis of cognitive disorders is at medical and ethical stake. The aim of an qualitative study based on interviews was to explore the views of general practitioners on this diagnosis. General practitioners are ambivalent about the relevance and temporality of the diagnosis of cognitive disorders, which could be resolved by a shared decision making at each stage of the diagnostic approach.

Evaluation of a guidelines website capitalizing on Finnish content and Belgium interface: A pilot study in French general practice.

No reference point-of-care, web-based medical compendium is available in general practice in France. We have then conducted the experimentation of EBMPracticeNet, a Belgian website of guidelines translated and adapted from the Finnish EBM Guidelines. We collected data from three sources: (i) the website logbook; (ii) a search-specific assessment questionnaire; (iii) a global assessment questionnaire. A cumulative number of 262 (62.8%) physicians performed at least one search on the website and clicked on average 5.9 times per month. Physicians globally got an accurate answer (74.2%). They found the information provided by the website reliable (92.2%) and useful for practice (78.6%). They perceived the website ergonomics as good. The main reported barriers were the time and effort required to find an accurate answer and the uneven relevance of the information retrieved. Improvements should focus on guidelines indexing and their adaptation to the French context, and training physicians to search medical databases.

Men's experience of first fatherhood discovery: a descriptive study based on free hierarchical evocation by associative networks.

Objective and Background: Men's experiences of first-fatherhood discovery differ widely with various circumstances; they were examined according to the intended/unintended occurrence of partner's pregnancy.Methods: An Associative Network study targeted 44 first-time fathers and analysed their reactions to a stimulus-sentence 'In the first days after pregnancy announcement … 'Results: Word-associations formed 19 themes and 5 metathemes. The main metathemes were Emotional (30%), Cognitive (27%) and Relational (23%). Negative emotions were more frequent in unintended vs. intended pregnancies. Subthemes Chock, Feeling of unreality, Emotion control, Guilt, Denial, or Regret prevailed in unintended pregnancies. The major theme in all pregnancies was Personal advancement but subthemes Physical and psychological preparation and Responsibility prevailed in intended pregnancies vs. Acceptation and Personal progress in unintended pregnancies. Themes Relationships (with partner and others) were more frequently mentioned in unintended pregnancies vs. theme Logistics in intended pregnancies. Overall, the participants expressed opposed conflicting emotions but a desire for real involvement in pregnancy, birth, and child-raising.Conclusion: The participants proved interested and concerned. Fathers's presence and support should be solicited, accounted for, and valued by mothers-to-be and health professionals in all pregnancies. Involving fathers since pregnancy is essential for mental equilibrium, child-parent attachment, child and parent development, and family relationships.

Motifs et résultats de consultations de mineurs non accompagnés dans une permanence d'accès aux soins.

OBJECTIVE: To describe the unaccompanied minors' reasons for consulting and their health problems managed in a permanence of access to health care (PASS) at the Hospices civils de Lyon. METHODS: Consultation data of the unaccompanied minors cared for in 2016 and 2017 at the Edouard Herriot Hospital PASS, Lyon, were collected and coded according to the International Classification of Primary Care (CISP-2). RESULTS: The majority of unaccompanied minors were male adolescents from French-speaking sub-Saharan African countries. Each consultation included an average of 1.6 reason for encounter (95%CI: 1.5-1.8) and 2.0 health problems diagnosed (95%CI: 1.9-2.1). Apart from the discussion of test results, the most frequent reasons for consultation were physical symptoms, particularly generalized abdominal pain (8.7%), headache (6.6%) or pruritus (6.5%). Health problems diagnosed were mainly digestive (11.4%), cutaneous (11.0%) and osteoarticular (7.0%) problems, psychic diagnoses being rare. CONCLUSIONS: Unaccompanied minors seems to be apparently in good health, which probably results from under-diagnosing infectious diseases and psychic disorders. We recommend the implementation in the PASS of a common protocol for screening infectious conditions and detecting psychic disorders.

Cancer screening and follow-up in general practice: A French nationwide cross-sectional study.

BACKGROUND: The overall activity of general practitioners (GPs) related to cancer screening and follow-up is poorly documented. OBJECTIVES: To describe cancer screening and follow-up activities carried out in general practice and analyse them according to the socio-economic characteristics of patients. METHODS: We used data from a French nationwide, multicentre, cross-sectional study that described the distribution of health problems managed in general practice and the associated processes of care. Analyses were adjusted on age and gender when appropriate, using a multivariate, hierarchical, linear mixed-effects model. RESULTS: Among 20,613 consultations recorded, 580 involved cancer screening (2.8%) and 475 cancer follow-ups (2.3%). The most frequent cancer screening procedures concerned colorectal cancer (38.6% of screening procedures), breast cancer (32.6%), cervical cancer (17.0%), and prostate cancer (9.3%). In consultations with female patients, the most frequent types of cancer followed up were breast (44.9%) and colorectal cancer (10.5%), and with male patients, the most frequent were prostate (37.3%) and skin cancer (10.3%). After adjustment on age and gender, consultations with cancer follow-up included a mean 1.9 health problems managed in addition to cancer. Consultations with cancer screening or follow-up issue less often involved a patient on low income than other consultations (2.4% vs. 4.2%, and 1.1% vs. 4.2%, respectively). CONCLUSION: Around 5% of French general practice consultations include cancer screening or follow-up. Socio-economical inequalities demand further research.

Scope of health problems managed by general practitioners in Mali and France: awaiting practice transition in sub-Saharan Africa?

BACKGROUND: Minimal data are available on the clinical activity of general practitioners (GPs) in Africa. OBJECTIVE: To describe the health problems managed by GPs in Mali as compared with France where epidemiological transition is already advanced. METHODS: A retrospective, multicenter study, conducted in five Malian Community Health Centers. We compared their consultation data to those of the ECOGEN (Eléments de la COnsultation en médecine GENérale) study conducted in 128 French general practices, after data standardization for age and sex. RESULTS: Malian and French databases included 19 068 and 19 341 consultations, respectively. Patients had an average of 1.2 health problems managed per consultation in Mali, versus 2.2 in France. They were dominated by infections (51.3%) in Mali, including malaria (24.9%), pneumonia (9.0%) and gastrointestinal infections (5.0%). In comparison with French GPs, Malian GPs more frequently managed cardiovascular (20.2% versus 13.5%), respiratory (15.0% versus 12.4%) and digestive (13.3% versus 7.8%) problems, and less frequently musculoskeletal (3.1% versus 12.6%), endocrine/metabolic (1.5% versus 10.7%) and psychological (0.2% versus 8.2%) problems. The main activity performed by French GPs was prevention (11.0%), which was nominal in Mali. Apart from hypertension, which accounted for 18.9% of the health problems managed in Mali, chronic conditions were less often managed by Malian GPs than by French GPs (12.3% versus 39.6%). CONCLUSIONS: Africa is currently at the crossroads where chronic conditions carried with the epidemiological transition are progressing, while the burden of communicable diseases is still overwhelming. Along with the enhancing medicalization of primary care in Mali, the transition of practices is just emerging.

Drug prescription goals in primary care: a cross-sectional study.

BACKGROUND: Care goals are often implicit, although their identification is a key element of any prescription process. This study aimed to describe the clinical goals of drug prescriptions in general practice, their determinants and the agreement between physicians and patients. METHODS: This was a cross-sectional study conducted by 11 resident trainees acting as observers in 23 general practices. The residents recorded the indication and main physician's goal for all drugs prescribed during five consultation days in each practice in December 2015, and the main patient's goal for a sub-sample of consultations. We used an eight-category generic classification of prescription goals, including three specific (mortality, morbidity and cure), three non-specific (symptoms, quality of life, functioning) and two non-specified (other goal, no goal) categories. Analyses were based on a multivariable, multilevel model and on the kappa statistic applied to the sub-sample of consultations. RESULTS: The sample encompassed 2141 consultations and 5036 drugs. The main physicians' goal of drug prescriptions was to relieve symptoms (43.3%). The other goals were to decrease the risk of morbidity (22.4%), to cure disease (11.7%), to improve quality of life (10.6%), to decrease the risk of mortality (8.5%) and to improve functioning (1.8%). The choice of a specific goal was more frequent in patients with the following characteristics: over 50 (OR [1.09;1.15]), of male gender (OR [1.09;1.39]), with full financial coverage for a long-term condition (OR [1.47;1.97]), known by the physician (OR [1.19;2.23]), or with a somatic health problem (OR [2.56;4.17]). Cohen's kappa for drug prescription goals between the patients and the physicians was 0.26 (0.23-0.30). CONCLUSIONS: Physicians' goals are poorly shared with patients. It remains to be assessed whether it is possible to collect and discuss information on prescription goals on a daily basis.

Breast cancer specialists' perspective on their role in their patients' return to work: A qualitative study.

Objectives This study aimed to explore the views of breast cancer (BC) specialists as to their role in the return-to-work (RTW) process of their BC patients. Methods A qualitative study using semi-structured interviews was conducted in a sample of 20 BC specialists selected according to age, gender, medical specialty (medical oncology, radiation oncology, gynecological surgery), and healthcare organization (regional cancer center, university or private hospital). All interviews were audiotaped and transcribed for qualitative thematic content analysis. Results BC specialists had heterogeneous representations and practices regarding their role in their patients` RTW process, ranging from non-involvement to frequent discussion. Most BC specialists had concerns regarding the "right time and right way" to address patient`s RTW. They hardly mentioned workplace and job factors as potential barriers but rather stressed motivation. The main reported barriers to involvement in the RTW process were lack of time, lack of knowledge, lack of skills, and a professional attitude exclusively focused on cancer care issues. Conclusion While our study showed varying representations and practices among BC specialists, participants consistently identified barriers in supporting BC survivors` RTW. The results will guide the development of an intervention to facilitate the role of BC specialists in the RTW process as part of a multicomponent intervention to facilitate BC survivors` RTW.

Off-label drug prescriptions in French general practice: a cross-sectional study.

OBJECTIVES: Off-label drug prescribing is a public health and economic issue. The aim of this study was to describe off-label prescription in general practice in France, in terms of frequency and nature, and to identify its main determining factors. DESIGN: Multicentre cross-sectional study SETTING: Twenty-three training general practice offices PARTICIPANTS: All the voluntary patients coming for a medical consultation or visited at home over a cumulative period of 5 days per office between November 2015 and January 2016. METHODS: Eleven interns, acting as observers, collected data. Two reviewers analysed the drugs prescribed by the trainers, in order to identify those prescribed off-label in terms of their indication or the age of the patient. We used a univariate, then a multivariate model, based on hierarchical mixed-effects logistic regression. RESULTS: Among the 4932 drug prescriptions registered, 911 (18.5%[95% CI17.4% to 19.6%]) were off-label, of which 865 (17.6%) due to the indication of the drug and 58 (1.2%) due to the age of the patient. The prescription never mentioned the off-label use, neither was the patient informed of it, as required by the French law. With the multivariate analysis, variables contributing to off-label prescription were the number of drugs (OR=1.05 for each additional drug), the initiation of new drug therapy (OR=1.26) and the non-specific goal of the prescription (OR=1.43); the age of the patient ≤14 years (OR=1.42); the rural location of the physician's practice (OR=1.38) and the low frequency of the visits of national health insurance representatives (OR=0.93). CONCLUSION: Almost one out of five drugs prescribed in French general practice was off-label. It seems necessary to better train physicians in clinical pharmacology, to provide them with more effective drug prescription software, to reinforce postmarketing surveillance and to clearly define off-label use by consensus.

Asthma patients' perception on their care pathway: a qualitative study.

Because of insufficient asthma control in many patients, the collaboration between stakeholders is regarded as a promising strategy to improve asthma outcomes. This study explored the perceptions of French adult asthma patients on their care pathway. We conducted a qualitative study based on the interviews of 30 asthma patients aged 18-40 years, recruited in French primary care. We performed a thematic analysis of the data collected, using the NVivo software. According to the patients, the stakeholders involved in asthma management included those visible to healthcare professionals (patient, general practitioner, specialist(s), pharmacist, physiotherapist, family and friends) and those concealed by the patients (complementary and alternative practitioners); other stakeholders, such as nurses and occupational physicians, were not involved. Asthma management at diagnosis and follow-up phases proved to be unstructured, and were associated with poor patient education. This was supported by patients' ambivalence (in relation to illness and treatments), poor communication between patients and healthcare professionals (lack of listening and use of inappropriate vocabulary by physicians, underreporting of alternative medicine use by patients) and weak cooperation between professionals (limited to interaction between the general practitioner and the specialist, either pulmonologist or allergist). Asthma management would probably benefit from a more coordinated care pathway at each phase of the disease that is consistent with the expectations and goals of the patients. It should be based on improved organization (involvement of other healthcare professionals and the patient as partners) and processes (regular follow-up, specific tools such as peak flow meter or action plan).

A multimodal and multidisciplinary program to prevent loss of mobility in patients aged over 70 years: study protocol of a multicenter cluster randomized study in primary care (the PRISME-3P study).

BACKGROUND: Reduced mobility is the first sign of functional decline and can lead to dependency in elderly people. Screening for the risk of mobility limitation in this population is an important public health issue to prevent further disabilities. Despite the current lack of guidelines, primary care healthcare providers may have a central role to play in this type of screening. Multi-domain physical exercise interventions in older persons have shown some efficacy/effectiveness on frailty status, yet, to the best of our knowledge, no published study has focused on patients screened in primary care. METHOD: The PRISME-3P study is a national, interventional, multicenter, cluster randomized trial. Patients over 70 years of age will be systematically screened by their general practitioner (GP) on the basis of clinical criteria of mobility limitation. To avoid contamination bias, the unit of randomization will be the GP practice. In the intervention group, patients will consult a geriatrician and a dietician, and will receive a physical training program from a personal trainer who will demonstrate the exercises and provide follow-up coaching. The control group will receive standard care. The primary outcome will be the change in Short Physical Performance Battery (SPPB) scores between inclusion and 6-months follow-up. DISCUSSION: We expect an improvement of the SPPB between inclusion and 6 months of follow-up. TRIAL REGISTRATION: This study is registered in ClinicalTrials.gov ( NCT02847871 , 27 July 2016).