Impact of a store-and-forward teledermatology intervention versus usual care on delay before beginning treatment: A pragmatic cluster-randomized trial in ambulatory care.

Introduction In France, 66% of patients forego getting specialized care by dermatologists because of difficulty obtaining appointments. Store-and-forward teledermatology could improve how promptly treatment begins by reducing the delay in obtaining a specialist's opinion. In this study, we compared the delay before care between general practitioners (GPs) using a store-and-forward teledermatology intervention and GPs addressing their patients with a standard referral letter. Methods We performed an open-label, pragmatic cluster-randomized controlled trial with two parallel arms. GP clinics in Paris (France) were randomly assigned to use either teledermatology referral (use of electronics to send clinical images taken using a mobile phone) or conventional referral (using standard letters) to care for patients for whom a dermatologist's advice was needed for the diagnosis or treatment of skin lesions. Dermatologists integrated responses to teledermatology requests in their usual schedule. Patients were followed up for three months. Primary outcome was the delay, in days, between the GP's consultation and a reply by the specialist allowing treatment to begin. Analyses were adjusted for clustering of GPs and identities of dermatologists. Results Between February and June 2014, 103 patients were included in the study (53 patients of 20 GPs in the intervention group). The median delay between the initial GP's consultation and the reply allowing for treatment to begin was four days in the intervention group and 40 days in the control group (adjusted hazard ratio = 2.55; p < 0.011). Discussion We showed that a simple store-and-forward teledermatology intervention significantly reduced the delay before beginning care (ClinicalTrials.gov identifier: NCT02122432).

Profile of French general practitioners providing opportunistic primary preventive care--an observational cross-sectional multicentre study.

BACKGROUND: Preventive services provided opportunistically by GPs are insufficient. Reasons are most often gathered through GPs' self-reports, rather than through independent observation. OBJECTIVE: To assess with passive observers, the degree to which French GPs opportunistically perform primary preventive care during routine consultation. METHODS: Observational cross-sectional multicentre ancillary study of the French ECOGEN study. The study period extended from 28 November 2011 to 30 April 2012. The inclusion criteria were patients seen by GPs at surgery and home consultations in non-randomized pre-determined half-day blocks per week. The non-inclusion criteria were patient's refusal and consultations initially focused on primary prevention in response to patient's request (ancillary study's specific criterion). Using passive observers, data were collected based on the second version of International Classification of Primary Care. Preventive consultations were defined if at least one problem/diagnosis was considered by consensus as definitely related to primary prevention. For each one of the 128 participating GPs, aggregation of data was performed from all his/her consultations. Determinants of the proportion of preventive consultations per GP were assessed by multivariate linear regression. RESULTS: Considering 19003 consultations, the median proportion of preventive consultations per GP was 14.9% (range: 0-78.3%). It decreased with increased proportion of patients aged 18 or less (P = 0.006), with increased proportion of home visits (P = 0.008) and with increased proportion of consultations lasting under 10 minutes (P = 0.02). None of the GPs' personal characteristics were significantly associated. CONCLUSION: Primary preventive care activity was related to the characteristics of GPs' patients and practice organizational markers and not to GPs' personal characteristics.

Preventive services recommendations for adults in primary care settings: agreement between Canada, France and the USA--a systematic review.

OBJECTIVE: To analyze the level of agreement between recommendations on preventive services developed by Canada, France and the USA. METHODS: We gathered recommendations on primary and secondary preventive services to adults up to November 3rd, 2011 from Canadian and US Task Forces, and equivalent French agencies. We excluded recommendations on immunization, long-term diseases or pregnancy. RESULTS: Among 250 recommendations, 84 (34%) issued by a single country could not be compared; 43 (26%) of the remaining 166 were in strong agreement (strictly identical grades between advising countries); 25 of 43 resulted in a proposal to be implemented in clinical practice, two others not to be implemented in clinical practice and 16 were indeterminate about implementation. Strong agreement was more frequent for recommendations concerning history-taking and physical examination than for those concerning interventions (odds ratio (OR)=11.3, 95%CI: 1.6-241.2; p=0.04), and for recommendations concerning a high-risk population than for those concerning the general population (OR=3.1, 95%CI: 1.4-7.0; p=0.006). Agreement did not differ either according to maximum time range between recommendations' publication or according to the advising country. CONCLUSION: Agreement between recommendations is low particularly on those concerning non-clinical preventive services or non-high-risk individuals.

Medical errors reported by French general practitioners in training: results of a survey and individual interviews.

CONTEXT: French interns in general practice are, like all medical students, exposed to medical errors during their training. OBJECTIVE: To measure the professional and personal impact of medical errors on French general practitioner (GP) trainees. DESIGN, SETTING AND PARTICIPANTS: Quantitative and qualitative study of medical errors and GP trainees enrolled at Paris Diderot University. METHOD: An online anonymous questionnaire was sent to all GP trainees at Paris Diderot University and recorded semi-structured interviews were conducted with 10 volunteers. RESULTS: 70 of the 392 (18%) interns contacted replied to the questionnaire and 10 semi-structured interviews were then conducted. 97% of the participants had already made a medical error. Even with the extreme, conservative assumption that non-respondents would have reported no errors, the prevalence of self-reported medical errors in the whole sample would still have been 17%. 64% said they were at least strongly affected by their error and 74% made constructive changes to their work after the error. The interns revealed that the emotional impact of their errors were great with feelings such as guilt that could remain for more than 2 years after the event. 33% would have liked to talk more about the circumstances of their error with their superior. Most interns suggest more training on medical errors and more open-minded discussion when the error actually happens rather than formal training at the university. CONCLUSION: Medical errors remain a sensitive subject that is not broached enough in our university but interns need to talk about their experiences with their peers to improve risk management and prevent the recurrence of new errors.

[Prevac B: prevention of hepatitis B among migrants from subsaharian Africa and Asia]. / Prévac B: prévention de i'hépatite B dans les populations migrantes originaires de zones de forte endémie, Afrique subsaharienne et Asie.

CONTEXT: In 2004, 22% of French citizen were vaccinated against Hepatitis B Virus (HBV), 7.3% had previously been protected by a contact with HBV, and 0.65% were carriers of HBV Those rates are not known among migrant people, especially if they have no health insurance. It is not known whether those people have adequate personal strategies of prevention. AIMS AND METHOD: Prospective study to assess the effectiveness of an internet-accessible expert system in helping the GP to determine the most accurate strategy of prevention, related to the serologic HBV profile of each patient, and to apply this strategy, among migrant people coming from subsaharian Africa and Asia, attending their GP. The prevalence of each serologic profile was measured. RESULTS: From 11.5.2007 to 12.31.2008, 28 GPs included 547 migrant people. 8% are HBV carriers, 33% have been protected by a contact with HBV, 16% are vaccinated, and 23% have had no contact with virus nor vaccination. A full accurate preventive information strategy could be carried out with help of the expert system, respectively among 100% of HBV carriers, 100% of vaccinated people, 98% of people protected by HBV contact, and 40% of people who had no marker A vaccination has been done among 64% of people who required it. For people whose only marker of HBV infection was anti HBc, 41% was considered protected by HBV contact, 48% was vaccinated, this result can be related to a lack of accuracy in international guidelines in this situation. CONCLUSION: Prevalence of contact with HBV is much higher in migrant people coming from subsaharian Africa and Asia, than in the average French population. An internet-accessible expert system is a useful tool for GPs in order to enhance strategies of prevention in HBV infection.

[Evaluation of a screening programme for diabetic retinopathy (DODIA study)]. / Dépistage de la rétinopathie diabétique par des photographies do fond d'oeil. Evaluation d'un programme en médecine libérale (étude DODIA).

CONTEXT: In France, 43% to 63% of diabetics have an annual fundoscopy. Do the new screening tools, coupled with teletransmission of the images, allow for satisfying ophthalmological screening? It is an important matter given the foreseeable reduction in the number of French ophthalmologists in the forthcoming years. OBJECTIVES: To measure the quality of screening for diabetic retinopathy (DR), in the framework of a network, by the provision of a retinograph by numeric camera (with teletransmission of the images and centralised interpretation), in a screening centre located in town. METHOD: The study evaluated the quality of screening obtained in two comparable groups of general practitioners, one using the retinograph and the other using the classical method of screening by ophthalmologist. The screening was targeted at diabetics who had not had a fundoscopy in the preceding year, nor had known DR or a treating ophthalmologist (for the retinography group only). RESULTS: 667 patients were sampled in the retinography group (456 included) and 707 in the control group (426 included) between 1/04/02 and 1/11/02; 417 patients were followed until the end of the study in the 2 groups. A screening examination was considered effective if it was performed within the six months following its request, and by the presence of a report in the file of the general practitioner. The percentage of patients thus screened was 74% in the retinography group and 71,5% in the other group (not significant). 16% of diabetics in the retinography group had DR compared with 10% of patients in the control group. The analysis of the level of satisfaction of patients tended to show a preference for the system of screening by fundal photography. CONCLUSION: In the framework of a healthcare network, the availability of a retinograph by numeric camera, with the interpretation of photos by teletransmission of the images, obtained a high level of quality of screening for diabetic retinopathy that was at least as good as that obtained by a healthcare network using the classical ophthalmological screening method.