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.

Vitamin K antagonists and emergencies.

The recent emergence of 'non-VKA' oral anticoagulants may have led to some forgetting that vitamin K antagonists (VKA) are by far the most widely prescribed oral anticoagulants worldwide. Consequently, we decided to summarize the information available on them. This paper presents the problems facing emergency physicians confronted with patients on VKAs in 10 points, from pharmacological data to emergency management. Vitamin K antagonists remain preferable in many situations including in the elderly, in patients with extreme body weights, severe chronic kidney or liver disease or valvular heart disease, and in patients taking VKAs with well-controlled international normalized ratios (INRs). Given the way VKAs work, a stable anticoagulant state can only be achieved at the earliest 5 days after starting therapy. The induction phase of VKA treatment is associated with the highest risk of bleeding; validated algorithms based on INR values have to be followed. VKA asymptomatic overdoses and 'non-severe' hemorrhage are managed by omitting a dose or stopping treatment plus administering vitamin K depending on the INR. Major bleeding is managed using a VKA reversal strategy. A prothrombin complex concentrate infusion plus vitamin K is preferred to rapidly achieve an INR of up to 1.5 and maintain a normal coagulation profile. The INR must be measured 30 min after the infusion. Before an invasive procedure, if an INR of less than 1.5 (<1.3 in neurosurgery) is required, it can be achieved by combining prothrombin complex concentrate and vitamin K. A well-codified strategy is essential for managing patients requiring emergency invasive procedures or presenting bleeding complications.

Efficacy and safety of insulin in type 2 diabetes: meta-analysis of randomised controlled trials.

BACKGROUND: It is essential to anticipate and limit the social, economic and sanitary cost of type 2 diabetes (T2D), which is in constant progression worldwide. When blood glucose targets are not achieved with diet and lifestyle intervention, insulin is recommended whether or not the patient is already taking hypoglycaemic drugs. However, the benefit/risk balance of insulin remains controversial. Our aim was to determine the efficacy and safety of insulin vs. hypoglycaemic drugs or diet/placebo on clinically relevant endpoints. METHODS: A systematic literature review (Pubmed, Embase, Cochrane Library) including all randomised clinical trials (RCT) analysing insulin vs. hypoglycaemic drugs or diet/placebo, published between 1950 and 2013, was performed. We included all RCTs reporting effects on all-cause mortality, cardiovascular mortality, death by cancer, cardiovascular morbidity, microvascular complications and hypoglycaemia in adults ≥ 18 years with T2D. Two authors independently assessed trial eligibility and extracted the data. Internal validity of studies was analyzed according to the Cochrane Risk of Bias tool. Risk ratios (RR) with 95 % confidence intervals (95 % CI) were calculated, using the fixed effect model in first approach. The I(2) statistic assessed heterogeneity. In case of statistical heterogeneity, subgroup and sensitivity analyses then a random effect model were performed. The alpha threshold was 0.05. Primary outcomes were all-cause mortality and cardiovascular mortality. Secondary outcomes were non-fatal cardiovascular events, hypoglycaemic events, death from cancer, and macro- or microvascular complications. RESULTS: Twenty RCTs were included out of the 1632 initially identified studies. 18 599 patients were analysed: Insulin had no effect vs. hypoglycaemic drugs on all-cause mortality RR = 0.99 (95 % CI =0.92-1.06) and cardiovascular mortality RR = 0.99 (95 % CI =0.90-1.09), nor vs. diet/placebo RR = 0.92 (95 % CI = 0.80-1.07) and RR = 0.95 (95 % CI 0.77-1.18) respectively. No effect was found on secondary outcomes either. However, severe hypoglycaemia was more frequent with insulin compared to hypoglycaemic drugs RR = 1.70 (95 % CI = 1.51-1.91). CONCLUSIONS: There is no significant evidence of long term efficacy of insulin on any clinical outcome in T2D. However, there is a trend to clinically harmful adverse effects such as hypoglycaemia and weight gain. The only benefit could be limited to reducing short term hyperglycemia. This needs to be confirmed with further studies.

Comparison of French training and non-training general practices: a cross-sectional study.

BACKGROUND: As the medicine practiced in hospital settings has become more specialized, training in primary care is becoming increasingly essential for medical students, especially for future general practitioners (GPs). Only a few limited studies have investigated the representativeness of medical practices delivering this training. The aim of this study was to assess the representativeness of French GP trainers in terms of socio-demographics, patients and activities. METHODS: We conducted a cross-sectional study covering all private GPs practicing in the Rhône-Alpes region of France in 2011. This population consisted of 4992 GPs, including 623 trainers and 4369 non-trainers, managing 8,198,684 individual patients. Data from 2011 to 2012 were provided by the Regional Health Care Insurance (RHCI). We compared GP trainers with non-trainers using the Pearson chi-square test for qualitative variables and the Student t-test for quantitative variables RESULTS: GP trainers do not differ from non-trainers for gender, but they tend to be younger, more frequently in mid-career, and more likely to practice in a rural area. Their patients are broadly representative of patients attending general practice for age (with the exception of a higher consultation rate for infants), but patients with medical fee exemption status relating to low income are underrepresented. GP trainers have a heavier workload in terms of office visits and on-call duties. They prescribe a higher proportion of generic drugs, perform more electrocardiograms and cervical smears, and fewer plaster casts. GP trainers show better performance in diabetes follow-up, and to a lesser extent for seasonal flu vaccination and mammograms. CONCLUSIONS: GPs and patients of training practices are globally representative, which is particularly critical in countries such as France, where the length of specialty training in a general practice setting is still limited to a few months. In addition, GP trainers tend to have better clinical performance, which conforms to their teaching modelling role and may encourage other GPs to become trainers.

[Cooperation between general practitioners and pharmacists: a systematic review]. / Coopération entre médecins généralistes et pharmaciens : une revue systématique de la littérature.

INTRODUCTION: Despite the emphasis on interprofessional cooperation between general practitioners and pharmacists, the effectiveness of interventions in this area is poorly understood. The purpose of this study was to assess the effectiveness of interventions based on cooperation between general practitioners and pharmacists. METHODS: A systematic literature review was conducted using MEDLINE, the Cochrane Database and the PASCAL database. Keywords and/or search terms ("family physician(s)" or "general practitioner(s)" and "pharmacist(s)") were cross-referenced. We included the results of all randomized clinical trials published in English or French and assessed the effectiveness of pharmacist interventions designed to complement the work of general practitioners. RESULTS: In total, 22 articles were included. Sixteen trials showed that pharmacist interventions in the management of chronic health conditions and drug therapy management benefit patients. The evidence suggests that pharmacist interventions have a positive impact on the management of arterial hypertension and hypercholesterolemia and the management of drug-related problems. The criteria used for the trials were generally procedural or surrogate criteria and never included cost-effectiveness analyses. DISCUSSION: Cooperation between pharmacists and general practitioners can contribute to improving the quality of primary care, especially in the areas of cardiometabolic and prescription problems.