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Background As health care accounts for 4–5% of global carbon emissions, many health organisations have called for implementing sustainable development actions in health care. However, sustainable development measures in general practice are rarely implemented by physicians. The aim of this study was to explore the practices of general practitioners (GPs) in terms of sustainable development to identify which actions are appropriate and achievable. Methods A qualitative study was conducted in 12 French GPs using face-to-face or telephone interviews, transcribed verbatim and analysed through a global inductive analysis with constant comparison. Semi-structured interviews were focussed on waste management, relationships between health professionals, sustainable development, and GPs’ activity. Results The mean age of the GPs was 42.8 years and they mainly worked in an urban environment. The interviews highlighted 4 themes. It appeared that a balance needs to be found between the environmental impact and the constraints related to medical care. To be able to think about integrating sustainable development into health care, GPs should make a personal commitment to change their routine. In practice, consumption should be reassessed, prescriptions and prevention reconsidered. These actions could be applied to the GPs’ environment as role models for their patients, business leaders, and members of the healthcare system. Conclusion GPs felt concerned by sustainable development and were already involved in its implementation in their practice. Tools are available to help GPs to continue to implement their actions described in this article, but their impact remains to be investigated.

ObjectiveBreast cancer screening decision aids (DAs) are designed to help women decide whether or not to participate in mammography-based programmes. We aimed to explore women’s and healthcare professionals’ expectations of a breast cancer screening DA, as part of the French DEDICACES study.MethodsThis French qualitative study was based on semistructured, individual interviews with women from the general population, general practitioners (GPs), midwives, gynaecologists, radiologists and screening centre managers. Sampling was purposive and used diversification criteria. The inductive analysis was based on grounded theory.ResultsBetween April 2018 and May 2019, we interviewed 40 people: 13 women, 14 GPs, 4 gynaecologists, 3 midwives, 3 radiologists and 3 screening centre managers. The women and the healthcare professionals considered that a DA could help to improve levels of knowledge, harmonise medical practice and provide reliable, comprehensive information. Overall, the interviewees wanted an easy-to-use, intuitive, graphic-rich, interactive, computer-based, patient-centred DA. Use of the DA might be limited by a lack of familiarity with shared decision-making (SDM), the risk of misuse and a preference for asymmetric positive information.ConclusionThe present results are likely to facilitate the development of the first validated tool for SDM support in French breast cancer screening programmes.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer in men and the second in women worldwide. During the period 2017-2018, in France, 32.1% of the eligible population completed screening, which is under the acceptable uptake rate. The FORCEPS study aimed to test whether a training program focused on improving general practitioners’ (GPs’) communication skills could increase their patients’ CRC screening rate. Our study reports on the construction of, participation in and evaluation of the e-learning training program tested in the FORCEPS study.METHODS: An interdisciplinary team designed an e-learning program for French GPs on the Moodle® platform. Learning activities related to the stated learning objectives and interactive approaches were specified. Two sessions took place, in May and November 2018. The training lasted 6 weeks. RESULTS: In all, 116 GPs registered for the training program. Seventy per cent of the GPs who registered for the first session opted to follow the training via e-learning rather than in person. Among the participants, 36.0% followed the training in its entirety during session 1, as did 24.0% during session 2. At the end of the training, none of the participating GPs self-assessed themselves as a “novice”, and the number of GPs self-assessing as “intermediate” or “experienced” increased. Overall, 62.9% of the participants were generally satisfied with the e-learning course.CONCLUSIONS: The web-based program focused on improving GPs’ communication skills to encourage CRC screening was chosen by a large majority of the participating GPs and received positive reviews. While GPs’ theoretical knowledge can be improved through our training program, it remains to be seen whether or not this will be reflected in their everyday practice, thus resulting in an increased CRC screening participation rate among patients.

Objectives Cancer survival rates vary widely between European countries, with differences in timeliness of diagnosis thought to be one key reason. There is little evidence on the way in which different healthcare systems influence primary care practitioners' (PCPs) referral decisions in patients who could have cancer. This study aimed to explore PCPs' diagnostic actions (whether or not they perform a key diagnostic test and/or refer to a specialist) in patients with symptoms that could be due to cancer and how they vary across European countries. Design A primary care survey. PCPs were given vignettes describing patients with symptoms that could indicate cancer and asked how they would manage these patients. The likelihood of taking immediate diagnostic action (a diagnostic test and/or referral) in the different participating countries was analysed. Comparisons between the likelihood of taking immediate diagnostic action and physician characteristics were calculated. Setting Centres in 20 European countries with widely varying cancer survival rates. ParticipantsA total of 2086 PCPs answered the survey question, with a median of 72 PCPs per country. Results PCPs' likelihood of immediate diagnostic action at the first consultation varied from 50% to 82% between countries. PCPs who were more experienced were more likely to take immediate diagnostic action than their peers. Conclusion When given vignettes of patients with a low but significant possibility of cancer, more than half of PCPs across Europe would take diagnostic action, most often by ordering diagnostic tests. However, there are substantial between-country variations., ALN's time is supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translation Research Centre, with her infrastructure support provided by the NIHR Imperial Biomedical Research Centre (BRC).

An effective health system is based on effective primary care, at the center of which is family medicine. Cancer prevention and screening are integral aspects of general practitioners skills. Prevention is linked with the notion of risk. The relationship between the general practitioner and his or her patient reinforces the prevention of the development of preventable risk factors. It also strengthens information on intrinsic risk factors for patients. The protective factors highlighted by the general practitioner can thus reduce the risk a little more. Screening strategies differs across cancers and countries. In France, general practitioner's involvement is important for colorectal cancer screening. The active participation of their general practitioner, strengths patient's adherence and participation. Their role is to inform and collect data for breast cancer screening. Recently organized cervical cancer screening requires greater involvement of general practitioners who can act as both actors and informants. Family medicine is at the heart of cancer prevention and screening. It is a central hub for improving the health of patients in our healthcare system. The general practitioner knows the patient, which gives him an important advantage to accompany him in the prevention and screening of his risk factors.

Background Cancer survival rates vary widely between European countries, with differences in timeliness of diagnosis thought to be one key reason. There is little evidence on the way in which different healthcare systems influence Primary Care Practitioners’ (PCPs’) referral decisions in patients that could have cancer, and how this links with cancer survival. This study aimed to explore PCPs’ diagnostic actions in patients with symptoms that could be due to cancer, how they vary across European countries with marked differences in socio-economic development, healthcare investment and organisation, and how they relate to cancer survival rates. Methods A primary care study, with centres in twenty European countries with widely varying cancer survival rates. The on-line survey of PCPs used vignettes describing four patients with symptoms that could indicate cancer (lung, ovary, breast and colorectal). PCPs were asked how they would manage these patients. Correlations between the likelihood of taking immediate diagnostic action and physician characteristics were calculated. The likelihood of taking immediate diagnostic action in the different participating countries was also analysed, as well as the correlation with national 1-year relative cancer survival rates. Results A total of 2,086 PCPs answered the survey question, with a median of 72 PCPs per country. PCPs’ likelihood of organising a diagnostic test and/or referring to a specialist at the first consultation varied from 50 to 82% between countries PCPs who were more experienced, were working in more remote areas, or worked alone or in smaller practices, were more likely to take immediate diagnostic action than their peers. There was a significant negative correlation between national healthcare expenditure levels and likelihood of immediate diagnostic action (r=–0.55, P=0.012). However, there was no significant correlation between the likelihood of taking immediate diagnostic action and cancer survival (r=–0.27, P=0.278). Conclusions Europe shows large between-country variations in PCPs’ diagnostic action rates for patients who could have cancer. These are linked with differences in healthcare organisation and levels of healthcare investment.

International audience; Background: France is the European country with the lowest level of confidence in vaccines. Measurement of patients' acceptability towards a future therapeutic HIV vaccine is critically important. Thus, the aim of this study was to evaluate patients' acceptability of a future therapeutic HIV vaccine in a representative cohort of French patients living with HIV-AIDS (PLWHs). Methods: This multicentre study used quantitative and qualitative methods to assess PLWHs' opinions and their potential acceptance of a future therapeutic HIV vaccine. Cross-sectional study on 220 HIV-1 infected outpatients, aged 18-75 years. Results: The participants' characteristics were similar to those of the overall French PLWH population. Responses from the questionnaires showed high indices of acceptance: the mean score for acceptability on the Visual Analog Scale VAS was 8.4 of 10, and 92% of patients agreed to be vaccinated if a therapeutic vaccine became available. Acceptability depended on the expected characteristics of the vaccine, notably the duration of its effectiveness: 44% of participants expected it to be effective for life. This acceptance was not associated with socio-demographic, clinical (mode of contamination, duration of disease), quality of life, or illness-perception parameters. Acceptability was also strongly correlated with confidence in the treating physician. Conclusion: The PLWHs within our cohort had high indices of acceptance to a future therapeutic HIV vaccine. Trial registration: This study was retroactively registered on ClinicalTrials.gov with ID: NCT02077101 in February 21, 2014.

An effective health system is based on effective primary care, at the center of which is family medicine. Cancer prevention and screening are integral aspects of general practitioners skills. Prevention is linked with the notion of risk. The relationship between the general practitioner and his or her patient reinforces the prevention of the development of preventable risk factors. It also strengthens information on intrinsic risk factors for patients. The protective factors highlighted by the general practitioner can thus reduce the risk a little more. Screening strategies differs across cancers and countries. In France, general practitioner's involvement is important for colorectal cancer screening. The active participation of their general practitioner, strengths patient's adherence and participation. Their role is to inform and collect data for breast cancer screening. Recently organized cervical cancer screening requires greater involvement of general practitioners who can act as both actors and informants. Family medicine is at the heart of cancer prevention and screening. It is a central hub for improving the health of patients in our healthcare system. The general practitioner knows the patient, which gives him an important advantage to accompany him in the prevention and screening of his risk factors.

Objectives Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners' (PCPs') referral decisions is lacking. This study analyses health system factors potentially influencing PCPs' referral decision-making when consulting with patients who may have cancer, and how these vary between European countries. Design Based on a content-validity consensus, a list of 45 items relating to a PCP's decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs' referral decision-making. Setting A primary care study; 25 participating centres in 20 European countries. Participants 1830 PCPs completed the survey. The median response rate for participating centres was 20.7%. Outcome measures The factors derived from items related to PCPs' referral decision-making. Mean factor scores were produced for each country, allowing comparisons. Results Factor analysis identified five underlying factors: PCPs' ability to refer; degree of direct patient access to secondary care; PCPs' perceptions of being under pressure; expectations of PCPs' role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses. Conclusions Five healthcare system factors influencing PCPs' referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes., ALN is supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translation Research Centre, with infrastructure support provided by the NIHR Imperial Biomedical Research Centre (BRC).

ObjectivesTo elaborate and validate operational definitions for appropriate inaction and for inappropriate inertia in the management of patients with hypertension in primary care.DesignA two-step approach was used to reach a definition consensus. First, nominal groups provided practice-based information on the two concepts. Second, a Delphi procedure was used to modify and validate the two definitions created from the nominal groups results.Participants14 French practicing general practitioners participated in each of the two nominal groups, held in two different areas in France. For the Delphi procedure, 30 academics, international experts in the field, were contacted; 20 agreed to participate and 19 completed the procedure.ResultsInappropriate inertia was defined as: to not initiate or intensify an antihypertensive treatment for a patient who is not at the blood pressure goals defined for this patient in the guidelines when all following conditions are fulfilled: (1) elevated blood pressure has been confirmed by self-measurement or ambulatory blood pressure monitoring, (2) there is no legitimate doubt on the reliability of the measurements, (3) there is no observance issue regarding pharmacological treatment, (4) there is no specific iatrogenic risk (which alters the risk-benefit balance of treatment for this patient), in particular orthostatic hypotension in the elderly, (5) there is no other medical priority more important and more urgent, and (6) access to treatment is not difficult. Appropriate inaction was defined as the exact mirror, that is, when at least one of the above conditions is not met.ConclusionDefinitions of appropriate inaction and inappropriate inertia in the management of patients with hypertension have been established from empirical practice-based data and validated by an international panel of academics as useful for practice and research.

Michaël Benzimra,1 Béatrix Bonnamour,1 Martin Duracinsky,2 Christophe Lalanne,2 Jean-Pierre Aubert,2,3 Olivier Chassany,2,3 Isabelle Aubin-Auger,2,3 Isabelle Mahé1,2 1Internal Medicine Department, Hôpital Louis Mourier, APHP, Colombes, France; 2Méthodologies et Société (REMES) EA 7334, Recherche Clinique Ville-hôpital, Université Paris Diderot, Sorbonne Paris Cité, Paris, France; 3General Medicine Deparment, Université Paris 7, Paris, France Introduction: Direct oral anticoagulants (DOACs) have shown noninferiority to vitaminK antagonists (VKA) in stroke prevention in patients with atrial fibrillation. DOAC treatment may be less demanding than VKA, improving quality of life. To date, there have been no studies of the real-life experience of outpatients receiving anticoagulation therapy for atrial fibrillation in France.Methods: An observational descriptive real-life epidemiological study used three validated questionnaires (EQ-5D, PACT-Q2, and MMAS-8 French Translation) to assess quality of life, treatment satisfaction, and adherence, respectively, in 200 patients managed on an outpatient basis for atrial fibrillation who were receiving anticoagulation therapy by VKA or DOAC for at least 3 months. Patients were distributed between four groups: primary VKA (P-VKA), switch from VKA to DOAC (S-DOAC), primary DOAC (P-DOAC), and switch from DOAC to VKA (S-VKA).Results: Two hundred patients responded to the questionnaires: 89, 50, 52, and 9 in the P-VKA, S-DOAC, P-DOAC and S-VKA groups, respectively. Only the first three groups were compared statistically, because of the small size of the S-VKA group. Quality of life and satisfaction were good in all three groups, with no significant difference in quality of life but significantly greater satisfaction with respect to the “convenience” and “satisfaction” dimensions for DOACs (S-DOAC and P-DOAC groups versus P-VKA group; p

Colorectal cancer (CRC) mass screening has been implemented in France since 2008. Participation rates remain too low. The objective of this study was to test if the implementation of a training course focused on communication skills among general practitioners (GP) would increase the delivery of gaiac faecal occult blood test and CRC screening participation among the target population of each participating GP. A cluster randomised controlled trial was conducted with GPs practice as a cluster unit. GPs from practices in the control group were asked to continue their usual care. GPs of the intervention group received a 4-h educational training, builtwith previous qualitative data on CRC screening focusing on doctorpatient communication with a follow-up of 7 months for both groups. The primary outcome measure was the patients participation rate in the target population for each GP. Seventeen GPs (16 practices) in intervention group and 28 GPs (19 practices) in control group participated. The patients participation rate in the intervention group were 36.7% vs. 24.5% in the control group (P = 0.03). Doctorpatient communication should be developed and appear to be one of the possible targets of improvement patients adherence and participation rate in the target population forCRCmass screening.

Background: Colorectal cancer (CRC) is the third most common cancer worldwide. In France, mass screening has been established with FOBT since 2008. The participation rate remains too low. Previous studies were conducted to explore doctors' and patients' perspectives. Objective: This study was conducted to explore GPs' performance during consultations in which patients ask for FOBT, focusing on two different aspects: the core content of the consultation and the communication style used between GPs and patients. Methods: Nine purposively sampled GPs were asked to audiotape specific consultations. Content analysis was performed using Nvivo 9 software. Communication between doctors and patients was explored using RIAS coding. Results: GPs audio taped specific parts of 35 different consultations when they discussed and delivered the FOBT. The core content included primarily biomedical statements with a large portion dedicated to technical aspects. The communication style was not patient-centred. Conclusion: While the participation rate of mass screening in France is still low, the analysis of recorded consultations by French GPs confirms that the way of delivering FOBT can be improved. Read More: http://informahealthcare.com/doi/abs/10.3109/13814788.2013.780162

Objective To construct a typology of general practitioners’ (GPs) responses regarding their justification of therapeutic inertia in cardiovascular primary prevention for high-risk patients with hypertension. Design Empirically grounded construction of typology. Types were defined by attributes derived from the qualitative analysis of GPs’ reported reasons for inaction. Participants 256 GPs randomised in the intervention group of a cluster randomised controlled trial. Setting GPs members of 23 French Regional Colleges of Teachers in General Practice, included in the EffectS of a multifaceted intervention on CArdiovascular risk factors in high-risk hyPErtensive patients (ESCAPE) trial. Data collection and analysis The database consisted of 2638 written responses given by the GPs to an open-ended question asking for the reasons why drug treatment was not changed as suggested by the national guidelines. All answers were coded using constant comparison analysis. A matrix analysis of codes per GP allowed the construction of a response typology, where types were defined by codes as attributes. Initial coding and definition of types were performed independently by two teams. Results Initial coding resulted in a list of 69 codes in the final codebook, representing 4764 coded references in the question responses. A typology including seven types was constructed. 100 GPs were allocated to one and only one of these types, while 25 GPs did not provide enough data to allow classification. Types (numbers of GPs allocated) were: ‘optimists’ (28), ‘negotiators’ (20), ‘checkers’ (15), ‘contextualisers’ (13), ‘cautious’ (11), ‘rounders’ (8) and ‘scientists’ (5). For the 36 GPs that provided 50 or more coded references, analysis of the code evolution over time and across patients showed a consistent belonging to the initial type for any given GP. Conclusion This typology could provide GPs with some insight into their general ways of considering changes in the treatment/management of cardiovascular risk factors and guide design of specific physician-centred interventions to reduce inappropriate inaction. Trial registration number NCT00348855.

International audience; Background: Young French postgraduates in general practice increasingly prefer salaried practice to private practice in spite of the financial incentives offered by the French government or local communities to encourage the latter. This study aimed to explore the determinants of choice between private or salaried practice among young general practitioners.Methods: A qualitative study was conducted in the South West of France. Semi-structured interviews of young general practitioners were audio-recorded until data saturation. Recordings were transcribed and then analyzed according to Grounded Theory by three researchers working independently.Results: Sixteen general practitioners participated in this study. For salaried and private doctors, the main factors governing their choice were occupational factors: working conditions, need of varied scope of practice, quality of the doctor-patient relationship or career flexibility. Other factors such as postgraduate training, having worked as a locum or self-interest were also determining. Young general practitioners all expected a work-life balance. The fee-for-service scheme or home visits may have discouraged young general practitioners from choosing private practice.Conclusions: National health policies should increase the attractiveness of ambulatory general practice by promoting the diversification of modes of remuneration and encouraging the organization of group exercises in multidisciplinary medical homes and community health centers.

Colorectal cancer (CRC) is the third most common cancer worldwide. In France, although mass screening has been performed using the guaiac fecal occult blood test since 2008, the participation rate remains too low. Previous studies have explored the perspectives of doctors and patients as well as the performance of general practitioners (GPs) by recording and analyzing consultations in which patients came and asked for fecal occult blood test. Results indicated that improvement was needed in patient-centered communication. This research aims to develop educational material and training programs for GPs in order to enhance their communication with patients on CRC screening, based on data from two qualitative studies. Triangulation of all qualitative data was performed and discussed with communication experts in order to develop educational material and training programs based on the patient-centered clinical method. Two different scenarios were developed to improve communication with patients: one for a compliant patient and another for a noncompliant patient. Two videos were made featuring a doctor and a simulated patient. A two-sequence training program was built, including role-playing and presentation of the video followed by a discussion. The qualitative data helped us to produce a useful, relevant training program for GPs on CRC screening.

Background. The faecal occult blood test (FOBT) has proven efficiency at screening populations for an average risk of colorectal cancer. Mortality related to this cancer decreases by 1518% among adults, 5074 years old, tested every 2 years. A participation rate of at least 50% is desirable. This rate has not yet been reached in most French regions. Objective. To explore the obstacles to mass colorectal screening in France. Method. In 2009, five focus groups were conducted in different areas to explore physicians obstacles to FOBT screening. The patients obstacles were assessed in semi-structured interviews. A purposive sampling had been carried out for both GPs and patients. The focus groups were coded using Nvivo 8® software by three researchers; the interviews manually coded by two researchers. Results. GPs reported insufficient training and some doubted the relevance of screening. They expressed concern of having insufficient time for the test during a consultation, as well as practical and administrative obstacles. Some GPs experienced difficulty persuading patients who had no signs of colorectal disease. Obstacles for patients were mainly difficulties in doing screening themselves and a perception of health care that didnt match with screening. Information and organization were also important points to improve. The screening process was considered complex both by GPs and by patients. Conclusions. Numerous obstacles to colorectal screening, from both the physicians and the patients perspectives, were found. The major goal to improve mass screening may be to increase awareness and understanding of both physicians and patients regarding this process.

Background Therapeutic inertia has been defined as the failure of health-care provider to initiate or intensify therapy when therapeutic goals are not reached. It is regarded as a major cause of uncontrolled hypertension. The exploration of its causes and the interventions to reduce it are plagued by unclear conceptualizations and hypothesized mechanisms. We therefore systematically searched the literature for definitions and discussions on the concept of therapeutic inertia in hypertension in primary care, to try and form an operational definition. Methods A systematic review of all types of publications related to clinical inertia in hypertension was performed. Medline, EMbase, PsycInfo, the Cochrane library and databases, BDSP, CRD and NGC were searched from the start of their databases to June 2013. Articles were selected independently by two authors on the basis of their conceptual content, without other eligibility criteria or formal quality appraisal. Qualitative data were extracted independently by two teams of authors. Data were analyzed using a constant comparative qualitative method. Results The final selection included 89 articles. 112 codes were grouped in 4 categories: terms and definitions (semantics), who (physician, patient or system), how and why (mechanisms and reasons), and appropriateness. Regarding each of these categories, a number of contradictory assertions were found, most of them relying on little or no empirical data. Overall, the limits of what should be considered as inertia were not clear. A number of authors insisted that what was considered deleterious inertia might in fact be appropriate care, depending on the situation. Conclusions Our data analysis revealed a major lack of conceptualization of therapeutic inertia in hypertension and important discrepancies regarding its possible causes, mechanisms and outcomes. The concept should be split in two parts: appropriate inaction and inappropriate inertia. The development of consensual and operational definitions relying on empirical data and the exploration of the intimate mechanisms that underlie these behaviors are now needed.