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Our research is designed to understand how and under what conditions general practitioners contribute to equitable access to patient education (PE).We conducted a survey based on interactionist sociology in a sample of 32 doctors. These practitioners worked in the context of health networks and health care centres and were also involved in the PE resource centre for the Île-de-France region, thereby providing a favourable setting for our study, also reflected by the fact that one-half of practitioners were aware of the importance of or had been trained in PE.Doctors stress that their engagement in the patient-doctor relationship does not depend on the patient's psycho-social characteristics. Their educational practice nevertheless appears to be influenced by their a priori judgement of these characteristics. Based on their judgement, some clinicians develop practices that seem to promote better access for their socially underprivileged patients. This process is facilitated by several dynamics described in this article.The results of this research open up opportunities for office-based physicians and PE development structures to facilitate better access to PE for all patients.

Long-time invisible, the role of informal carers in providing assistance to elderly patients losing their autonomy is gaining recognition. A policy in favour of carers coordinated with that aimed at the people being cared for is necessary, but it is struggling to establish itself in France. Some progress can however be seen with the French bill on adapting society to the ageing of the population., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Background: In France, the referring GP is responsible for coordination of the patient's care pathway, but GPs appear to have few resources to achieve this task A general practitioner support network (Arespa) was developed in the Franche-Comté region (Arespa)for complex patients., Objective: To analyse the functioning and effects, of this network on the GP's practices., Methods: Qualitative research. Material based on individual semistructured interviews of members of Arespa staff and regulatory bodies; collective interviews of all coordinators (12; 4 groups) and general practitioners (37, 7 groups). Clinical vignettes were used to determine the nature of the coordinators' work; the doctor's perception of the network and how and why they used it; the perceived impact of the network; but also regulation byfunding bodies., Results: This coordinating network can be considered to be an original case management organisation, as it addresses the consequences of the disease on the patient's everyday life in order to facilitate the care pathway and life. The main differences are that it is primarily directed to GPs and coordinator interventions may therefore focus on treatment the consequences of disease rather than the patient's expectations. Secondly, there are no eligibility criteriafora patient's entitlement toArespa intervention, which depends exclusively on each doctor's assessment., Discussion: This approach is part of a specific institutional and regulatoryframework designed to ensure the use and individual and collective efficacy of the Arespa network. The authors discuss the results in the light of the literature on case management.

Background: Avoidable hospitalizations are used as a performance indicator of primary care in many countries. We investigate here the validity and usefulness of this measure both at a global scale and for the French healthcare system., Methods: A scoping study was performed to take a critical look at this concept. The different uses of avoidable hospitalizations as an indicator have already been reported in two recent systematic literature reviews., Results: Rates of avoidable hospitalizations seem to be far more correlated with the socioeconomic attributes of patients than with primary care supply. The few studies conducted in France confirm this international trend. Several weaknesses have been spotted in the building of this indicator: the choice of conditions that can be considered as sources of avoidable hospitalizations, their identification among hospitalization disease codes, the quality of hospital coding procedures, the ecological bias in the data collection of illustrative variables., Conclusion: Guidelines for improvement of this indicator are provided. In particular, we discuss the possibility of its use at the scale of the whole healthcare system., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Context: In France, a new payment for performance (P4P) scheme for primary care physicians was introduced in 2009 through the 'Contract for Improving Individual Practice' programme. Its objective was to reduce healthcare expenditures while enhancing improvement in guidelines' observance. Nevertheless, in all countries where the scheme was implemented, it raised several concerns in the domain of professional ethics., Objective: To draw out in France the ethical tensions arising in the general practitioner's (GP) profession linked to the introduction of P4P., Method: Qualitative research using two focus groups: first one with a sample of GPs who joined P4P and second one with those who did not. All collective interviews were recorded and fully transcribed. An inductive analysis of thematic content with construction of categories was conducted. All the data were triangulated., Results: All participants agreed that conflicts of interest were a real issue, leading to the resurgence of doctor's dirigisme, which could be detrimental for patient's autonomy. GPs who did not join P4P believed that the scheme would lead to patient's selection while those who joined P4P did not. The level of the maximal bonus of the P4P was considered low by all GPs. This was considered as an offense by non-participating GPs, whereas for participating ones, this low level minimised the risk of patient's selection., Conclusion: This work identified several areas of ethical tension, some being different from those previously described in other countries. The authors discuss the potential impact of institutional contexts and variability of implementation processes on shaping these differences.

Primary care has been identified as key to improving health care delivery systems across the globe. France and the United States have been ranked low on scales of primary care orientation. However, each nation has developed significant approaches to structuring primary care and organizing primary care-focused systems. This article reviews those efforts and finds that both nations face similar barriers to implementing many primary care initiatives.

Context: From one country to another, the pay-for-performance mechanisms differ on one significant point: the identification of target populations, that is, populations which serve as a basis for calculating the indicators. The aim of this study was to compare clinical versus medication-based identification of populations of patients with diabetes and hypertension over the age of 50 (for men) or 60 (for women), and any consequences this may have on the calculation of P4P indicators., Methods: A comparative, retrospective, observational study was carried out with clinical and prescription data from a panel of general practitioners (GPs), the Observatory of General Medicine (OMG) for the year 2007. Two indicators regarding the prescription for statins and aspirin in these populations were calculated., Results: We analyzed data from 21.690 patients collected by 61 GPs via electronic medical files. Following the clinical-based approach, 2.278 patients were diabetic, 8,271 had hypertension and 1.539 had both against respectively 1.730, 8.511 and 1.304 following the medication-based approach (% agreement = 96%, kappa = 0.69). The main reasons for these differences were: forgetting to code the morbidities in the clinical approach, not taking into account the population of patients who were given life style and diet rules only or taking into account patients for whom morbidities other than hypertension could justify the use of antihypertensive drugs in the medication-based approach. The mean (confidence interval) per doctor was 33.7% (31.5-35.9) for statin indicator and 38.4% (35.4-41.4) for aspirin indicator when the target populations were identified on the basis of clinical criteria whereas they were 37.9% (36.3-39.4) and 43.8% (41.4-46.3) on the basis of treatment criteria., Conclusion: The two approaches yield very "similar" scores but these scores cover different realities and offer food for thought on the possible usage of these indicators in the framework of P4P programmes.

Objectives: Since 2006 France experiences an innovative version of Gate-keeping which aims at regulating access to outpatient specialist care. We describe the reform's initial objectives, the political pathway which lead to the implementation of a reshaped reform and discuss the first outcomes after 1 year implementation. In the conclusion, we try to catch a glimpse for future steps of the reform., Methods: In order to observe the implantation and impact on the reform, we used national sickness fund databases and a sample of 7198 individuals from the 2006 French Health, Health Care and Insurance Survey (ESPS), including health, socio-economic and insurance status, questions relating to patient's understanding and compliance with the scheme, self-assessed unmet specialist needs since the reform., Results and Discussion: 2006 results show that 94% chose a preferred doctor, in a vast majority their family doctor. Impact on access to specialist care appears significant for the less well off and those not covered by a complementary insurance. From the specialist's side, new constraints on access to care seem to have been offset by rises in fee schedules., Conclusion: Notwithstanding disappointing short terms results, the new scheme may however lead up to reinforced managed care reforms.

Initially introduced by Juppé in 1996, the legislative reforms of January 2nd and March 4th 2002 legally enacted new forms of consumer representation and participation in the development of the health system. However, it appears that while this new role which was created to ensure legitimate participation has been recognised by law in theory, it has not necessarily received the same recognition and incorporation in practice at the grass roots level. As a result, it is now essential to think about practical methods of representation in order to sustain local legitimacy of consumers and patients on the ground and construct it from the bottom-up. The goal of this work was to understand how and under what conditions local legitimacy for health care system consumers, as a particular group of actors, can be effectively built, independently and irrespective of the specific question of elective democratic processes. The foundation of this work is based on material which resides in the collection of data from various local participation experiments that we or other researchers have contributed to establishing in a select group of health care settings. The results of this analysis serve to update a list of principle factors through which the legitimacy of the health care system's users is constructed. Such factors include the following: the promoting agents' expectations vis-à-vis the system's users and the a priori status which is given to them; the identification and selection methods used for choosing users, and the link to the types of users in terms of representation; the nature of the "generalisation" process for decision-making, understood as the process which transforms individuals' words and perspectives into collective ones; and the conditions for and modes of interaction between laypersons and professional experts. Finally, the paper presents the potential conflictive relationship or tension which may exist between representation and legitimacy with regard to the process for building legitimacy. The authors discuss the links between local, direct and elective democracy. The paper describes how effective democratic conditions can be built on the ground (from self-administered legitimacy to externally acknowledged legitimacy). In conclusion the paper succinctly distinguishes the articulation between representative democracy and participatory democracy, and how local processes relying upon direct democracy may be properly linked to the more "classical representative model of democracy".

The implementation of health care networks is accompanied by a certain number of changes in professional practices. At the heart of the economic, organisational, and political stakes, new questions are posed, especially in terms of evaluation. It is true that no matter what the level of evaluation, it is essential today to rely on the support of existing information systems to develop methodologies and to better describe the produced effects, in economic terms and health outcomes, but also from a more qualitative point of view, in terms of public satisfaction and benefits to clients. Laying down some reference points for evaluating health care networks can only contribute to developing new strategies for showing their effectiveness and efficiency and learning from this experimentation.

Background: The goal of our study was to develop a predictive model of resource use for pregnancy and perinatal care based on the knowledge of the distribution of risk factors in a given population of pregnant women., Methods: Data recorded in Outcome of Pregnancy Certificates (CIG) from 11 voluntary maternities of the district of Seine-Saint-Denis allowed us to identify those pathologies that were predictive of premature births and prenatal hospitalization of mothers. We built a classification of disease states and of risk level. A logistic regression using disease states as dependent variables and risk levels as independent variables allowed us to compute expected rates with their confidence intervals., Results: Among singletons, malformations, diabetes, toxemia, intra-uterin growth retardation, premature rupture of membranes covered 25% of all pregnancies but explained 64% of maternal hospitalizations; 90% of all mothers hospitalized and with delivery before 37 weeks gestation had at least one of these disease states. But 85% of the women who did not belong to disease classes had a normal pregnancy and delivery., Conclusions: In a given population, the distribution of risk levels is predictive of the incidence of disease per class. Then, given the length of stay of mothers per class, the rate of transfer of babies and the length of stay in postnatal care, we can simulate bed occupancy and compute bed capacities. The precision of the model is globally good, despite the relatively modest size of our initial data base: it will improve with the use of the model and the expected more widespread availability of data in France.

In this study, we analysed the potential impact of organizational factors to explain the variation of cesarean sections' rates. We used a retrospective sample of 84,372 deliveries and two subsamples of low risk deliveries for cesarean sections. We determined different organisational factors that included: juridical and financial status of maternities, their architecture, the type of on-call for obstetricians, pediatrists and anesthetists, the annual number of deliveries and the level of pediatric staff and equipments of the maternities. We used multiple regression techniques to study the specific effect of each parameter, while controlling effects of age and parity of the mothers. We have found that even on the low risk samples, variation of rates were important. The type of on-call, the level of pediatric services and the architecture of maternities exerted a strong and significant effect on the rate of cesarean sections compared to the absence of impact of the number of deliveries. We discuss the reasons why, explaining the occurrence of those factors and then, stress the need to take into account the relevant factors for organizational audits. It appears that, in the context of the new regulation of the health system, these results should give obstetricians reasons to enhance their efforts to correct inefficient practices and to respect consensual guidelines and joint accreditation of obstetric and pediatric units.

Aims: To identify maternities (in terms of level of activity and linkage with pediatric services) where, in 1991, mothers gave birth to infants of gestational age less than 33 weeks and/or with birth weight under 1500 g. To analyse factors linked to the probability of choosing a particular maternity as place of delivery for this population and measure the impact of maternal transferts on the rates of deliveries. To estimate the number of neonate transferts which could be avoided with simple recommendations. To propose policies that would allow France to come closer to the results of other reference countries in term of management of obstetrical and neonate care., Material and Method: We extracted from a retrospective sample of 84,279 births (out of a total of 770,148), 717 infants meeting previously defined criteria and related to the population described above, using univariate and multivariate analysis and logistic regression., Results: The Odds-ratio for a delivery to take place in a maternity with a volume of more than 2000 deliveries a year, compared with those doing less than 300 deliveries, is 4, 12. Only 15.8% of those deliveries took place in maternities linked to a level 3 pediatric unit (i.e where an intensive care neonates unit was located in the same building). 39.5% of births took place in level 1 maternities where no required pediatric service existed. Logistic regression techniques showed that the choice of a maternity for mother referral was more linked to the number of deliveries than to its level of pediatric services. In the studied population, 46% of the difference between the observed number of births in high volume maternities (compared to the expected number) could be explained by a maternal referral. The analysis of deliveries showed that for 34% of mothers who gave birth to a baby in a level 1 or 2 maternity, there was a possibility of being referred easily in a level 3 maternity., Conclusion: This study shows that the level of care of mothers at high risk of delivering a very premature and/or hypotrophic infant is far from international standards. Simple actions could double the number of births taking place in adapted maternities. We propose to both obstetricians and pediatrists, a common program to enhance the level of care.

The authors review the difficulties presented by the description of medical data, on the basis of the french experience with the programme to medicalize the hospital information system. They explain the different steps in preparing a hospital discharge abstract, and the difficulties presented by each one. They particularly stress the phase of hierarchization in choosing the principal diagnosis. They propose some solutions to improve data quality and an approach based on medical practice patterns.

Measles hemagglutination-inhibiting (HAI) antibody titers and measles-specific lymphocyte reactivity were studied in subjects who had previously received killed measles vaccine and had been recently reimmunized with live vaccine--persons who previously had atypical measles, subjects with multiple immunizations with live vaccine, adults with a history of measles, and persons with primary measles immunization. Twelve to 18 months after revaccination of former recipients of killed vaccine, all 31 subjects had measles HAI antibody titers greater than or equal to 10 and only three had lymphocyte stimulation indices (LSI) greater than 2.8. The mean LSI and geometric mean titer of antibody were similar to those of persons who had had natural measles many years ago. One subject who previously had atypical measles had an HAI titer of less than 5 and an LSI of 0.5; another had an LSI of 6.0 and an HAI titer of 80. Only one of seven subjects who were immunized more than once with live vaccine had an LSI of greater than 2.8 one year later. The finding of measles-specific lymphocyte reactivity and antibody levels in revaccinated former recipients of killed vaccine that are similar to those in persons who had natural measles suggests that the risk of future atypical measles in this group is slight.

Clinical and immunologic studies were performed in association with revaccination with live measles vaccine in 75 adolescents 11 to 14 years after immunization with killed measles vaccine. Ten subjects had local pain with swelling or erythema or both at the injection site; in three, the local reactions were severe and disturbing systemic complaints were also noted. These marked reactions were more common in subjects in whom the interval between the last dose of killed vaccine and the dose of live vaccine of the primary immunization series was less than or equal to 2 months, in subjects with prevaccination serum HAI antibody titers of less than or equal to 5, and in subjects with high measles antigen specific lymphocyte stimulation ratios. Serum complement levels could not be correlated with clinical reactions. Measles specific lymphocyte stimulation ratios were significantly higher in recipients of killed vaccine than in three compara,ive groups, in subjects with a killed-live interval in the initial vaccine series of less than or equal to 2 months as compared with greater than or equal to 3 months, and in subjects with prevaccination HAI antibody titers of less than or equal to 5 as compared with titers greater than or equal to 10. Although both low serum antibody and high measles specific lymphocyte reactivity were associated with marked local reactions, and probably indicative of susceptibility to atypical measles, our findings suggest that exaggerated lymphocyte reactivity is of greater importance in the adverse clinical response.

For many years it was generally believed that all convulsions associated with exanthem subitum were febrile in origin. More recently several investigators have suggested that the causative agent of this disease has a selective action on brain tissue aside from the effect of high temperature. In support of this concept are a variety of neurological manifestations sometimes observed during the course of exanthem subitum. These include prolonged and repeated convulsions, hemiparesis, headache, vomiting, bulging fontanelle, vertigo, cervical rigidity, extreme irritability and a reversal of the time of sleep. Abnormalities in the spinal fluid have been reported on a few occasions. By chance the authors observed a case of exanthem subitum that began with a prolonged and severe afebrile convulsion and transient left hemiparesis. Serial electroencephalograms showed a focal lesion with suppression and slowing in the right parietal area. Behavior disorders of brief duration were noted. This case is interpreted as additional evidence of the presence of an encephalitic process. The nature of the cerebral lesion remains unknown. The remote possibility of disturbed behavior in later life deserves consideration.