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Objectives: To provide an introduction to the 2020 International Medical Informatics Association (IMIA) Yearbook by the editors. Methods: This editorial provides an introduction and overview to the 2020 IMIA Yearbook which special topic is: “Ethics in Health Informatics”. The keynote paper, the survey paper of the Special Topic section, and the paper about Donald Lindberg’s ethical scientific openness in the History of Medical Informatics chapter of the Yearbook are discussed. Changes in the Yearbook Editorial Committee are also described. Results: Inspired by medical ethics, ethics in health informatics progresses with the advances in biomedical informatics. With the wide use of EHRs, the enlargement of the care team perimeter, the need for data sharing for care continuity, the reuse of data for the sake of research, and the implementation of AI-powered decision support tools, new ethics requirements are necessary to address issues such as threats on privacy, confidentiality breaches, poor security practices, lack of patient information, tension on data sharing and reuse policies, need for more transparency on apps effectiveness, biased algorithms with discriminatory outcomes, guarantee on trustworthy AI, concerns on the re-identification of de-identified data. Conclusions: Despite privacy rules rooted in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in the USA and even more restrictive new regulations such as the EU General Data Protection Regulation published in May 2018, some people do not believe their data will be kept confidential and may not share sensitive information with a provider, which may also induce unethical situations. Transparency on healthcare data processes is a condition of healthcare professionals’ and patients’ trust and their adoption of digital tools.

International audience

Introduction Clinical decision support systems (CDSS) implementing clinical practice guidelines (CPGs) have 2 main limitations: they target only patients for whom CPGs provide explicit recommendations, and their rationale may be difficult to understand. These 2 limitations result in poor CDSS adoption. We designed AntibioHelp® as a CDSS for antibiotic treatment. It displays the recommended and nonrecommended antibiotics, together with their properties, weighted by degree of importance as outlined in the CPGs. The aim of this study was to determine whether AntibioHelp® could increase the confidence of general practitioners (GPs) in CPG recommendations and help them to extrapolate guidelines to patients for whom CPGs provide no explicit recommendations. Materials and Methods We carried out a 2-stage crossover study in which GPs responded to clinical cases using CPG recommendations either alone or with explanations displayed through AntibioHelp®. We compared error rates, confidence levels, and response times. Results We included 64 GPs. When no explicit recommendation existed for a particular situation, AntibioHelp® significantly decreased the error rate (−41%, P value = 6x10−13), and significantly increased GP confidence (+8%, P value = .02). This CDSS was considered to be usable by GPs (SUS score = 64), despite a longer interaction time (+9–22 seconds). By contrast, AntibioHelp® had no significant effect if there was an explicit recommendation. Discussion/Conclusion The visualization of weighted antibiotic properties helps GPs to extrapolate recommendations to patients for whom CPGs provide no explicit recommendations. It also increases GP confidence in their prescriptions for these patients. Further evaluations are required to determine the impact of AntibioHelp® on antibiotic prescriptions in real clinical practice.

Resume But Etudier les opinions, pratiques et difficultes des medecins generalistes de la ville de Besancon vis-a-vis de la vaccination anti-HPV en 2015. Materiels et methodes Une etude par questionnaire anonyme a ete menee en 2015 aupres des 140 medecins generalistes (MG) de Besancon. Resultats Un pourcentage de 77,1 des MG sont favorables a la vaccination anti-HPV et 72,9 % declarent pratiquer la vaccination chez leurs patientes. Les 2 obstacles principaux a la vaccination rencontres par les MG sont : les effets secondaires a long terme mal connus (pour 40,6 % d’entre eux) et le doute sur le benefice clinique (pour 36,5 % d’entre eux). La polemique autour de la vaccination anti-VHB, les effets secondaires a long terme mal connus, le manque de recul, le manque de confiance vis-a-vis des hautes autorites de sante sont des obstacles a la vaccination anti-HPV chez les patientes d’apres respectivement 77,1 %, 76 %, 74 % et 49 % des MG. Conclusion Les formations des MG sur la vaccination anti-HPV doivent etre poursuivies et renforcees. Un programme scolaire d’information des patientes et leurs parents pourrait etre mis en place afin de faciliter la relation des MG et leurs patientes sur le sujet de la vaccination anti-HPV et ainsi augmenter la couverture vaccinale.

International audience; CONTEXT:General practitioners and family physicians (GP/FPs) play a key role in the vaccination of the public in many countries and serve as role models for their patients through their own health behaviors.OBJECTIVES AND METHODS:a) To search for and document recommended/mandated vaccines for GP/FPs in high-income countries; b) To systematically search and review the literature on these physicians' knowledge, attitudes, beliefs, and behaviors (KABB) toward their own vaccination with the recommended/mandated vaccines and the factors determining it.RESULTSa) The 14 countries included recommended or mandated as many as 12 vaccines; b) The systematic review identified 11 studies published in the last 10 y. All considered seasonal influenza vaccination but differed in the variables investigated.DISCUSSION/CONCLUSIONS:This review highlights the need for further studies on this topic, including qualitative and interventional studies (based on behavior change theories). These should cover occupational vaccines and determinants known to be associated with vaccine hesitancy.

Objective General practitioners (GPs) play a crucial role in human papillomavirus (HPV) vaccine acceptance in France. We sought to study: (1) GPs’ perceptions of its risks and efficacy and their recommendation behavior; (2) the relative importance of factors associated with the frequency of their recommendations. Methods Cross-sectional observational study in 2014 nested in a national panel of 1712 randomly selected GPs in private practice in France (response rate: 92.4%). We used model averaging to analyze the associations of self-reported frequency of GPs’ HPV vaccine recommendations with their perception of its risk-benefit balance and their opinions about the utility of vaccines in general. Results Overall, 72% of participants reported frequently recommending HPV vaccination; 60% considered that not enough is known about its risks. The model averaging showed that the factors most associated with infrequent recommendation of this vaccine by GPs were: unfavorable perceptions of its risk-benefit balance (OR = 0.13; 95%CI = 0.09–0.21; partial R 2 = 0.10), a decision not to vaccinate one's own daughter(s) with this vaccine (OR = 0.13; 95%CI = 0.07–0.24; partial R 2 = 0.05), and doubts about vaccine utility in general (OR = 0.78; 95%CI = 0.71–0.86; partial R 2 = 0.03). Conclusion Although nearly three-quarters of French GPs frequently recommended the HPV vaccine, our findings indicate that a substantial percentage of them are hesitant about it. Doubts about its risks and efficacy strongly influence their recommendation behavior. More research is warranted to help design and evaluate tailored tools and multicomponent intervention strategies to address physician's hesitancy about this vaccine.

Objective: To study, in a sample of French Family Practitioners (FPs), beliefs and attitudes toward depression and how they vary according to training received in mental health. Methods: The Depression Attitude Questionnaire (DAQ) was completed by 468 FPs from all regions of France, recruited by pharmaceutical company representatives to attend focus groups on the management of depression in general practice. Results: A three-factor model was derived from the DAQ, accounting for 37.7% of the total variance. The correlations between individual items of each component varied from 0.4 to 0.65, with an overall internal consistency of 0.47 (Cronbach's alpha). FPs had an overall neutral position on component 1, professional ease, a positive view on the origins of depression and its amenability to change (component 2), and a belief in the necessity of medication and the benefit of antidepressant therapy (component 3). Training in mental health, specifically through continuing medical education and postgraduate psychiatric hospital training, was significantly and positively associated with both professional ease and a medication approach to treating depression. Conclusion: This study is the first description of the beliefs and attitudes of French FPs toward depression using a standardized measure, the DAQ, despite the instrument's limited psychometric properties. It shows the positive effect of training in mental health on attitudes toward depression.

Summary Background While cardiologists are very active in the prevention of cardiovascular disease, their attitudes towards patients’ smoking habits are poorly studied. Aims In a nationwide French survey, we assessed cardiologists’ levels of knowledge and management of smoking cessation. Methods We sent out a questionnaire to a random sample of 1000 cardiologists. Results A total of 371 cardiologists agreed to participate in the survey; 8.1% were current smokers and 32.4% were past smokers. Most classified smoking cessation as the top priority for patients with coronary artery disease (56.5%) and peripheral arterial disease (88.5%). Cardiologists routinely assessed active and passive smoking in 96.2% and 43% of their patients, respectively. Only 29.2% considered themselves well informed about smoking-cessation management. While 39.9% declared they knew about the minimal counselling 7.3% described it correctly. Only 17.5% used the Fagerstrom questionnaire. Smoking cessation was advised systematically by 85% but only 5.4% of cardiologists followed up their patients specifically on this issue. They referred smokers to either their general practitioner or to smoking-cessation centres and/or quitlines in 16.0% and 67.0% of cases, respectively; 31.8% never referred their patients to a smoking-cessation centre, and 25% declared being unaware of any such centre in their area. Cardiologists who smoked were less likely to ask about patients’ smoking status than non-smokers (90% vs 98.2%, p = 0.039). Similarly, they were more passive in offering smoking-cessation counselling (23% vs 7%, p = 0.011), and referred less frequently their patients to a smoking-cessation centre (37% vs 64%, p = 0.028). Conclusion French cardiologists are rarely involved in the management of smoking cessation. Their own smoking status influences their attitudes towards the management of smoking cessation.

Objectives France is currently facing a vaccine-hesitancy crisis. We conducted a questionnaire-based telephone interview with a large sample of general practitioners (GPs) as they play a crucial role in the vaccination process. Our main objectives were to study the GPs’ vaccination behaviors when it comes to their own vaccination and that of their relatives, and the vaccine recommendations made to their patients. We also aimed to understand their opinion related to the severity of vaccine-preventable diseases and to assess their trust in various sources of information. Finally, we enquired about their opinion in terms of vaccination-related tools that could help them in their daily practice. The article aimed to present the design of this panel and survey. Patients and methods Four samples of GPs (one national and three regional) were selected among all the French GPs (metropolitan France) using random sampling. Five cross-sectional surveys should be conducted with that panel. The mean targeted sample size is 2350 GPs for each survey. The survey dedicated to vaccination was conducted by telephone or on the Internet. Results GPs were included in the survey between December 2013 and February 2014. The national sample included 1582 GPs (response rate: 46%) and the three regional samples included 1297 GPs (response rate: 44%). The survey dedicated to vaccination was conducted between April and July 2014; the national sample response rate was 92% (1582/1712). Conclusion The results of the first wave of surveys, conducted on a large sample of French GPs, provide important information to guide the French vaccination policy.

International audience; BACKGROUND:Care provider support for therapeutic patient education (TPE), its results and relationships with patients are factors in the setting up and sustainability of this practice.AIM:With a view to understanding the factors determining TPE care provider participation and favouring its development, the aim of this study was to describe the perception healthcare providers have of TPE in heart failure.METHODS:A national survey by self-administered questionnaire was performed in 2013 in 61 Observatoire de l'INsuffisance cardiaque (ODIN; Heart Failure Observatory) centres participating in the I-CARE programme. The cardiologist in charge of each centre received five questionnaires: one for him/herself and four for other healthcare providers working with him/her.RESULTS:We received 116 responses out of the 305 questionnaires sent (38.0%). Almost all of the responders stated that the patients were more observant after TPE sessions (91.4%). According to the responders, patients were better informed thanks to TPE (53.9%); they stated that TPE had changed their relationships with patients (81.9%); they also felt that they were educating the patient's close family/friends at the same time as the patients (86.2%).CONCLUSION:The survey showed that TPE improves care relationships. Healthcare providers recognize that they have been working differently since the programme was set up, and want the patient's close family/friends to be involved in treatment.

International audience; BACKGROUND: Fluoroquinolones are frequently prescribed for non complicated urinary tract infection treatments and have a negative ecological impact. We aimed to substitute them by antibiotics with narrower activity spectrum in order to preserve fluoroquinolone activity in complicated hospital infections. OBJECTIVE: To assess the impact of a multi-modal approach that combines the dispatching of antibiotic prescription guidelines and voluntary attendance at educational sessions on general practitioners' (GP) antibiotic prescription habits. SETTING: This study was led in Franche-Comté, a French eastern region, where GPs were given a guideline recommending a restricted use of fluoroquinolones for urinary tract infections. METHOD: Segmented regression analysis of interrupted time series was used to assess changes in antibiotic prescription. MAIN OUTCOME MEASURE: The antibiotic prescription data of nitrofurantoin, fosfomycin-trometamol and fluoroquinolones for women aged 15-65 years were obtained from the regional agency of health insurance. RESULTS: Twenty months after intervention, the number of nitrofurantoin and fosfomycintrometamol prescriptions increased by 36.8% (95% CI: 30.6-42.2) and 28.5% (95% CI: 22.9-35.4), respectively, while that of norfloxacin decreased by 9.1% (95% CI: -15.3 to -3.5). CONCLUSION: This study suggests that the dispatch of the guideline on urinary tract infection had a moderate impact on antibiotic prescriptions.

International audience; PURPOSE: The present study aimed at analyzing if patient participation constitutes a promising way of improvement of patient safety, or not. The hypothesis is that patient participation is a means to develop a safety culture based on the cooperation between patients and healthcare providers, to improve patients' satisfaction and to reduce the costs associated to adverse events. PATIENTS AND METHODS: A half-day session was organized on this theme during a training of radiotherapy professionals on risk management. Professionals were first distributed in three subgroups according to their specialty (radiation oncologists, radiation physicists and medical technicians), and had to work on four main questions relating to participation, among which the collection of real situations in which patients effectively contributed (positively or negatively) to patient safety. Results were then collectively discussed. RESULTS: Patient participation allows not only to detect and recover some mistakes or errors made by the professionals (error of identity), but also to decrease patients' risk behaviors (purposely taking the place of another patient in order to be treated faster). However, it must be seen as a possibility offered to patients, and not as an obligation. CONCLUSION: Patient participation to patient safety is a field of study, which requires to be developed in order to define the conditions enhancing such participation and to implement a set of actions to improve healthcare safety by a cooperative management of this one.

Wednesday, 4 pm. At the beginning of December, I was in a meeting inside Paris, my assistant called me: roads were blocked from an exceptional snowstorm and she was stuck in our hospital, which is a part of Paris hospital complex, localized in the West Paris suburb. Hopefully, trains were still working and I could go back to it. Between the train station and the hospital, it looked like a “war scene”: at nightfall, street lamps lighted the bright white desolated boulevard; some cars were in the middle of the sloping road without anybody inside; some people were standing next to their car, without moving, waiting for release. The sudden snow falls immobilize everybody. In front of the hospital, few ambulances are trying to get out without any success. At 6pm, the pre-hospital emergency system decided to dispatch paramedics all around in our district and to refuse hospitals transfers (except in case of life threatening which can’t be managed in some hospitals). Disable patients (major specialty of our hospital) and families of patients were stuck, such as health staff. The night shift was not be able to come. An emergency committee was set up at 3pm by the director. Considering I was the referent of the disaster plan of the hospital, I joined the committee. It included managers and head nurses. They already applied different decisions: leave the staff nursery open and ask the technical staff to stay (restaurant, technical support and gardeners to clear the road inside hospital). It has been asked to all the nurses and health staff to stay until relief teams could come. However, every nurses, auxiliary nurses, technicians, doctors, managers, physicians assistants, paramedics proposed themselves to stay, considering nursery and restaurants staid opened. All people of the hospital staff (2000 workers) cooperated together to great patients, family, colleagues who could not go home. The head nurses were the link between managers and nursing staff. The emergency committee had to ask people who were not essential in actual care and who could go home to leave, considering the very unusual circumstances could last some days. Communications by phone were also disturbed from a technical problem. At 8pm, the situation was more clear: no car could come and leave the hospital. Nursing staff was asked to stay at their shift the night if they had not any relief team. Everybody was invited to eat at the restaurant at this time. At 9pm30, the emergency committee numbers around 100 extra people who had to spend the night at hospital, including patients who could not be transferred, family of patients, and staff. The problem was then to find extra blankets and beds, and a solution was found with the help of the Red Cross. Breakfast was organized and the relief in the morning was made with workers who work around. We considered at this time that everything was under control and those who could go home, should do, with a morning point. During the night, snow had stop and roads were cleared; the meeting point was short. A final meeting at the end of the day was decided to debrief. Two weeks later, with a long period a snow, nursing staff, supports, are now accustomed to manage this situation, without activating a formal emergency committee. Only regular points were made. In conclusion, this experience feedback was very interesting. For instance, one major though about future improvement in our hospital organization was to elaborate an intermediate continuity activity plan. Actually, such as many hospitals, we have disaster plans to face heat wave, terrorist attack, pandemic flu and more, with an increase of the number of patients where we could bring back many health workers. However, no plan was elaborated in case of isolation situation and without necessity of disaster care. This event highlights the need of an intermediate procedure. It also a good example of collaboration in all units, unfortunate unusual between managers, nursing care (including doctors), technical support in this era of reengineering process of French hospitals. It showed that we must protect the unique richness of our hospital, I mean our workers.

International audience; PURPOSE: The present study aimed at analyzing if patient participation constitutes a promising way of improvement of patient safety, or not. The hypothesis is that patient participation is a means to develop a safety culture based on the cooperation between patients and healthcare providers, to improve patients' satisfaction and to reduce the costs associated to adverse events. PATIENTS AND METHODS: A half-day session was organized on this theme during a training of radiotherapy professionals on risk management. Professionals were first distributed in three subgroups according to their specialty (radiation oncologists, radiation physicists and medical technicians), and had to work on four main questions relating to participation, among which the collection of real situations in which patients effectively contributed (positively or negatively) to patient safety. Results were then collectively discussed. RESULTS: Patient participation allows not only to detect and recover some mistakes or errors made by the professionals (error of identity), but also to decrease patients' risk behaviors (purposely taking the place of another patient in order to be treated faster). However, it must be seen as a possibility offered to patients, and not as an obligation. CONCLUSION: Patient participation to patient safety is a field of study, which requires to be developed in order to define the conditions enhancing such participation and to implement a set of actions to improve healthcare safety by a cooperative management of this one.

Background A number of studies have identified advanced age as a barrier to accessing specialised oncological care. Many factors can influence the care provided for elderly patients after a diagnosis of cancer has been established or is suspected. Only one European study has analysed the decision processes leading general practitioners (GPs) to refer elderly patients with cancer to oncologists. The objectives of the current study are to describe the factors that influence these decisions and to identify the particular factors and GP characteristics that are associated with systematic referral of these patients in South-West France. Methods This is a cross-sectional study on a representative sample of GPs in Aquitaine, South-West France. Questionnaire items were selected using a Delphi consensus approach and sent by post. Two logistic regression models were constructed to investigate GPs' decisions to refer these patients. Results The response rate obtained was 30%. Half of the general practitioners reported "always" referring their elderly cancer patients to oncologists. More than 75% reported being influenced by patient-related elements (patient and/or family wishes, comorbid factors, unsuitability of invasive investigations, physical and mental autonomy), by cancer-related elements (severity of symptoms, expected side-effects) and an organisational element (whether the general practitioner was used to collaborating with oncologists). Logistic regression analysis showed that cancer site and organisational difficulties in patient management were significantly associated with the decision to refer elderly patients with early-stage cancer. For advanced stages, oncology training, patient age, organisational difficulties in patient management and stage of cancer were significantly associated with the decision to refer elderly patients. Conclusions Cancer-linked factors and organisational difficulties have been highlighted as influencing the decisions of GPs in the referral of elderly patients to a cancer team. These results highlight the need to implement continuous medical education specific for the management of elderly patients, to better apprehend the nature of these difficulties and to suggest solutions suited to local settings.

International audience; Attitudes of general practitioners (GPs) towards A/H1N1 pandemic vaccination are unknown. We conducted a cross-sectional survey with computer-assisted telephone interviewing in the French Regional Panel of General Practices from June 16 to September 22, 2009. Of 1434 respondents representative of GPs in four French regions, 885 (61.7%) were willing to accept A/H1N1 pandemic vaccination for themselves. The personal history of seasonal flu vaccination was the strongest independent predictive factor of willingness to accept A/H1N1 pandemic vaccination (p

International audience; Attitudes of general practitioners (GPs) towards A/H1N1 pandemic vaccination are unknown. We conducted a cross-sectional survey with computer-assisted telephone interviewing in the French Regional Panel of General Practices from June 16 to September 22, 2009. Of 1434 respondents representative of GPs in four French regions, 885 (61.7%) were willing to accept A/H1N1 pandemic vaccination for themselves. The personal history of seasonal flu vaccination was the strongest independent predictive factor of willingness to accept A/H1N1 pandemic vaccination (p

International audience; AIM: To evaluate our practice following Clinical Practice Guidelines (CPG) of the French College of Obstetricians and Gynecologists (CNGOF) in 2005 advocating a policy of restrictive episiotomy and to show that a significative decrease in the rate of episiotomy does not increase the number of third and fourth degree perineal tears. MATERIAL AND METHODS: A retrospective study of episiotomies and third/fourth degree perineal tears of the year 2003 (before the CPG) was compared with the year 2007 (after the CPG). We analyzed the indications of episiotomies and compared the rate of episiotomies and severe perineal tears between the two periods. RESULTS: In 2003, the rate of episiotomies was 18.8% (upon 1755 vaginal deliveries). We observed 16 (9 per thousand) third-degree perineal tears, five of which was associated with episiotomies; and two (1 per thousand) fourth-degree perineal tears. In 2007, the rate of episiotomies was 3.4% (upon 1940 vaginal deliveries). There were eight (4 per thousand) third-degree and four (2 per thousand) fourth-degree perineal tears. The two periods of study were similar in terms of age, parity, gestational age, birthweight, rate of spontaneous deliveries, breech and instrumental deliveries. There were a difference regarding deliveries in the occipitoposterior position (5.8% vs 13.8% ; p=0.02). No significant difference was found between the rates of third degree (9 per thousand vs 4 per thousand ; p=0.059) and fourth degree perineal tears (1 per thousand vs 2 per thousand ; p=0.487). However, there was a significant decrease in the rate of episiotomies between the two periods (18.8% vs 3.4% ; p

French version available; International audience; BACKGROUND: Many clinical scales contain items that are scored separately prior to being compiled into a single score. However, if the items have different degrees of importance, they should be weighted differently before being compiled. The principal aims of this study were to show how the "analytic hierarchy process" (AHP), which has never been used for this purpose, can be applied to weighting the six items of the "London handicap scale", and to compare the AHP to the "conjoint analysis" (CA), which was previously implemented by Harwood et al. (1994) [1]. DESIGN: In order to assess the relative importance of the six items, we submitted AHP and CA to a group of 10 physiatrists. We compared the methods in terms of item ranking according to importance, assessment of fictitious patients based on weights determined by each method, and perceived difficulty by the physiatrist. RESULTS: For both techniques, "Physical independence" (PHY) was the best-weighted item, but other ranks varied depending on the technique. AHP was better than CA in terms of accuracy (global assessment of the clinical status) and perceived difficulty. CONCLUSION: AHP may be used to reveal the importance that experts assign to the items of a multidimensional scale, and to calculate the appropriate weights for specific items. For this purpose, AHP seems to be more accurate than CA.

International audience; Multidisciplinary meeting (MDM) in oncology has been institutionalised in France by the Cancer Plan. This study aims to determine the place of MDM in the decision process. From November 2004 to July 2005, we observed 29 meetings at the Tours Hospital and 324 case presentations, 80 in orthopaedics, 151 in gastroenterology and 93 in chest medicine. Forty physicians attending the meetings answered a questionnaire exploring their opinions on MDM and the collegial decision. We found that MDM is mostly the place for technical discussions and that patients' wishes are rarely addressed. The different medical specialities are well represented but we observed that only physicians attend MDM. Decisions for straightforward cases are rapidly validated. For more complex clinical situations (25 to 40% of case presentations), the multidisciplinary approach allows to adapt guidelines or to choose alternative treatments. All the physicians interviewed express that MDM legitimates the medical decision. It occurs that they disagree with the RCP decision. We discuss how MDM impacts on the medical decision as well as the shift from the individual decision to the collective one, particularly in term of responsibility.

International audience; There are no specific studies evaluating the benefit/risk of antithrombotic prophylactic treatment in patients hospitalised in a palliative care unit. So, the aim of this study was to evaluate the clinicians attitudes about antithrombotic prophylaxis for patients in palliative care units and the elements which determined their decisions. METHODS: The clinical data of 4 terminally ill patients were extracted from database of a Palliative Care Unit in France. These 4 patients were selected as they represented several different situations according to the presence or not of major thrombotic risk factors, bleeding risk factors, and request of compassionate care. Through an open questionnaire, fourteen clinicians usually in charge of palliative care patients were individually interviewed about antithrombotic prophylactic therapy for each case of patients. RESULTS: except in the case of a patient with major thrombotic risk factors, no bleeding risk factor and wishing to receive active care, both the attitudes of clinicians to initiate or continue a prophylactic therapy and the elements which lead to their decisions were heterogeneous at least. CONCLUSION: the absence of recommendations based on validated clinical trials evaluating the efficacy and safety of thromboembolism prophylactic treatment in palliative care patients lead to uncertain decisions for clinicians. Added to an objective evaluation of thrombotic and hemorrhagic risks factors, the wish of patient to receive or not active care is probably the most important element to consider.

International audience; RATIONALE: Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs. OBJECTIVES: To record the prevalence, characteristics, and risk factors for conflicts in ICUs. METHODS: One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries). MEASUREMENTS AND MAIN RESULTS: Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings. CONCLUSIONS: Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.

International audience; BACKGROUND: In France, neither Bioethics Law nor law related to abortion make reference to selective terminations (ST). Because they apply in the context of multiple pregnancies, ST raises problems which differ from those we usually see in prenatal medicine.We wanted to know: 1) which approaches were used by obstetricians to inform couples about processes and risks of ST, 2) their role in the decision-making process of couples, and 3) their representations about the level of autonomy that couples are able to assume. METHODS: Qualitative research, eight semi-structured interviews performed with eight obstetricians from seven public hospitals in Parisian region. RESULTS: Similarities: *Necessity to devote a lot of time to information. *Importance to give the couples the maximum of time for reflection. *Belief that the final decision belongs to couples. Discordances: *Heterogeneity of revealed information. *Discrepancy in the will to assure a complete and non directive information transfer. *Divergence in representations of what is an ethical support. *Differences in the limits of the autonomy of couples. CONCLUSIONS: All physicians believe that they respect the autonomy of couples, arguing that final decision belongs to them. Paradoxically, some results are indicative of a sizeable level of directiveness from the physicians.

International audience; OBJECTIVE: Since screening for cancer has been advocated, funded, and promoted in France, it is important to evaluate the attitudes of subjects in the general population and general practitioners (GPs) toward cancer screening strategies. METHODS: EDIFICE is a nationwide opinion poll that was carried out by telephone among a representative sample of 1,504 subjects living in France and aged between 40 and 75 years and among a representative sample of 600 GPs. The questionnaire administered to subjects queried about previous screening for cancer. RESULTS: Ninety-three percent of women stated that they had undergone at least one mammography. Although rated "A" recommendation-strongly recommended-by the US Preventive Services Task Force, screening for colorectal cancer received less attention than prostate cancer screening which is rated "I"-insufficient evidence-(reported screening rates of 25% and 36%, respectively). Six percent of subjects stated that they had undergone lung cancer screening. GPs' attitudes toward cancer screening showed similar inconsistencies. CONCLUSIONS: It thus appears that understanding of cancer screening practices in the French general population does not match scientific evidence. To a lesser extent, this also holds for GPs.

International audience; BACKGROUND: In developed countries at present, death mostly occurs in hospitals, but the circumstances and factors associated with the quality of organization and care surrounding death are not well described. METHODS: We designed a large multicenter cross-sectional study to analyze the setting and clinical course of each patient on the day of death. We included 2750 clinical departments of 294 hospitals. Of these, 1033 departments (37.6%) of 200 hospitals (68.0%) contributed to the Mort-a-l'Hôpital survey. Data were collected prospectively by the bedside nurse of each patient within 10 days of the occurrence of death. Main outcome measures included circumstances of death in hospitalized patients; secondary outcomes, nurses' perceptions of quality of end-of-life care. RESULTS: Of the 1033 participating departments, 420 recorded no deaths during the study period and 613 declared at least 1 death. In the 3793 patients who died and were included for assessment, only 925 (24.4%) had loved ones present at the time of death; 70.1% had respiratory distress during the period before death; and only 12.0% were in pain. Written protocols for end-of-life care were available in 12.2% of participating departments. Only 35.1% of nurses judged the quality of dying and death acceptable for themselves. Principal factors significantly associated with this perception were availability of a written protocol for end-of-life care, anticipation of death, informing the family, surrogate designation, adequate control of pain, presence of family or friends at the time of death, and staff meeting with the family after the death. CONCLUSIONS: This large prospective study identifies nonoptimal circumstances of death for hospitalized patients and a number of suggestions for improvement. A combination of factors reflected in the nurses' satisfaction may improve the quality of end-of-life care.

International audience

Purpose Colorectal cancer (CRC) screening has been shown to decrease CRC mortality. Organised mass screening programs are being implemented in France. Its perception in the general population and by general practitioners is not well known. Methods Two nationwide observational telephone surveys were conducted in early 2005. First among a representative sample of subjects living in France and aged between 50 and 74 years that covered both geographical departments with and without implemented screening services. Second among General Practionners (Gps). Descriptive and multiple logistic regression was carried out. Results Twenty-five percent of the persons(N = 1509) reported having undergone at least one CRC screening, 18% of the 600 interviewed GPs reported recommending a screening test for CRC systematically to their patients aged 50–74 years. The odds ratio (OR) of having undergone a screening test using FOBT was 3.91 (95% CI: 2.49–6.16) for those living in organised departments (referent group living in departments without organised screening), almost twice as high as impact educational level (OR = 2.03; 95% CI: 1.19–3.47). Conclusion CRC screening is improved in geographical departments where it is organised by health authorities. In France, an organised screening programs decrease inequalities for CRC screening.

International audience; OBJECTIVE: To examine perceptions by intensive care unit (ICU) workers of unrestricted visitation, to measure visiting times, and to determine prevalence of symptoms of anxiety and depression in family members. DESIGN: Observational, prospective, single-center cohort. SETTING: Medical-surgical ICU in a 460-bed tertiary-care hospital. PATIENTS: Two hundred nine consecutive patients hospitalized >3 days were studied over the first 5 ICU days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Characteristics of patients (n = 209), families (n = 149), and ICU workers (n = 43) were collected. ICU workers reported their perceptions of unrestricted visitation, and family members completed the Hospital Anxiety and Depression Scale. Daily severity scores (Simplified Acute Physiology Score II and Logistic Organ Failure) and a workload score (Nine Equivalents of Nursing Manpower) were computed. Maximum median visit length was 120 mins per patient per day and occurred on days 4 and 5. No correlations were found among severity of illness, workload, and visit length. For 115 patients, both nurse and physician questionnaires were available; although several differences were noted, neither nurses nor physicians perceived open visitation as disrupting patient care. The median rating for delay in organizing care was "never" for physicians and "occasionally" for nurses. Nurses perceived more disorganization of care than physicians (p = .008). Compared with nurses, the physicians reported greater family trust (p = .0023), more family stress (p = .047), and greater unease when examining the patient (p = .02). The Hospital Anxiety and Depression Scale indicated symptoms of anxiety in 73 (49%) family members and depression in 44 (29.5%). CONCLUSIONS: The 24-hr visitation policy was perceived favorably by families. It induced only moderate discomfort among ICU workers, due to the potential for care interruption, in particular for nurses.

International audience; OBJECTIVE: To identify subjective factors that lead investigators not to invite eligible individuals to participate in pediatric studies. DESIGN: Qualitative study with semistructured interviews. SETTING: Four pediatric teaching hospitals in Paris. PARTICIPANTS: Pediatric investigators (n=24). MAIN OUTCOME MEASURE: Report by investigator that eligible patients were not invited by him or her to participate in a clinical research study. RESULTS: Sixty-three percent of investigators (15 of 24) reported not inviting eligible patients. The noninvitation patterns were global (ie, investigators did not invite anyone) (37.5% [9/24]) or targeted specific patient subgroups (37.5% [9/24]). Noninvitation was often described as driven by ethical concerns related to the study design or patients or by anticipated patient refusal (58.3% [14/24]). None of the investigators kept records of noninvitation rates or refusal rates. Investigators estimated refusal rates of 1% to 10%, and none remembered a study that had failed because of potential subjects' refusals (including healthy participants). CONCLUSIONS: Noninvitation to participate in studies is not an absence of action but rather is an organized practice that reflects investigators' perceptions. Consequences are practical (eg, recruitment bias and study failure) and ethical (eg, unequal access to trials and failure to respect the autonomy of eligible patients). Our data suggest an urgent need for quantitative studies aimed at documenting and understanding noninvitation of eligible patients to participate in research studies in pediatrics and in other medical specialties.

International audience; PURPOSE: To evaluate the cosmetic results of sequential vs. concurrent adjuvant chemotherapy with radiotherapy after breast-conserving surgery for breast cancer, and to compare ratings by patients and physicians. METHODS AND MATERIALS: From 1996 to 2000, 716 patients with Stage I-II breast cancers were included in a multicenter, Phase III trial (the ARCOSEIN study) comparing, after breast-conserving surgery with axillary dissection, sequential treatment with chemotherapy first followed by radiotherapy vs. chemotherapy administered concurrently with radiotherapy. Cosmetic results with regard to both the overall aspect of the breast and specific changes (color, scar) were evaluated in a total of 214 patients (107 in each arm) by means of questionnaires to both the patient and a physician whose rating was blinded to treatment allocation. RESULTS: Patients' overall satisfaction with cosmesis was not statistically different between the two arms, with approximately 92% with at least satisfactory results (p = 0.72), although differences between the treated and untreated breasts were greater after the concurrent regimen (29% vs. 14% with more than moderate differences; p = 0.0015). Physician assessment of overall cosmesis was less favorable, with lower rates of at least satisfactory results in the concurrent arm (60% vs. 85%; p = 0.001). Consequently, the concordance for overall satisfaction with cosmesis between patients and doctors was only fair (kappa = 0.62). CONCLUSION: After breast-conserving surgery, the concurrent use of chemotherapy with radiotherapy is significantly associated with greater differences between the breasts. These differences do not translate into patients' lessened satisfaction with cosmesis.

International audience; OBJECTIVE: . The aim of this study was to assess clinical staff's opinions on the results of in-patient satisfaction surveys and their use within the quality improvement process. SETTING: The institution is a 2200-bed teaching hospital of tertiary health care employing 8000 professionals. Patient satisfaction surveys are carried out each year using a validated questionnaire mailed to a random sample of patients. The specific results of each department are sent to the medical and paramedical managers. METHODS: We conducted a questionnaire survey on 500 care providers randomly selected in every medical and surgical department. RESULTS: A total of 261 questionnaires were returned and analysed. Overall, 94% of responders had a favourable opinion of the patient satisfaction surveys. They considered that the patient was able to judge hospital service quality, especially in its relational, organizational, and environmental dimensions. The specific results for the department were less well known than the overall hospital results (60 versus 76%). These results were formally discussed in the department according to 40% of responders; 40% declared that these data resulted in improvement actions and considered that they led to modifications in their behaviour with patients. CONCLUSIONS: Despite a declared interest in satisfaction surveys, the results remain underused by hospital staff and insufficiently discussed within teams.

International audience; L'éducation thérapeutique doit faire partie intégrante du soin, mais l'éducation, en tant que simple diffusion de connaissance reste insuffisante. Il paraît indispensable que le corps médical s'implique davantage, qu'il encourage les patients à participer aux programmes éducatifs et propose systématiquement aux patients des outils de contrôle, tels que le plan d'action qui doit être écrit et personnalisé. Pour ce faire, il semble nécessaire de développer des prises en charge, en amont de l'éducation, qui doivent, par nature, être centrées sur le patient, c'est-à-dire tenir compte du système de croyances dans lequel il évolue et ainsi renforcer les comportements, qui en matière de santé sont jugés sains et modifier les stratégies à la fois cognitives et comportementales considérés comme délétères. L'éducation thérapeutique n'est pas la solution miracle, mais avec une meilleure définition des contenus et une diffusion plus large des outils de contrôle, elle semble, en tout cas, améliorer considérablement les facteurs de morbidité.

Background Providing care for mental health problems concerns General Practitioners (GPs), Private Psychiatrists (PrPs) and Public Psychiatrists (PuPs). As patient distribution and patterns of practice among these professionals are not well known, a survey was planned prior to a re-organisation of mental health services in an area close to Paris Methods All GPs (n = 492), PrPs (n = 82) and PuPs (n = 78) in the South-Yvelines area in France were informed of the implementation of a local mental health program. Practitioners interested in taking part were invited to include prospectively all patients with mental health problem they saw over an 8-day period and to complete a 6-month retrospective questionnaire on their mental health practice. 180 GPs (36.6%), 45 PrPs (54.9%) and 63 PuPs (84.0%) responded. Results GPs and PrPs were very similar but very different from PuPs for the proportion of patients with anxious or depressive disorders (70% v. 65% v. 38%, p < .001), psychotic disorders (5% v. 7% v. 30%, p < .001), previous psychiatric hospitalization (22% v. 26 v. 61%, p < .001) and receiving disability allowance (16% v. 18% v. 52%, p < .001). GPs had fewer patients with long-standing psychiatric disorders than PrPs and PuPs (52%, 64% v. 63%, p < .001). Time-lapse between consultations was longest for GPs, intermediate for PuPs and shortest for PrPs (36 days v. 26 v. 18, p < .001). Access to care had been delayed longer for Psychiatrists (PrPs, PuPs) than for GPs (61% v. 53% v. 25%, p < .001). GPs and PuPs frequently felt a need for collaboration for their patients, PrPs rarely (42% v. 61%. v. 10%, p < .001). Satisfaction with mental health practice was low for all categories of physicians (42.6% encountered difficulties hospitalizing patients and 61.4% had patients they would prefer not to cater for). GPs more often reported unsatisfactory relationships with mental health professionals than did PrPs and PuPs (54% v. 15% v. 8%, p < .001). Conclusion GP patients with mental health problems are very similar to patients of private psychiatrists; there is a lack of the collaboration felt to be necessary, because of psychiatrists' workload, and because GPs have specific needs in this respect. The "Yvelines-Sud Mental Health Network" has been created to enhance collaboration.

Background Theory-based approaches are advocated to improve our understanding of prescription behaviour. This study is an application of the theory of planned behaviour (TPB) with additional variables. It was designed to assess which variables were associated with the intention to prescribe hormone therapy (HT). In addition, variations in the measures across medical specialities (GPs and gynaecologists) and across countries (France and Quebec) were investigated. Methods A survey among 2,000 doctors from France and 1,044 doctors from Quebec was conducted. Data were collected by means of a self-administered questionnaire. A clinical vignette was used to elicit doctors' opinions. The following TPB variables were assessed: attitude, subjective norm, perceived behavioural control, attitudinal beliefs, normative beliefs and power of control beliefs. Additional variables (role belief, moral norm and practice pattern-related factors) were also assessed. A stepwise logistic regression was used to assess which variables were associated with the intention to prescribe HT. GPs and gynaecologists were compared to each other within countries and the two countries were compared within the specialties. Results Overall, 1,085 doctors from France returned their questionnaire and 516 doctors from Quebec (response rate = 54% and 49%, respectively). In the overall regression model, power of control beliefs, moral norm and role belief were significantly associated with intention (all at p < 0.0001). The models by specialty and country were: for GPs in Quebec, power of control beliefs (p < 0.0001), moral norm (p < 0.01) and cytology and hormonal dosage (both at p < 0.05); for GPs in France, power of control beliefs and role belief (both at p < 0.0001) and perception of behavioural control (p < 0.05) and cessation of menses (p < 0.01); for gynaecologists in Quebec, moral norm and power of control beliefs (both at p = 0.01); and for gynaecologists in France, power of control beliefs (p < 0.0001), and moral norm, role belief and lipid profile (all at p < 0.05). Conclusion In both countries, compared with GPs, intention to prescribe HT was higher for gynaecologists. Psychosocial determinants of doctors' intention to prescribe HT varied according to the specialty and the country thus, suggesting an influence of contextual factors on these determinants.

International audience; The aim of pharmacogenetic studies is to adapt therapeutic strategies to individual genetic profiles, thus maximising their efficacy and minimising the likelihood of adverse side effects. Since the advent of personalised medicine, the issue of communicating research results to participants has become increasingly important. We addressed this question in the context of HIV infection, as patients and associations are particularly concerned by research and therapeutic advances. We explored the standpoints of both research professionals and participants involved in a pharmacogenetic study conducted in a cohort of HIV-infected patients. The setting of the research protocol was followed over a 2-year period. Participants' standpoints were collected through a questionnaire and interviews were conducted with research professionals. Of 125 participants, 76% wished to receive individual results and 71% wished to receive collective results; 39% did not know when results might be expected. Communication of global research results is a principle that is generally accepted by professionals. Concerning individual feedback, the professionals felt that it was necessary if it could be of direct benefit to the participant, but they expressed doubts for situations with no recognised benefit. Our results highlight the necessity to consider this issue in greater detail. We suggest the need to anticipate the debates concerning individual feedback, to differentiate between situations and the importance of further investigations on the opportunities and modalities of communication. Finally, our work emphasised the opposite pressures between the pursuit of scientific knowledge and the therapeutic orientation of clinical trials.

International audience; Depression is a frequent symptom in psychiatry, either isolated (major depression) or entangled with other psychiatric symptoms (psychotic depression, depression of bipolar disorders). Many antidepressant drugs are available with different pharmacological profiles from different classes: tricyclic antidepressants, monoamine oxydase inhibitors, selective serotonin reuptake inhibitors (SSRI). However, there are some limitations with these drugs because there is a long delay before relief for symptoms, some patients with major depression are resistant to treatment, there is a risk to induce manic symptoms in patients with bipolar disorders and these drugs have no effect on the psychotic symptoms frequently associated to major depression. The leading hypothesis for the search of more efficient new antidepressants has been the amine deficit hypothesis: noradrenaline and/or serotonin deficit and more recently dopamine deficit. Moreover, a dopamine deficit has been also hypothesized as the central mechanism explaining the negative symptoms of schizophrenia. These symptoms are the consequence of a deficit of normal behaviours and include affective flattening, alogia, apathy, avolition and social withdrawal. There is thus a great overlap between symptoms of depression and negative symptoms of schizophrenia. Atypical antipsychotics, in contrast with conventional neuroleptics, have been shown to decrease negative symptoms, most probably through the release of dopamine in prefrontal cortex, thus improving psychomotor activity, motivation, pleasure, appetite, etc. The dopamine deficit in cortical prefrontal areas was thus an unifying hypothesis to explain both some symptoms of depression and negative symptoms of schizophrenia. Studies in animal confirm this view and show that the association of an atypical antipsychotic drug and an SSRI (olanzapine plus fluoxetine) increases synergistically the release of dopamine in prefrontal areas. Moreover, most of the atypical antipsychotics have a large action spectrum, beyond the only dopamine receptors: their effects on the serotonin receptors--particularly the 5-HT2A and 5-HT2C receptors--suggest that their association to SSRI could be a promising treatment for depression. Indeed, SSRI act mainly by increasing the serotonin level in the synapse, thus leading to a non specific activation of all pre- and post-synaptic serotonin receptors. Among them, 5-HT2A/2C receptors have been involved in some of the unwanted effects of SSRI: agitation, anxiety, insomnia, sexual disorders, etc. The inhibition of these receptors could be thus beneficial for patients treated with SSRI. Amisulpride is an unique atypical antipsychotic that selectively blocks dopamine receptors presynaptically in the frontal cortex, possibly enhancing dopaminergic transmission. The antidepressant effect of amisulpride was shown in dysthymia in many clinical studies versus placebo, tricyclic antidepressants, SSRI or others. However, a shorter delay for symptom relief was not demonstrated for amisulpride as compared to comparative antidepressants. Other atypical antipsychotics (clozapine, olanzapine), which act on a large variety of receptors, have shown antidepressant effects--mainly in association with SSRI--in different psychiatric diseases: treatment-resistant major depression, major depression with psychotic symptoms and depression of bipolar disorders, with no increase of manic symptoms in this latter case. Moreover, the delay for symptom relief was greatly shortened. More comparative double-blind studies are required to confirm and to precise the antidepressant effects of atypical antipsychotics. Nevertheless, these studies suggest that atypical anti-psychotics could be of great value in depressive conditions reputed for their resistance to treatment with usual antidepressants. Particularly, new strategies emerge that combine atypical antipsychotics and antidepressants for greater efficacy and more rapid relief of depression symptoms.

International audience; This paper explores service users' experiences of a 'person-centred' mental health service. We describe the development of a model of social psychiatry that places the emphasis on the experiences of the person within social and political contexts. This establishes the foundations of a 'person-centred' approach, the values of which are described briefly. The results of interviews with 20 people are presented, in which their experiences of the service are explored in detail. These interviews reveal the struggle that lies at the heart of the professional-service user dialectic, which relates to issues of institutional power, roles and responsibility, and which places professional staff in conflict with the very notion of 'person-centredness'. No matter how 'person-centred' a mental health service may strive to be, there remain serious obstacles to the full realization of this approach. Despite this critique, there were many things that were valued by those who used the service. More detailed qualitative studies are required to explicate the complex relationships and paradoxes that emerged.

There is a need to promote research within and on general practice to strengthen the place and prestige of the discipline, in particular within the Universities. This kind of research would contribute to improving the day-to-day work of GP's and consequently, the quality of the services they provide to the patients. The process is under way in all the industrialized countries. However, contradictory forces are crossing the field. The solo practice of most GP's is a barrier to interchange, it slows down the learning process and prevents all kinds of team work, all things necessary to research work. Furthermore, qualitative methods, which are inherent to research in general practice may not be recognized by the scientific community. On the other side, there is a great temptation to reject the conventional standards and proclaim the right to differency, which might be fatal.; Cet article a pour objet de cerner, à partir d'un état des lieux, ce que représente aujourd'hui, en France, la recherche en médecine générale, en insistant sur les enjeux et les perspectives de ce domaine d'activité qui n'a pas pour autant l'évidence d'une "nouvelle discipline". Une analyse détaillée de revues professionnelles a permis de construire un corpus de publications de recherche et de proposer une typologie des recherches, en approchant en même temps le groupe professionnel des "chercheurs en médecine générale", tel qu'il est repérable aujourd'hui en France. L'article présente en premier lieu le contexte institutionnel et les enjeux de la recherche en médecine générale, ensuite la production de recherche, tant par les thèmes traités et les démarches retenues que par les contraintes et les dynamiques observées, est analysée. Une première comparaison avec certains travaux européens permettra, en conclusion, de brosser quelques perspectives. (extrait du texte).

Background The development of resistance to antimicrobial therapy by Neisseria gonorrhoeae causes on-going problems for individual case management of gonorrhoea. Surveillance data about N. gonorrhoeae have indicated an increase in the incidence of gonorrhoea in France in 2006. As a consequence of the development of antibiotic resistance in N. gonorrhoeae, French guidelines excluded fluoroquinolones as a standard treatment for N. gonorrhoeae. Ceftriaxone became the recommended treatment, associated with azithromycin for Clamydia trachomatis infection. Our aim was to describe the practice patterns of general practitioners (GPs) in managing the antibiotic treatment of patients with symptoms suggestive of uncomplicated male urethritis. Methods We developed a clinical vignette describing a man with typical gonococcal urethritis symptoms to elicit questions about antibiotic treatment. We mailed the electronic questionnaire to a random sample of 1000 French GPs belonging to the Sentinelles Network. Results By the end of the survey period, 350 vignettes were received, yielding a response rate of 35%. Sixty-six GPs (20.2%) prescribed the recommended antibiotics for the simultaneous treatment of N. gonorrhoeae and C. trachomatis infections, while 132 GPs (40.4%) prescribed only non-recommended antibiotics, including ciprofloxacin in 69 cases (21.1%). General practitioners with less than 10 years in practice showed better compliance to guidelines than those with more years in practice (p < 0.05). Conclusions The results suggest a mismatch between the guidelines and the antibiotic treatment of male uncomplicated urethritis by French GPs, mostly among the subgroup of physicians who have been in practice longer. Educational approaches based on practice feedback need to be developed to improve these deficits in the quality of care.