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

Aim: Antihypertensive drugs are thought to be responsible for adverse drug events in 25% of patients, with severe consequences in 13% of cases. The purpose of this study was to develop an interactive booklet designed to inform and involve patients with a view to preventing adverse drug events., Methods: The development of the booklet involved several stages, including a literature review, a Delphi survey, a readability assessment, a qualitative study in primary care, a revision process, and graphic design work. 27 experts (patients, general practitioners, public health practitioners, cardiologists, geriatricians, psychologists, economists, pharmacists, nurses and ethicists) participated in the Delphi survey, while the qualitative study was based on a sample that included 7 doctors, 13 patients and 2 healthcare assistants., Results: We developed an interactive booklet containing information items on the benefits and risks of antihypertensive drugs, a care plan to be completed by the patient, and a form for reporting adverse drug events. Ambiguous sentences and incomprehensible medical terms were rephrased. The time required to present the booklet and ease of use were key acceptability criteria for caregivers. Among the patients, the study found that interest in the booklet required clear evidence of an expected benefit., Conclusion: An understandable and acceptable interactive booklet was developed using a systematic process to prevent severe adverse drug events in primary care.

Background: Prescription of sick leave periods is a common but complex task in general practice in many countries., Objectives: The objective was to identify issues around sickness certification and solutions aimed at improving this process., Methods: Through Medline, Cochrane, and Web of Science bibliographic databases, 56 relevant original articles in English or French were retrieved, focusing on the certification process in general practice. Data was synthesized using a thematic analysis., Results: The various issues identified were difficulties in assessing the need for sick leave and its length, difficulties in the doctor-patient relationship, and difficulties related to healthcare system organization and to the socioeconomic environment. Some possible solutions to these difficulties have been assessed either for validity or effectiveness. In particular, patient functional assessment or cooperation with occupational practitioners could help in adjusting the sick periods. Guidelines or legislative reforms on sickness certification could only potentially improve the filling in of certificates., Conclusion: Sickness certification represents a procedural as well as a relational, organizational and political challenge. Well-validated tools or procedures to support doctors in this task are lacking. The development of functional assessment and cooperation with occupational practitioners requires appropriate training and education for present and future GPs. Further research is needed to refine these strategies, which should be tailored to each country.

In France, there is a discrepancy between perceptions and practices related to vaccination, the causes of which are poorly understood. The purpose of this study was to examine and compare patients' and physicians' social representations of vaccination. A qualitative study based on hierarchized evocation was conducted on a sample of 30 patients and 30 general practitioners. The participants were asked to write down seven words or word groups (word associations) induced by the concept of "vaccination" and to rank them in order of importance. The associations were grouped by theme and sub-theme. Their frequency, connotations and importance were compared between the two groups. The results show that, overall, the physicians had a positive view of vaccination, while the patients had a more neutral view (polarity index: + 0.38 vs + 0.07, p < 0.01). Among both patients and general practitioners, vaccination tends to be perceived as a form of medical care mainly targeting children and aimed at prevention, and its effectiveness is considered to be implicit. However, the patients appeared to be more concerned about the potential side effects of certain vaccinations, while the GPs emphasized the harmlessness of vaccination. The participating GPs also tended to take a collective view of vaccination, while some patients criticized the lack of targeted vaccinations. Better communication on these key aspects of representations may help to increase confidence in vaccination and to close the gap between perception and practice.

The Mini Nutritional Assessment (MNA), the most used scale for detecting undernutrition in clinical practice, has been validated in the hospital setting. We have evaluated its reproducibility in a French nursing home for dependent elderly people. It is globally acceptable, but some items should be more standardized.

Background: Infantile colics or excessive crying represent a source of stress for parents and a frequent reason for encounter in primary care., Objective: To assess the effectiveness of treatments of this syndrome from a systematic review., Information Sources: Medline, Cochrane and Embase databases., Selection of Studies: We used the following inclusion criteria: therapeutic assessment of infant colics or excessive crying, randomized controlled trials or meta-analyses, published in English or French language. Thirty-one randomized controlled trials and one meta-analysis have been included., Results: Allopathic drugs have not proved effectiveness (simethicone, lactase) and some of them can cause potentially serious adverse reactions (dicyclomine). Protein hydrolysate or soy formulas seem to be effective, but soy milk can induce allergies. Sucrose solutions provide some benefit in studies with low level of evidence. Effectiveness is likely for a probiotics (Lactobacillus reuteri) and for herbal mixtures containing fennel extracts. Evidence is lacking for manual (osteopathy, acupuncture) and behavioural therapies (decreased stimulations, reassurance of parents)., Limitations: The definition of infantile colics and the methods used for crying measurement changed across trials. The included trials were of variable quality, especially with no double-blind procedure in 17 trials., Conclusion: The most validated treatments for infantile colics are the substitution of cows' milk by a hydrolysed formula, the use of L. reuteri and of fennel extracts., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Context: Inability to identify clinically group A streptococcal (GAS) tonsillitis has resulted for a long time in treating all tonsillitis with antibiotics in France. The use of the rapid detection tests (RDT) for GAS is currently recommended, in order to keep antibiotics only for GAS tonsillitis. Our objective was to carry out a cost-effectiveness analysis, comparing various strategies for the management of acute tonsillitis in France., Methods: We used a decision analysis model, including seven strategies (S) for tonsillitis management, specifically in children and in adults: S1: observation only (reference strategy); S2: clinical scoring; S3: RDT testing; S4: throat culture; S5: clinical scoring combined with RDT testing; S6: RDT testing combined with throat culture; S7: systematic antibiotic therapy. The criterion for effectiveness was the absence of locoregional suppurative complications., Results: The use of the RDT alone had the best cost-effectiveness ratio in both adults and children. For this strategy, we estimated the cost per suppurative complication avoided at 970€ in children and at 903€ in adults. For the strategy associating a confirmative throat culture to the RDT, the extra cost per suppurative complication avoided was estimated at 106,666€ in children and at 228,000€ in adults. Sensitivity analysis showed the stability of the model while making the main parameters vary., Conclusion: In acute tonsillitis, in both adults and children, RDT testing by practitioners is the more efficient strategy to identify and treat patients with GAS tonsillitis. Combining RDT testing with throat culture can provide additional effectiveness, but at the cost of a significant extra charge for the community., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Purpose: Background rates for common health problems have seldom been estimated to facilitate interpretation of signals that may occur after a new public health intervention. Background rates of diagnoses from general practitioners (GPs) and gynecologists (GYNs) were assessed before the implementation of human papillomavirus (HPV) immunization program., Methods: This cross-sectional study used data collected in 2006 in France. All visits of women (aged 11-23 years) to a GP or a GYN participating in the longitudinal patient data (LPD) network were considered. Diagnoses and symptoms were retrieved and classified according to the International Classification of Primary Care. Only diagnoses made in ≥ 1% of visits were reported in primary analyses. Independent analyses were performed for visits to GPs and GYNs and for adolescents and young adults. Finally, the rates of pre-specified health problems of interest (e.g., because of their potential identification as signals after HPV immunization) were computed from processed diagnostic data, using time windows consistent with HPV vaccination scheme., Results: About 380,813 GP and 36,329 GYN visits were analyzed. Acute upper respiratory infections were the most frequently recorded diagnoses by GPs, accounting for 11,783 per 100,000 visits per year. Visits related to the respiratory system accounted for 10 of the 23 most frequent diagnoses by GPs. Genital candidiasis was the most frequent GYN diagnosis, accounting for 4746 per 100,000 visits per year. Most GYN visits were for pregnancy-related issues or menstrual problems. The main diagnoses were similar in adolescents compared with young adults in both GP and GYN settings. Pre-specified health problems occurred at high rates, as exemplified by acne that was diagnosed in 0.8% of patients during time windows consistent with HPV immunization., Conclusion: Diagnostic data processed from electronic health records identified the rates of common health events experienced by young female patients routinely visiting their GP or GYN before HPV immunization. Such rates may prove useful in interpreting adverse events reported after the launch of new medical interventions., (Copyright © 2011 John Wiley & Sons, Ltd.)

Unlabelled: In an aim to standardize the terminology used in patient safety research, the World Health Organization (WHO) has recommended the use of internationally acceptable patient safety concepts for the collection and classification of adverse events and near misses in health care settings worldwide., Objective: The principal aims of this study were to clarify patient safety terminology and concepts, to suggest a comprehensible definition of medical error, and to propose patient safety classifications for use in primary health care., Design: Systematic review and synthesis of the international medical literature., Methods: In order to define "medical error" as a health care term and to identify various published or unpublished classifications of medical errors, we searched the Medline, Web of Science, Cochrane Library, Pascal, and French Data Bank of Public Health bibliographical medical databases for the years 2000 through 2011. A grey literature search was carried out using the Google and Google Scholar search engines. We used the recommendations of WHO to analyze these classifications. The principal key words used were: primary care, family practice, patient safety event, adverse event and taxonomy., Results: The online search identified 191 documents; among these, 51 articles, eight reports and two books were deemed appropriate. Twelve classifications were analyzed and compared using WHO recommendations. Eight definitions of medical error were identified during this analysis., Conclusion: The WHO Alliance for Patient Safety has clarified the definition of several terms - medical error, adverse event, patient safety event, and near miss - through the development of the International Patient Safety Event Classification. This conceptual framework and classification for patient safety should be applicable across the full spectrum of health care, including primary health care., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background: Recruiting GPs is an issue faced by most research teams in primary care., Objectives: To assess GPs' willingness and expectations with regard to research in French primary care and to identify factors that may increase their participation in research projects., Methods: Cross-sectional study conducted with a representative sample of 452 GPs from the Rhone-Alpes region in France., Results: Among 284 GPs (63%) who participated, 85 [29.9%, 95% confidence interval (CI) = 26.4-35.3%] were willing to participate in research as investigators and 83 (29.2%, 95% CI: 23.9-34.5%) had already participated in research projects. Multivariate analysis showed that an earlier participation in research projects [odds ratio (OR) = 3.3], a training practice (OR = 2.3), membership in a research network (OR = 2.1) and younger age (OR = 1.9 for 10 years less) were associated with the willingness to participate in future research projects. Whereas 55% of practitioners who already had an experience in research had participated in a therapeutic trial, those willing to participate in the future preferred to participate in descriptive (26%) or etiologic (22%) studies. Preventive, diagnostic and therapeutic procedures and quality of care were the domains, which interested GPs most. The most expected clinical themes concerned cardiovascular, metabolic, musculoskeletal and respiratory problems., Conclusions: To meet the expectations of French GPs willing to participate in primary care research, it is advisable to diversify studies with respect to their types, domains and themes. Linkage to universities and research networks should also be encouraged.

Background: Nutritional education is one of the tasks of the family physicians. The aims of the Nutrimege study were to describe the frequency and modes of patients' nutritional education in family medicine, the characteristics of family physicians and patients involved, and its impact on the consultation length., Methods: Cross-sectional study, performed with questionnaires mailed to sixty family physicians from the Val-de-Marne in December 2007. Each physician had to include the first ten patients seen during a given day., Results: 45 family physicians participated, allowing the inclusion of 410 patients. The sample of family physicians was representative of the physicians in Val-de-Marne and in France. Nutritional counseling was delivered in 42.4% of consultations (95% CI: 37.6-47.2%). It mainly consisted in a dietary advice (90.2%), delivered orally (80.5%), at the initiative of the physician (81.6%). Collaborating with other healthcare professionals for nutritional purposes was rare (5.4%). Nutritional counseling was especially delivered for secondary prevention, to patients either aged 40 or older, obese, having one or more chronic conditions. The physicians who delivered nutritional counseling most were aged 45 and over, were practicing with free fees agreement, and had a specific practice. When nutritional counseling was delivered, the consultation lasted one minute more on average., Conclusion: The use of written tailored media (edited with appropriate computer tools), a better collaboration with other healthcare professionals, and the strengthening of the medical training on preventive medicine may help to improve the quality of patients' nutritional education process.

Background: The conditions of use and access to medical records have become an important source of interest in the last decade. In this context, our main objective was to assess the impact of a paper patient-held records, shared with healthcare professionals., Methods: In the particular case of breast cancer management, we identified the expectations of practitioners and patients. Secondly and according to a Delphi method, we defined the content and size of a medical record, which could be held by the patient. Following these preliminary studies, we conducted a randomized controlled trial, comparing patients with usual follow-up to others holding the new record containing essential information for coordination of care., Results: The patient-held record favoured membership and satisfaction of both patients and health professionals. It was used as a communication tool between physicians and patients, but could also cause anxiety to some patients. Patient quality of life, data confidentiality and costs of care remained identical in the two arms. With its benefits for both patients and healthcare professionals, a new concept of medical records was revealed by this study., Conclusion: New models for healthcare organization deeply modify the roles and relationships of all the actors in the healthcare system. Further research on patient-held records is needed to evaluate the full range of its benefits and limits.

Unlabelled: Allowing cancer patients to hold medical records containing essential information for managing their disease may improve their satisfaction and the coordination of their medical care., Objective: Our aim was to determine breast cancer patients' interest in and expectations of such medical records and the exchange of information during their treatment., Methods: Eighty-six hospital physicians were selected to distribute an anonymous questionnaire to all of the breast cancer patients they saw in consultations., Results: Out of 194 patients asked, 140 (72%) participated in the survey. Forty-eight percent were "highly satisfied", 47% were "quite satisfied" with their involvement in their treatment and 43% preferred to play a relatively passive role in decisions concerning treatments. When offered, 79% agreed to hold paper medical records containing test results, reports and letters. Many found these medical records to be useful and a possible means for improving communication. Others, however, expressed reservations concerning privacy or losing or forgetting the records., Conclusion: The principle of shared medical records could satisfy the majority of breast cancer patients. Experimenting with this concept in the field would enable practitioners to better determine the content of the records and how they can be used on a practical basis.

Aim: To measure the impact of French national consensus guidelines on the clinical practices of primary care paediatricians and general practitioners., Design: Non-randomized intervention study, with a first survey 1 year before the consensus development conference and a second survey 1 year after., Intervention: Implementation of bronchiolitis management guidelines through the medical press and the Internet., Subjects: Paediatricians and general practitioners treating infants 1 year of age and under consulting for a first-time episode of bronchiolitis., Results: Ninety-three doctors and 510 infants were included during the first phase of the study and 96 doctors and 394 infants during the second phase. This study showed a slight increase in adherence to the guidelines for non-validated drugs (6.6% adherence before and 14.3% after), general advice (29.0% adherence before and 57.1% after) and flow modulation respiratory physical therapy (91.9% adherence before and 98.8% after). Increase in adherence to guidelines for other practices, that is, hospitalization, prescribing antibiotics and complementary examinations, was not statistically significant. Adherence to the guidelines on providing general advice increased the most between the two studies., Conclusion: The guidelines helped practitioners evolve slightly in their approach to the treatment of bronchiolitis. Non-validated drugs remain frequently used. Additional resources for implementing the guidelines should be provided to improve primary care doctors' practices.

The multidisciplinary dimension which imposes the follow up of patients suffering from breast cancer raises difficulties of communication between community and hospital practitioners. The aim of this study was to assess information needs and expectations when the general practitioners and private gynecologists on one hand, and the hospital practitioners on the other hand, exchange medical information in the follow up of patients suffering from breast cancer. This descriptive study included a sample of 225 general practitioners and 216 gynecologists in private practice, and 233 hospital practitioners in the Rhone-Alps French region. Response rate was respectively 68 % (153), 64 % (139) and 42 % (99). This study showed different perceptions on the frequency of shared documents (reports, letters) or phone calls according to the speciality. In spite of a strongly felt partnership, an expectation of change was found with notably the wish of a stronger implication in the follow up and the wish to receive numerous information concerning the patients. The community practitioners expected to be more aware of the stage of the cancer, the prognosis and the level of information given to the patients. The hospital specialists expected to be informed about psychological problems or comorbidity. Pending the generalization of an electronic shared medical records, the experiment of a patient-held records may help to fulfil these expectations.

Objectives: To describe the role of gynecologists in the care of women with breast cancer, their relationship with hospital specialists and with patients, and their expectations in terms of the quality of this relationship., Materials and Methods: A descriptive cross-sectional study was performed in 2002. Two hundred and fifty gynecologists from Rhone Alpes region were randomly selected and received a questionnaire., Results: Sixty-four percent of the polled practitioners answered. Forty-two percent of gynecologists had about 25-50 patients with breast cancer. Their participation in the care principally concerned the phases of diagnosis (99%) and remission (98.5%). Eight percent took part in therapeutic decision making. Ninety-two percent of the gynecologists wanted to receive systematically feedback concerning any consultation or hospitalization and 98% wanted to know the name and address details of the care coordinator., Conclusion: Gynecologists are willing to participate in the care of breast cancer patients. This for, they want to have more details about therapy, follow-up and the level of information given to the patients.

The continuous surveillance of suicide and attempted suicide cases was added to the tasks of the French Sentinel Network of General Practitioners (GPs) in 1999. In 2001, 9700 suicides were estimated to have occurred and an estimated 61 500 attempted suicide cases were diagnosed by GPs, representing approximately 40% of cases nationwide. The majority of suicide and attempted suicide cases involved women (67%) and 43% of all cases involved patients aged 25-44 years. The fatality rate increased with age. About 80% of GPs complied with the current recommendation to refer patients who had attempted suicide to hospital.

Objective: To study both surgical and nonsurgical nosocomial infections (NIs) seen by primary-care physicians (general practitioners [GPs]) in France., Design: Ongoing surveillance of postdischarge NIs by an organized group of GPs, from August 1997 to July 1999. Both the GP who personally examined the case spontaneously presenting with NI and the responsible hospital physician or surgeon were interviewed by telephone., Setting: 305 general practices from all French regions., Results: 2,199 (29%) of 7,540 patients referred for hospitalization reconsulted the GP within 30 days of discharge. In 21 (1%) of the 2,199 cases, an NI was diagnosed by the GP and confirmed as plausible by the responsible hospital physician. We diagnosed an NI in 8 (1.3%) of the post-surgical patients and in 13 (0.8%) of the non-surgical cases within the cohort. We saw eight urinary tract infections, seven surgical-site infections, three soft-tissue infections, two respiratory tract infections, and one primary bloodstream infection. In 19 patients (90%), clinical signs of NI appeared within 7 days of discharge. Assuming that all 5,431 patients who were missed for follow-up did not experience any NI, an attack rate of 0.3 per 100 admissions may be estimated for the whole group., Conclusion: We diagnosed 1% of NIs following discharge from a hospital in a cohort of 2,199 patients, of which 1.3% were seen post-surgery and 0.8% following nonsurgical admissions. The percentage of postdischarge visits that were for an NI in nonsurgical patients warrants a major effort with feedback to the hospital physician to reduce infection rates.

Although the coding of medical data is expected to benefit both patients and the health care system, its implementation as a manual process often represents a poorly attractive workload for the physician. For epidemiological purpose, we developed a simple automatic coding system based on string matching, which was designed to process free-text sentences stating reasons for hospital referral, as collected from general practitioners (GPs). This system relied on a look-up table, built up from 2590 reports giving a single reason for referral, which were coded manually according to the International Classification of Primary Care (ICPC). We tested the system by entering 797 new reasons for referral. The match rate was estimated at 77%, and the accuracy rate, at 80% at code level and 92% at chapter level. This simple system is now routinely used by a national epidemiological network of sentinel physicians.