Etude d'acceptabilité de procédures de dépistage de la maladie d'Alzheimer en médecine générale

TOURS-BU Médecine (372612103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Priorités de recherche qualitative en médecine générale

International audienc

Pourquoi les médecins généralistes n'observent-ils pas les recommandations de bonnes pratiques cliniques ? L'exemple du diabète de type 2

Why general practitioners do not respect recommendations for good clinical practices? The case of non insulin dependent diabetes mellitus In 1999, the National Agency for Accreditation and Evaluation in Health (ANAES) produced a set of recommendations for good clinical practices in the follow up of non insulin dependent diabetes mellitus. Since this date, the French national health fund (CNAMTS) observed that these recommendations were not strictly respected by general practitioners. This research tries to explain why general practitioners do not respect the guidelines. The survey shows that doctors do know the recommendations. However they declare to have difficulties to apply them strictly, because guidelines do not meet their needs in daily practice. At first, guidelines are specific, whereas general practitioners' comprehensive approach of patients makes them prescribe preferentially drugs and focus on the quality of the relation with their clients. Secondly, guidelines do not take into considération the personal features of these diabetic patients. The interaction between doctor and patient is determinant, and doctors are obliged to adjust their prescriptions, which induces heterogeneous styles of practice.Résumé. En 1999, l'Agence nationale d'accréditation et d'évaluation en santé a élaboré un guide de recommandations de bonnes pratiques cliniques concernant le suivi du diabète de type 2. Depuis cette date, la CNAMTS constate que ces recommandations ne sont pas scrupuleusement suivies par les médecins généralistes. Notre article part de l'interro- gation suivante : pourquoi les médecins généralistes ne respectent-ils pas les recommandations ? Nous montrons que si les médecins ont bien connaissance de leur existence, en revanche ils disent avoir des difficultés à les appliquer scrupuleusement car elles répondent mal à leurs besoins en pratique quotidienne. Les recommandations mettent en avant des actes techniques codifiés, alors que la pratique en médecine générale, dans le suivi global du patient, privilégie la prescription de médicaments et la dimension relationnelle. Par ailleurs, elles ne prennent pas en compte les caractéristiques propres de cette population de patients dans la situation de consultation. Les interactions entre le médecin et le patient sont essentielles, et les médecins sont contraints d'ajuster leurs prescriptions, ce qui induit une hétérogénéité des pratiques.¿ Por qué los médicos clínicos no siguen las recomendaciones de las guías de diagnóstico y tratamiento ? El ejemplo de la diabètes de tipo 2 En 1999 la Agencia Nacional de Acreditación y de Evaluación en Salud elaboró en Francia una guía para el seguimiento de la diabètes de tipo 2. Desde entonces, la Caja Nacional de Seguro por Enfermedad de los Trabajadores Asalariados (CNAMTS) constata que las recomendaciones de esta guía no son seguidas escrupulosamente por los médicos clínicos. En este artículo mostramos que los médicos tienen dificultades para aplicarlas porque las mismas no se adaptan a las necesidades de su práctica cotidiana. Por un lado, estas recomendaciones están en contradicción con la especificidad de la práctica de la medicina general, que privilégia la prescripción de medicamentos y la dimensión relacional sobre los actos técnicos codificados. Por otro lado, la guía no tiene en cuenta la particularidad de la situación de consulta en la que las interacciones entre el médico y el paciente son esenciales. Las características de los diabéticos de tipo 2 obligan a los médicos a adaptar sus prescripciones, de lo cual résulta una heterogeneidad de prácticas.Bachimont Janine, Cogneau Joël, Letourmy Alain. Pourquoi les médecins généralistes n'observent-ils pas les recommandations de bonnes pratiques cliniques ? L'exemple du diabète de type 2. In: Sciences sociales et santé. Volume 24, n°2, 2006. pp. 75-103

Assessment of diabetes screening by general practitioners in France: the EPIDIA Study.: diabetes screening in France

AIM: To audit Type 2 diabetes screening in general practice in France and to determine the frequency of undiagnosed diabetes in patients at high risk, after systematic screening and diagnosis. METHODS: For this study, 288 general practitioners volunteered to include all consecutive non-diabetic patients aged or= 7.0 mmol/l. RESULTS: There were 5950 patients included. The most frequent diabetes risk factors were: age >or= 40 years, 92%; overweight [body mass index (BMI) >or= 27 kg/m2], 59%; treated hypertension, 48%; treated dyslipidaemia, 37%; family history of diabetes, 24%. Of these subjects at high risk for diabetes, 88% had a FPG measurement in their medical record (75% measured during the preceding 12 months). In the 1499 patients in whom FPG was measured, diabetes was diagnosed in 40 patients (2.7% 95% CI 1.9-3.5) and 22% had impaired fasting glucose (IFG). Thus, the frequency of undiagnosed diabetes in the 5950 high-risk patients was 0.67% (0.46-0.88). CONCLUSION: Screening for diabetes by general practitioners in France appears to be adequate and undiagnosed diabetes is rare in patients with risk factors for diabetes, at least in those consulting the general practitioners studied

[Drug treatment of cardiovascular risk factors over six years of following the French DESIR cohort].

International audienceOBJECTIVE: To describe the treatment of cardiovascular risk factors within the context of a cohort study of adults, according to the risk estimated by the Framingham equation. METHOD: This prospective study, DESIR, followed 1526 men and 1652 women for six years. At the time of the study's initiation, all participants were aged 35 to 65, and none were being treated for hypertension or dyslipemia. Treatments for hypertension and dyslipemia initiated during the study were analyzed according to categories of cardiovascular risk based on the Framingham scale. RESULTS: At baseline, 24% of men and 5% of women had an estimated 10 years cardiovascular risk (for CHD) higher or equal to 10%. Three years later, only 19% of these men and 36% of these women had been treated, while 6% of men and 9% of women at risk < 10% had also been treated well. At six years, one third of men at high risk at baseline and/or at three years were treated, against half of the women. CONCLUSION: Despite a significant effort to communicate the importance of addressing and treating the individual risk factors, the currently prescribed treatments remain inadequate, especially given the necessity to treat them based on the assessment of the overall cardiovascular risk

Areas of improvement in anticoagulant safety. Data from the CACAO study, a cohort in general practice.

Real-world studies on anticoagulants are mostly performed on health insurance databases, limited to reported events, and sometimes far from every-day issues in family practice. We assess the presence of data for safe monitoring of oral anticoagulants in general practice, and compare patients' knowledge of taking an anticoagulant between vitamin K antagonists (VKA) and direct anticoagulants (DOAC), and the general practitioner's perception of their adherence to anticoagulation.The CACAO study is a national cohort study, conducted by general practitioners on ambulatory patients under oral anticoagulant. In the first phase, investigators provided safety data available from medical records at inclusion. They also evaluated patients' knowledge about anticoagulation and graded their perception of patients' adherence.Between April and December 2014, 463 general practitioners included 7154 patients. Renal and hepatic function tests were respectively unavailable in 109 (7.5%) and 359 (24.7%) DOAC patients. Among patients with atrial fibrillation, 345 patients (6.9%) had a questionable indication of anticoagulant (CHA2DS2-Vasc<2). One hundred and thirty-three VKA patients (2.3%) and 70 DOAC patients (4.9%) answered they took no anticoagulant (p<0.0001). According to general practitioners' perception, 430 patients (6.1%) were classified as "not very" or "not adherent", with no difference between groups.Our results highlight the efforts needed to improve anticoagulant safety in daily practice: decreasing the rate of unknown biological data in patients with DOACs or the rate of patients with VKA with no strong indication of anticoagulation, and improving patient knowledge with regard to their anticoagulant. Patients' adherence seems highly over-estimated by the general practitioners.ClinicalTrials.gov NCT02376777

Anticoagulants' safety and effectiveness in general practice: a nationwide prospective cohort study

Most real-world studies on anticoagulants have been based on health insurance databases or performed in secondary care. The aim of this study was to compare safety and effectiveness between patients treated with vitamin K antagonists (VKAs) and patients treated with direct oral anticoagulants (DOACs) in a general practice setting