Contexte. La mesure de la pression artérielle (PA) est un geste rituel dans les consultations de médecine générale. Selon les dernières recommandations, une mesure de la PA tous les trois ans en cas de PA normale chez le sujet sain est suffisante. Objectif. Explorer le ressenti des médecins généralistes (MG) et des patients concernant l’absence de mesure de la PA. Méthode. Étude qualitative par théorisation ancrée. Les MG ont été recrutés de manière aléatoire via l’annuaire des Pages Jaunes et les patients par la méthode « boule de neige ». L’échantillonnage des MG et des patients a été effectué en recherche de variations maximales. Tous les entretiens individuels semi-dirigés ont été codés de manière individuelle puis de manière conjointe. Résultats. Lors des 12 entretiens avec les MG, deux typologies se sont dégagées : une « prise de tension » avec pour objectif de répondre aux attentes supposées des patients (objectif relationnel) et une mesure de PA réalisée avec un objectif médical dans le respect des recommandations. La « prise de tension » semblait favoriser l’inertie thérapeutique, car les MG tenaient moins compte des chiffres. Il y avait une discordance entre les attentes des 9 patients interrogés et celles supposées par les MG. Les patients interrogés n’attendaient pas de mesure systématique à chaque consultation. La relation avec leur MG et la confiance qu’il leur accordait ne dépendait pas de ce geste, mais d’un ensemble de compétences médicales et relationnelles. Conclusion. Il y a une discordance entre les attentes réelles des patients et celles supposées par les MG. Notre hypothèse initiale : « Les patients attendent une mesure systématique de leur PA » est contredite. Les patients pourraient accepter une mesure moins fréquente, mais de meilleure qualité de la PA.
Abstract Background To assess bleeding risk of patients treated by oral anticoagulants, several scores have been constructed to assist physicians in the evaluation of the benefit risk. Most of these scores lack a strong enough level of evidence for use in family practice. Objective To assess the predictive prognostic accuracy of 13 scores designed to assess the risk of major or clinically relevant non-major (CRNM) bleeding events in a French ambulatory cohort receiving Vitamin-K antagonists (VKA) or direct oral anticoagulants (DOACs) in a family practice setting. Methods CACAO (Comparison of Accidents and their Circumstances with Oral Anticoagulants) was a multicentre prospective cohort of ambulatory patients prescribed oral anticoagulants. We selected patients from the cohort who had received an oral anticoagulant because of non-valvular atrial fibrillation (NVAF) and/or venous thromboembolism (VTE) to be followed during one year by their GP. The following scores were calculated: mOBRI, Shireman, Kuijer, HEMORR2HAGES, ATRIA, HAS-BLED, RIETE, VTE-BLEED, ACCP score, Rutherford, ABH-Score, GARFIEL-AF, and Outcomes Registry for Better InformedTreatment of Atrial Fibrillation (ORBIT). Prognostic accuracy was assessed by using receiver operating characteristic curves and c-statistics. Results During 1 year, 3,082 patients were followed. All of the scores demonstrated only poor to moderate ability to predict major bleeding or CRNM in NVAF patients on DOACs (c-statistic: 0.41–0.66 and 0.45–0.58), respectively. The results were only slightly better for patients prescribed VKA (0.47–0.66 and 0.5–0.55, respectively) in this indication. The results were also unsatisfactory in patients treated for VTE. Conclusion None of the scores demonstrated satisfactory discriminatory ability when used in family practice. Clinical Trial Registration ClinicalTrials.gov NCT02376777
In 2005, 10% of consultations in France ended without a prescription. In 2019, a review of the literature found 30 to 70% of prescription-free consultations in Northern Europe and 10 to 22% in Southern Europe and underlined the scarcity of quantitative data. Different factors contribute to this heterogeneity, such as product availability and status, modes of management, distribution channels, clinical practice recommendations, public policies targeting certain classes, etc. The main objective of our study was to quantify the rate of prescription-free consultations in general practice in France in 2021. The secondary objective was to characterize prescription-free consultations and analyze their determinants.
In 2005, the rate of prescription-free consultations in Europe varied widely: 57% in the Netherlands, 28% in Germany, 17% in Spain and 10% in France.To assess the number of prescription-free consultations in European countries since 2005 and to analyse the perceptions of patients and general practitioners (GPs).This was a systematic review of the literature from 2005 to 2019, including both quantitative and qualitative studies on prescription-free consultations.Of 13,380 studies, 28 were included. The rates of prescription-free consultations were 30% in Belgium, 41% in Slovenia, 47% in the UK and 22% in France, according to the most recent figures. Swedish GPs estimated their prescription-free consultation rate at 70%. The only significant factor that decreased the number of prescription-free consultations was laboratory visits. According to the qualitative data, the main constraint was lack of time; the main facilitating factor was a shared medical decision.Medical visits decreased the number of prescription-free consultations. According to qualitative studies, the main barrier was lack of time. The countries with the highest drug consumption levels were those with the lowest number of prescription-free consultations. Achieving prescription-free consultations to combat overmedication and for the quality of care and the environment is a priority. To understand and analyse consultations without prescriptions, a quantitative observational study was launched in France in 2020.
Abstract Background The ability of bleeding risk scores to predict major bleeding (MB) or clinically relevant nonmajor bleeding (CRNMB) remains a topic of contention, particularly in nonselected patients in family practice. In addition, the capacity to predict bleeding risk using simple variables has yet to be established. Objectives The main objective was to confirm that severe anemia was the most predictive factor for the estimation of bleeding risk in patients treated with vitamin K antagonists (VKAs). Secondary objectives were to test the capacity of different bleeding scores to detect high-risk patients. Subsequently, the impact of functional decline on bleeding incidence was explored. Methods The CACAO study was a multicenter prospective cohort study of patients who, due to nonvalvular atrial fibrillation (NVAF) and/or venous thromboembolism (VTE), had been prescribed an oral anticoagulant by their general practitioner (GP) as a prophylactic measure. Patient characteristics were collected at the time of inclusion by GPs, who then monitored them in accordance with standard practice for one year. MB and CRNMB were the main outcomes for one year. By applying this approach, a total of 13 scores were analyzed. Results Aaemia was found to be strongly associated with MB (HR: 2.77, 95% CI: 1.2–6.36), with a particularly pronounced association observed in cases of severe anemia (HR: 12.9, 95% CI: 2.76–60.35). Twelve out of 27 MB cases were not identified by at least half of the scores. By contrast, functional decline was identified as a novel factor associated with MB (HR: 2.45, 95% CI: 1.13–5.31). Conclusions Preexisting anemia is a major prognostic factor associated with the occurrence of bleeding. It seems relevant to suggest that functional decline should be considered by GPs when assessing bleeding risk.
Abstract Purpose Blood pressure (BP) is measured at almost every general practitioner (GP) consultation in the region of Auvergne, France. A 2018 qualitative study shows that GPs measure BP to satisfy patients, whereas patients declare themselves indifferent to the absence of the measurement. The objective was to validate the results of a qualitative study, to quantitatively assess patient satisfaction when BP is not measured, and to study the factors associated with the degree of patient satisfaction. Methods This was a quantitative observational study conducted using self-questionnaires among patients in medical practices in Auvergne. Results Four hundred and ninety-two questionnaires were evaluated in 20 medical practices. Sixty percent of patients had indifferent or favorable feelings in the absence of BP measurement. In bivariate analysis, young age, male sex, absence of pathology, and low frequency of visits were associated with indifferent or favorable feelings in the absence of BP measurement. In multivariable analysis, a history of hypertension and psychiatric history were associated with unfavorable feelings. The intraclass correlation coefficient for practice-related variability was 5.6%. Patients’ susceptibility to having particularly favorable or unfavorable feelings could be related to their GP (physician effect). Conclusion The hypothesis put forward in the qualitative study is confirmed: the majority of patients are in favor of or indifferent to the absence of BP measurement in general practice. General practice could be more efficient by measuring BP less frequently and better.
