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1.  The Effects of Obesity and Mobility Disability in Access to Breast and Cervical Cancer Screening in France: Results from the National Health and Disability Survey 
PLoS ONE  2014;9(8):e104901.
We aimed to disentangle the effects of obesity and mobility limitation on cervical and breast cancer screening among community dwelling women.
The data source was the French national Health and Disability Survey - Household Section, 2008. The Body Mass Index (BMI) was used to categorize obesity status. We constructed a continuous score of mobility limitations to assess the severity of disability (Cronbach's alpha = 0.84). Logistic regressions were performed to examine the association between obesity, mobility limitations and the use of Pap test (n = 8 133) and the use of mammography (n = 7 561). Adjusted odds ratios were calculated (AOR). Interaction terms between obesity and the disability score were included in models testing for effect modifications.
Compared with non-obese women, the odds of having a Pap test in the past 3 years was 24% lower in obese women (AOR = 0.76; 95% CI: 0.65 to 0.89), the odds of having a mammogram in the past 2 years was 23% lower (AOR = 0.77; 95% CI: 0.66 to 0.91). Each time the disability score was 5 points higher, the odds of having a Pap test decreases by 20% (AOR = 0.96; 95% CI: 0.94 to 0.98), the odds of having a mammogram decreases by 25% (AOR = 0.95; 95% CI: 0.94 to 0.97). There was no significant interaction between obesity and disability score.
Obesity and mobility limitation are independently associated with a lower likelihood of cervical and breast cancer screening. Protective outreach and follow-up are necessary to reduce inequalities and thus to reduce health disparities in these vulnerable and high-risk populations of obese women with disabilities.
PMCID: PMC4136821  PMID: 25133662
3.  Adaptation and validation of the patient assessment of chronic illness care in the French context 
Chronic diseases are major causes of disability worldwide with rising prevalence. Most patients suffering from chronic conditions do not always receive optimal care. The Chronic Care Model (CCM) has been developed to help general practitioners making quality improvements. The Patient Assessment of Chronic Illness Care (PACIC) questionnaire was increasingly used in several countries to appraise the implementation of the CCM from the patients’ perspective. The objective of this study was to adapt the PACIC questionnaire in the French context and to test the validity of this adaptation in a sample of patients with multiple chronic conditions.
The PACIC was translated into French language using a forward/backward procedure. The French version was validated using a sample of 150 patients treated for obstructive sleep apnea syndrome (OSAS) and having multiple chronic co-morbidities. Several forms of validity were analysed: content; face; construct; and internal consistency. The construct validity was investigated with an exploratory factorial analysis.
The French-version of the PACIC consisted in 18 items, after merging two pairs of items due to redundancy. The high number of items exhibiting floor/ceiling effects and the non-normality of the ratings suggested that a 5-points rating scale was somewhat inappropriate to assess the patients’ experience of care. The construct validity of the French-PACIC was verified and resulted in a bi-dimensional structure. Overall this structure showed a high level of internal consistency. The PACIC score appeared to be significantly related to the age and self-reported health of the patients.
A French-version of the PACIC questionnaire is now available to evaluate the patients’ experience of care and to monitor the quality improvements realised by the medical structures. This study also pointed out some methodological issues about the PACIC questionnaire, related to the format of the rating scale and to the structure of the questionnaire.
PMCID: PMC4094668  PMID: 24947538
4.  Cost-Effectiveness of a Community Pharmacist-Led Sleep Apnea Screening Program – A Markov Model 
PLoS ONE  2013;8(6):e63894.
Despite the high prevalence and major public health ramifications, obstructive sleep apnea syndrome (OSAS) remains underdiagnosed. In many developed countries, because community pharmacists (CP) are easily accessible, they have been developing additional clinical services that integrate the services of and collaborate with other healthcare providers (general practitioners (GPs), nurses, etc.). Alternative strategies for primary care screening programs for OSAS involving the CP are discussed.
To estimate the quality of life, costs, and cost-effectiveness of three screening strategies among patients who are at risk of having moderate to severe OSAS in primary care.
Markov decision model.
Data Sources
Published data.
Target Population
Hypothetical cohort of 50-year-old male patients with symptoms highly evocative of OSAS.
Time Horizon
The 5 years after initial evaluation for OSAS.
Screening strategy with CP (CP-GP collaboration), screening strategy without CP (GP alone) and no screening.
Outcomes measures
Quality of life, survival and costs for each screening strategy.
Results of base-case analysis
Under almost all modeled conditions, the involvement of CPs in OSAS screening was cost effective. The maximal incremental cost for “screening strategy with CP” was about 455€ per QALY gained.
Results of sensitivity analysis
Our results were robust but primarily sensitive to the treatment costs by continuous positive airway pressure, and the costs of untreated OSAS. The probabilistic sensitivity analysis showed that the “screening strategy with CP” was dominant in 80% of cases. It was more effective and less costly in 47% of cases, and within the cost-effective range (maximum incremental cost effectiveness ratio at €6186.67/QALY) in 33% of cases.
CP involvement in OSAS screening is a cost-effective strategy. This proposal is consistent with the trend in Europe and the United States to extend the practices and responsibilities of the pharmacist in primary care.
PMCID: PMC3689751  PMID: 23805176
5.  British residents’ views about general practice care in France – a telephone survey 
Many studies have been published over the past decade on patients’ views about the provision of health care. Though there is a high level of migration within the European Union, there are no studies on migrants’ views about the provision of care in the country to which they moved. Given the wide spectrum of primary care in Europe, we hypothesised, without prejudging the outcome, that patients’ confidence in the system they left, used as a proxy of ‘the experience of care’, may influence their preferences regarding specific aspects of care in the host country. The objective of the study was to analyse British migrants’ views on general practice care in France.
A telephone survey was conducted with a random sample of the adult population of British people residing in France. Participants were 437 women and 423 men, aged 18 and over, who had consulted a general practitioner at least once during the past 12 months. The main outcome measures were the responses to the 23-item Europep questionnaire evaluating different aspects of general practice care, using a five-point answering scale with the extremes labelled as “poor” and “excellent”.
Participants were generally satisfied with the GP care provided. The aspects that were rated the highest were related to the doctor-patient relationship which over 80% of the respondents judged as excellent or very good. Some aspects of the organisation of services received relatively negative evaluations. For instance, “waiting time in the waiting room” was evaluated as excellent or very good by only 40% of the respondents. Twenty seven percent of the respondents were not confident in the National Health Service (NHS) when they were still living in UK. After adjusting for age, sex and number of years of residence in France, the respondents who were not confident in the NHS provided a score of “excellent” significantly more frequently (on 11 out of the 23 aspects of care) than did the patients who were confident in the NHS. Most of these aspects concerned the doctor-patient relationship and information and support during the consultation.
British migrants’ views on general practice care in France varied with the degree of confidence they had in the NHS. This finding is in line with the discussion on whether the ‘experience of care’ influences patient satisfaction. A better understanding of this phenomenon should provide valuable insights to make the services more responsive to the patients.
PMCID: PMC3689084  PMID: 23777338
6.  Performance Scores in General Practice: A Comparison between the Clinical versus Medication-Based Approach to Identify Target Populations 
PLoS ONE  2012;7(4):e35721.
From one country to another, the pay-for-performance mechanisms differ on one significant point: the identification of target populations, that is, populations which serve as a basis for calculating the indicators. The aim of this study was to compare clinical versus medication-based identification of populations of patients with diabetes and hypertension over the age of 50 (for men) or 60 (for women), and any consequences this may have on the calculation of P4P indicators.
A comparative, retrospective, observational study was carried out with clinical and prescription data from a panel of general practitioners (GPs), the Observatory of General Medicine (OMG) for the year 2007. Two indicators regarding the prescription for statins and aspirin in these populations were calculated.
We analyzed data from 21.690 patients collected by 61 GPs via electronic medical files. Following the clinical-based approach, 2.278 patients were diabetic, 8,271 had hypertension and 1.539 had both against respectively 1.730, 8.511 and 1.304 following the medication-based approach (% agreement = 96%, kappa = 0.69). The main reasons for these differences were: forgetting to code the morbidities in the clinical approach, not taking into account the population of patients who were given life style and diet rules only or taking into account patients for whom morbidities other than hypertension could justify the use of antihypertensive drugs in the medication-based approach. The mean (confidence interval) per doctor was 33.7% (31.5–35.9) for statin indicator and 38.4% (35.4–41.4) for aspirin indicator when the target populations were identified on the basis of clinical criteria whereas they were 37.9% (36.3–39.4) and 43.8% (41.4–46.3) on the basis of treatment criteria.
The two approaches yield very “similar” scores but these scores cover different realities and offer food for thought on the possible usage of these indicators in the framework of P4P programmes.
PMCID: PMC3334971  PMID: 22536430
7.  The future of pharmaceutical care in France: a survey of final-year pharmacy students' opinions 
In the last decades, the provision of pharmaceutical care by community pharmacists has developed in OECD countries. These developments involved significant changes in professional practices and organization of primary care. In France, they have recently been encouraged by a new legal framework and favored by an increasing demand for health care (increase in the number of patients with chronic diseases) and reductions in services being offered (reduction in the number of general practitioners and huge regional disparities).
Objectives: This study aimed to investigate final-year pharmacy students' opinions on 1/expanding the scope of pharmacists' practices and 2/the potential barriers for the implementation of pharmaceutical care. We discussed these in the light of the experiences of pharmacists in Quebec, and other countries in Europe (United Kingdom and the Netherlands).
All final-year students in pharmaceutical studies, preparing to become community pharmacists, at the University Paris-Descartes in Paris during 2010 (n = 146) were recruited. All of them were interviewed by means of a questionnaire describing nine "professional" practices by pharmacists, arranged in four dimensions: (1) screening and chronic disease management, (2) medication surveillance, (3) pharmacy-prescribed medication and (4) participation in health care networks. Respondents were asked (1) how positively they view the extension of their current practices, using a 5 point Likert scale and (2) their perception of potential professional, technical, organizational and/or financial obstacles to developing these practices.
143 (97.9%) students completed the questionnaire. Most of practices studied received a greater than 80% approval rating, although only a third of respondents were in favor of the sales of over-the-counter (OTC) drugs. The most significant perceived barriers were working time, remuneration and organizational problems, specifically the need to create a physical location for consultations to respect patients' privacy within a pharmacy.
Despite remaining barriers to cross, this study showed that future French pharmacists were keen to develop their role in patient care, beyond the traditional role of dispensing. However, the willingness of doctors and patients to consent should be investigated and also rigorous studies to support or refute the positive impact of pharmaceutical care on the quality of care should be carried out.
PMCID: PMC3115856  PMID: 21612642
8.  Patients’ with obstructive sleep apnoea syndrome (OSAS) preferences and demand for treatment: a discrete choice experiment 
Thorax  2012;68(5):487-488.
Despite its high level of effectiveness, initial acceptance of continuous positive airway pressure (CPAP) and regular use in patients with obstructive sleep apneoa syndrome (OSAS) are still an issue. Alternatively, oral appliances (OAs) can be recommended. To improve patient engagement in their treatment, physicians are advised to take into account patient preferences and to share the therapeutic decision. We aimed to determine patients’ preferences for OSAS treatment-related attributes, and to predict patients’ demand for both CPAP and OAs.
A discrete choice experiment (DCE) was performed in 121 newly diagnosed patients consecutively recruited in a sleep unit.
Regression parameters were the highest for impact on daily life and effectiveness ahead of side effects. In the French context, the demanding probabilities for CPAP and OAs were 60.2% and 36.2%, respectively. They were sensitive to the variation in the amount of out-of-pocket expenses for both CPAP and OAs.
This first DCE in OSAS emphasises the importance to communicate with patients before the implementation of treatment.
PMCID: PMC3625824  PMID: 23002172
Health Economist; Sleep apnoea

Results 1-8 (8)