Bs m&ph 2003 157.indd

Baromètre santé médecins/pharmaciens 2003 254 l 18 l Methodology
to prevention and health education? This chapter provides information on the invol- vement of professionals in preventive and Arnaud Gautier
This chapter presents the method used for
data collection, the specific features of the
General Practitioners/Pharmacists Health 259 l 84 l Do immunization prac-
Barometer 2003, together with the types of tices need to be strengthened?
statistical analyses used. The structure of François Baudier, Marta Aleksandra Balinska
the two surveyed populations is described Are as many general practitioners in favour of
according to socio-demographic variables vaccination as before? Has their position on
and characteristics of professional activity.
Hepatitis B vaccination evolved? Has their attitude towards vaccination of the elderly changed since 1998? This chapter reviews 255 l 44 l Personal health
compares their opinions to those of dispen- pharmacists
Hélène Bourdessol, Arnaud Gautier,
Jean-François Collin
261 l 102 l Contraception,
Health care professionals were questioned STIs, HIV l Professionals adapt
as to their own health related behaviour: their practice to the new context
consumption of legal psychoactive products Nathalie Lydié, Colette Ménard, Christophe Léon
(tobacco, alcohol, sleeping tablets and Do general practitioners consider the preven-
tranquillizers), relation to screening (HIV, tion of high-risk sexual behaviour as part of
hepatitis C, etc.) and attitudes towards their job? Do pharmacists think they have an
prevention (influenza vaccination status, important role to play in AIDS prevention?
condom use). The behaviour of GPs and What proportion of health care professio-
pharmacists is compared, and assessed in nals monitors HIV-positive patients? This
relation with that of the general population.
chapter describes opinions and practices on the subject of contraception, STIs, and HIV.
257 l 64 l The place of general
practitioners and pharmacists in 263 l 130 l Screening and
Pierre Buttet, Cécile Fournier
Do general practitioners feel they are effective Marta Aleksandra Balinska
in helping their patients change behaviour in General practitioners were questioned as to
areas such as drug use or diet? Do pharma-
the number of HCV [hepatitis C Virus] blood cists consider their role in prevention to be tests prescribed in the last month and the important? What are the main obstacles proposal to screen according to possible current and past exposures (blood transfu- and cervical smears) and colorectal cancer sion prior to 1992, pregnant women, intrave- (testing for occult blood in the stools). Two nous drug users, etc.). Their responses are types of data are presented : the number of compared to those of the previous General examinations prescribed in the last month Practitioners Health Barometer.
and the last female patient seen in consul-tation aged between 50 and 60 and with no specific risk factor.
264 l 140 l Tobacco and alcohol l
270 l 206 l Pharmacists’ and
Hélène Perrin, Arnaud Gautier
General practitioners were questioned as to towards generic medicines
how they deal with patients suffering from Pierre Buttet, Stéphanie Pin
a tobacco or alcohol dependence problem. Are general practitioners in favour of prescri-
Information was also gathered about the bing according to international common
methods they use to help their patients denominations? Do registered dispen-
decrease or cease consumption and how sing pharmacists systematically dispense
effective they feel they are in their efforts. generic drugs? Have health care professio-
Pharmacists were asked how often they nals sought to change their relationship
discuss the issue of tobacco and alcohol with their patient or customer? This chapter
with their customers.
explores the behaviour and opinions of health care professionals towards dispen- 266 l 164 l Dealing with
drug-addicted patients
Stéphanie Pin
221 l Appendices
This chapter describes how health care
professionals deal with drug-addicted 223 l General Practitioners’
patients, the number of heroin addicts seen Questionnaire
per month, and the replacement treatments
prescribed or dispensed. GPs’ and pharma-
233 l Pharmacists’ Questionnaire
cists’ personal opinions on drugs and drug
addicts are also described and compared to 241 l List of tables and figures
those of previous Health Barometers.
251 l English summaries
268 l 192 l Cancer screening l
Striking variation in practices
François Baudier
This chapter takes a closer look at screening for gynaecological cancers (mammography General Practitioners/Pharmacists Health Barometer 2003 Health Barometers are periodic surveys that worked out the weighting variables used to measure opinions, knowledge, attitudes, and adjust the sample. The variables used for behaviour with regard to health in specific these adjustments were gender, region and populations. To date, four types of Health type of practice for GPs, and gender, age Barometer surveys have been conducted: and region for dispensing pharmacists. The 12-75 year olds, nutrition, general practitio- survey period began on Monday 4 November ners, and dispensing pharmacists. Health 2002 and ended on Friday 24 January 2003; Barometers are telephone surveys using a the total duration of the survey was nine random sampling technique.
weeks, with a break over Christmas and New For the first time since the creation of Year (from 26 December 2002 to 8 January ners (GPs) was surveyed at the same time as dispensing pharmacists (preparation of survey was 2,057 or about one in thirty GPs questionnaire, survey period, data proces- in general practice in France. The refusal rate sing) – which is why the results are presented was 31.8%.
in a single report.
The populations questioned in this questioned was 1,062 or almost one regis- Health Barometer were private practice tered dispensing pharmacist in twenty-six GPs and registered dispensing pharma- The average length of interviews was about from computer files supplied by Cegedim®. twenty-five minutes for GPs and twenty Interviewing and data collection was carried minutes for pharmacists.
out by the Ipsos survey institute. Ipsos also helped finalise both questionnaires and General Practitioners/Pharmacists Health Barometer 2003 Hélène BourdessolArnaud GautierJean-François Collin hepatitis C. For GPs, screening was affected only by the frequency of daily consultations, Almost a third of GPs (28.8%) said they whereas for pharmacists, variables of age, smoked, if only occasionally. This was true turnover, involvement in community activi-of proportionately fewer dispensing pharma- ties and training were all influential.
been screened for HIV, compared to eight sionals questioned, tobacco consumption out of ten pharmacists (80.3%). Knowledge was more likely to be a male characteristic. of HIV status was more widespread among Tobacco use among GPs has fallen since younger health care professionals. Other 1998, while it has remained stable amongst characteristics related to knowledge of pharmacists.
consultations a day for GPs, and importance tion of alcohol (at least three times a week) of turnover for pharmacists. Since 1998, the was slightly more widespread among frequency of HIV screening has markedly pharmacists: 31.5% compared to 30.3% of increased for both groups.
GPs. Again, consumption was primarily male and increased with age. Since 1998, alcohol testing for occult blood in the stools, consumption has remained stable among especially men (8.4%) and interviewees GPs, but has fallen among pharmacists.
(65.2%) had had a mammography within the 48.0% of the GPs questioned and 46.4% last three years, and more than eight out of of the pharmacists had been screened for ten (80.9%) had had a smear test.
General Practitioners/Pharmacists Health Barometer 2003 Among GPs, 63.2% said they had been vacci- three-quarters of dispensing pharmacists nated against influenza in the preceding (72.5%) said they had used a condom at winter, compared to 37.6% of pharmacists. some time in their life, a response more Practising in a rural area increased the likeli- hood of vaccination in both populations.
General Practitioners/Pharmacists Health Barometer 2003 A large majority of GPs said they thought tion (97.7%), smoking (77.4% - an increase they were effective in changing their patients’ since 1998) or AIDS prevention (53.4% - a behaviour in terms of primary prevention, decrease since 1998). Only a minority said i.e., cancer screening (89.5%), diet (65.8%), they had an important role to play in terms of condom use (65.4%), physical exercise diet (47.3%), hepatitis prevention (45.5%), (63.5%), abuse of psychotropics (62.5%) or alcoholism (30.7%).
or smoking (50.4%). On the other hand, less than half felt effective in dealing with spontaneously bring up the question of accidents of everyday life (45.8%), alcoho- smoking with their customers, especially lism (37.5%) and less than a third in dealing when they are involved in a specific profes-with the drug abuse (29.5%).
sional activity (pharmacists’ professional In addition, GPs said they thought they association, prevention association, further were effective in educating patients suffe- training, etc.). Only 55.8% spontaneously ring from hypertension (90.6%), asthma mention alcohol and the percentage who (87.6%) or diabetes (78.0%).
often raise the issue(3.8%) has decreased The great majority of GPs (64.8%), since 1998 (6.8%; p<0,001).
especially those aged over 50 years, do not use standard questionnaires to help identify ception, 72.4% of pharmacists said they risk factors or to screen for a condition (tests conducted a special interview, lasting more or scales).
than five minutes for one in five (21.5%).
(98.9%) in considering that prevention that their customers ask for information formed part of their professional role, about cancer screening, a significant increase whether in terms of correct use of medica- since 1998 (58.5%; p<0,001). The most General Practitioners/Pharmacists Health Barometer 2003 frequent requests are for breast (41.3%) and (4.8%) and by one pharmacist in eight colon (29.9%) cancer screening.
(12.5%). Among GPs, the higher the number The obstacles to prevention and health of daily consultations, the more frequently education most frequently mentioned are lack of time is cited as an obstacle to preven-patient resistance (51.2% of GPs, 24.0% tion. Among pharmacists, unsuitable of pharmacists) or lack of time (49.1% of premises and lack of confidentiality limit the pharmacists, 33.5% of GPs). Lack of training frequency and length of discussions with is mentioned by fewer than one GP in fifteen customers.
General Practitioners/Pharmacists Health Barometer 2003 François BaudierMarta Aleksandra Balinska The vast majority of GPs(97.1%) say they rence was observed between pharmacists are “favourable” to vaccination. However, and GPs in 2003 with regard to a “favou-over recent years, being “very favourable” rable” opinion on MMR (96.0% and 94.8% to immunization has become less frequent. respectively), the proportion of pharmacists In 1994, over 85% of GPs were “very favou- “very favourable” to vaccination in general rable”, whereas in 1998, this figure decreased is markedly lower than that among GPs by nearly 10%. With regard to pharmacists, (62.6% v 79.0%).
while overall “favourable” opinion is no With regard to vaccinations for the elderly, different from that of GPs, the percentage influenza immunization is widespread of “very favourable” pharmacists is signifi- (93.5% of GPs declare “systematically” or “often” proposing the vaccine). The same is Almost nine out of ten GPs (88.1%) are true for tetanus immunization (“systemati- “favourable” to BCG vaccination, with a signi- cally” and “often”: 87.0%) but with a signifi- ficant decrease between 1998 and 2003. On cant decrease in “systematically” responses the other hand, for measles-mumps-rubella between 1998 and 2003. Regarding anti-(MMR) vaccination, “favourable” opinion pneumococcus vaccine, fewer than a third of has remained relatively stable: 93.7%, 93.6% GPs(32.9%) state offering vaccination “syste-and 94.8% respectively in 1994, 1998, and matically” or “often” to elderly patients.
2003. Furthermore, the significant increase observed between 1994 and 1998 in the concerning hepatitis B virus (HBV) immuni-proportion of GPs “very favourable” to zation for adolescents and the general MMR continued in 2003. Currently, almost population. “Very favourable” opinions for four out of five GPs say they are “very favou- rable” to MMR. While no significant diffe- 1993) reached their peak in 1994 (85.7%) General Practitioners/Pharmacists Health Barometer 2003 and then fell very significantly between factors most often associated with being 1998 (55.5%) and 2003 (36.2%). However, favourable to vaccination (all vaccines) with regard to infant HBV immunization, are: practice in northern France, absence of a “favourable” opinion, which had not complimentary medical practice(principally changed between 1994 (51.7%) and 1998 homeopathy), sector 1, referral specialist, (51.2%), increased significantly between over 20 consultations a day, group practice, 1998 and 2003 (58.8%).
Data from this survey indicate that the sex, 40 years of age or under.
General Practitioners/Pharmacists Health Barometer 2003 Professionals adapt their practice to the new context Nathalie LydiéColette MénardChristophe Léon In the General Practitioners/Pharmacists 1998. By contrast, in terms of contraception, Health Barometer 2003, the role of GPs and and emergency contraception in particular, pharmacists in the prevention and guidance the survey indicates a genuine involvement of patients in relation to contraception and on the part of pharmacists: 85.4% say they STIs was measured at three levels of preven- mention the usefulness of a health check-up, 74.5% talk to patients about their tobacco At the primary level, GPs’ and pharmacists’ consumption when dispensing oral contra- attitudes towards their role in health educa- ceptives and almost three-quarters (74.0%) tion and prevention are largely positive: state having conducted an interview the last 98.6% of GPs consider that prevention in time they dispensed emergency contracep-terms of sexual behaviour is part of their tion.
job and almost two-thirds (65.4%) feel they At the secondary prevention level, analysis can effectively help patients change their of screening activities confirms that prescri-behaviour with regard to condoms. Similarly, bing an HIV serology is common practice more than half of dispensing pharmacists among GPs. In 2003, more than nine out of (53.4%) consider they play an important role ten GPs (93.4%) said they had prescribed in AIDS prevention. However, the survey at least one HIV screening test in the prece-shows a twofold development: first, in terms ding month, significantly more than in 1998 of preventing high-risk sexual behaviour and (85.9%). For other STIs, particularly syphilis, HIV, GPs consider they are less effective the GP’s role is still more effective when and pharmacists- that they are less involved backed by the public authorities. For all than in other areas. Second, both are also STIs, the probability of having to diagnose less involved in the prevention of high-risk at least one positive case was linked, in all sexual behaviour and HIV than they were in regression models, to a geographical and General Practitioners/Pharmacists Health Barometer 2003 Lastly, regarding tertiary prevention, it Alpes-Côte d’Azur] and Ile-de-France regions appears that a majority (63.8%) of GPs are still the epidemic centres for HIV and, monitor at least one patient suffering from broadly speaking, STIs, while the significant HIV. GPs and pharmacists who monitor HIV-proportion of people benefiting from CMU positive patients undergoing treatment play [free health care for those on low incomes] a critical role with regard to compliance, an among the positive cases reflects the effects additional challenge that strengthens their of social inequalities on health.
place at the heart of the healthcare system.
General Practitioners/Pharmacists Health Barometer 2003 In France, the proportion of adults with cally offering a screening test has increased. anti-HCV [hepatitis C virus] antibodies The greatest increase concerns patients is about 1%. Thus, somewhere between “presenting with asthenia” (from 23.3% 400,000 and 500,000 people are at risk of to 40.4%) and “tattooed” patients (from severe or fatal complications of HCV infec- 17.8% to 33.2%). People who have received tion. While nosocomial and iatrogenic trans- blood transfusions are, after drug users, the mission of the virus is largely controlled, the “at risk” category most frequently offered principal source of recent infection is drug a screening test: 79.9% in 1998 and 82.9% use, with a prevalence of 43% to 73% in drug in 2002. In all cases “the number of blood addicts. Screening is the very first step in the tests prescribed in the last month” has risen battle against hepatitis C. Not surprisingly, since 1998: in 1998, 13.9% of GPs reported GPs most systematically offer screening prescribing between 5 and 9 blood tests per tests to intravenous drug users (93.2%), and month compared to 22.5% in 2003; similarly, this percentage has not varied since 1998 in 1998, 9.1% of GPs said they prescribed 10 (92.2%). For all other categories of patients or more blood tests, compared to 26.1% in “at risk”, the percentages of GPs systemati- General Practitioners/Pharmacists Health Barometer 2003 exclusively and 3.5% in combination with The proportion of GPs having been consulted other methods. One GP in five recommends in the last seven days by at least one patient Zyban® (available since September 2001) wishing to give up smoking has increased in and one GP in fifteen prefers prescribing recent years, from 60.1% in 1998 to 67.1% mild medication.
in 2003. The average number of weekly Half the GPs questioned (50.4%) feel they patients presenting with this request has are effective in helping patients change their also increased significantly over the same smoking habits; this figure was 43.4% in period (from 1.9 to 2.1).
In 2003, as in previous years, the majority of GPs interviewed (86.5%) take sole charge (77.4%) think they play an important or very of their patients and 11.3% do so in liaison important role in relation to smoking. More with a specialist organisation. The use of than half say they often mention tobacco standard questionnaires on smoking is consumption spontaneously to their custo-still rare, with a mere 6.3% of GPs stating mers; 6.6% of them systematically talk about such use. The nicotine patch is the most it to their customers when dispensing oral frequently recommended method for contraceptives and 19.6% had talked about it stopping smoking: 53.0% of GPs use it with the last asthmatic patient they served.
General Practitioners/Pharmacists Health Barometer 2003 During the most recent sale of a nicotine they are fairly or very effective. Nonetheless, replacement, 58.7% of interviewed pharma- this proportion has risen by 7.4 points since cists assessed their customer’s motivation 1998.
to stop smoking using a test and 64.7% conducted a tobacco dependence test on questionnaires on the subject of alcohol.
the customer.
Pharmacists were more reserved about the importance of their role in relation to alcoho- lism than in relation to smoking: fewer than Half the GPs questioned (51.3%) said they a third (30.7%) considered this role to be had seen at least one patient about giving important or very important. They talked to up alcohol in the seven days preceding the their customers about alcohol significantly survey. This proportion has remained stable less often: 6.8% in 1998 and 3.8% in 2003. since 1998. 68.4% of general GPs care for Moreover, almost half (44.2%) said they these patients in liaison with a specialist never had the opportunity to speak to custo-body and 19.9% of them do so alone. The mers spontaneously about their alcohol feeling of being effective in helping patients consumption.
to change their alcohol consumption habits is not as high as for smoking: 37.5% feel General Practitioners/Pharmacists Health Barometer 2003 proportion of GPs seeing at least one heroin A majority of GPs (84.5%) said they were addict per month for replacement treatment involved in the care of drug-addicted patients has significantly increased since 1998, irres-as part of their consultations, and 34.0% had pective of the product dispensed.
seen an average of at least one heroin addict Slightly more than half of GPs dealing with per month. For all GPs, the average number drug-addicted patients (53.0%) carry out of heroin addicts seen per month was 1.6. the treatment themselves, either alone or in A significant increase has been observed in liaison with a specialist organisation. This the proportion of GPs involved in the care type of care (alone or in liaison with a specia-of drug addicts since 1993; by contrast, the list organisation) was reported by 76.2% of proportion of GPs seeing at least one heroin GPs who see at least one heroin addict per addict per month and the average number of month.
heroin addicts seen per month has remained stable since 1998.
Among GPs seeing at least one heroin drug-addicted customers addict per month, 90.3% prescribe an opiate Eight out of ten pharmacists (85.1%) deal substitute, 84.5% Subutex® and 26.0% with at least one drug addict per month in methadone. A large majority of GPs (61.3%) their dispensary. 69.6% of pharmacists who caring for heroin-addicted patients prescribe deal with drug-addicted customers said they Subutex® only, whilst a mere 3.4% prescribe dispense both replacement treatments and methadone only. For all GPs, the average syringes or Steribox® packs; 15.6% said they number of heroin addicts on replacement dispense only syringes or Steribox® packs treatment with Subutex® was 1.3. The and 12.1% replacement products. Despite General Practitioners/Pharmacists Health Barometer 2003 the changes to the questionnaire, there has cists. The difference between GPs and been a noticeable increase in the proportion pharmacists is significant. Close contact of pharmacists dealing with drug addicts and with drug-addicted patients for GPs and in the proportion of pharmacists dispensing drug-addicted customers for pharmacists syringes or Steribox® packs since 1998.
has a positive influence on health professio- Almost two-thirds of pharmacists (63.4%) nals’ opinion on this question.
consider they have had adequate training A large majority of health professionals in dispensing replacement drugs; 43.2% (87.3% of pharmacists and 82.5% of general consider they have had adequate training practitioners) agree with the statement that in dealing with drug-addicted patients and “the consumption of cannabis is a major risk 41.3% in risk reduction policy.
to health”. The proportion of GPs sharing Only one-third of pharmacists (30.3%) say this opinion has clearly increased since they are prepared to take part in a syringe 1998.
exchange programme. A majority of pharma- While the proportion of GPs who consider cists (57.1%), including those already issuing that “soft drugs should be on unrestricted syringes or Steribox® packs (56.8%), would sale” has been falling since 1992, it is signi-refuse to take part in such a programme.
ficantly higher than pharmacists (17.4% v 11.4%). GPs monitoring at least one heroin addict per month and pharmacists who deal with at least one drug addict per month in One GP in ten (9.7%) considers that “drug their dispensary more frequently agree with addicts comply with medical instructions”, this statement than professionals who are in whereas this is true of only 25.9% of pharma- less regular contact with this population.
General Practitioners/Pharmacists Health Barometer 2003 In the last month, almost all (98.2%) GPs A specific analysis was conducted on the had prescribed one of three recommended last female patient seen, aged between 50 screening checks investigated in this survey: and 60 years, with no specific individual or 96.4% for mammography (with a signifi- family risk factors for cancer, and whom the interviewed GP sees regularly. More than tage and average number: 6.0 v 4.8), 79.8% nine out of ten GPs (90.7%) said they had for cervical smear (with a significant reduc- tion since 1998 in the percentage, but an this patient within the last three years. A very increase in the average number: 6.5 v 5.5), significant increase in this percentage has 43.8% testing for occult blood in stools for been observed since 1998 (70.3% v 90.7%), screening purposes (with a large increase in as well as in the overall proportion of female the percentage since 1998 and a growth in patients who have had a mammography, the average number of tests prescribed: 3.5 v irrespective of prescriber (89.5% v 97.6%). 2.5). The number of chest X-rays prescribed Among prescribing GPs, 88.3% stated that (included in any recommendation) has risen the mammography was prescribed on their in percentage (65.7% v 55.7% in 1998) as well initiative. The percentage of mammogra-as in average number (2.6 to 3.2).
General Practitioners/Pharmacists Health Barometer 2003 screening campaign is relatively low: less and 60 years of age for this type of scree-than one GP in twenty (4.5%). Just over a ning seems to be highest (colorectal: 17.9%; third (35.7%) of GPs reported that their last breast: 9.0%; cervix: 6.4%). Lastly, for these female patient between 50 and 60 years of three types of cancer, these investigations age had not had a cervical smear within were done as part of a general health check-the last three years. Furthermore, in 2003, up in half the cases.
proportionately more GPs had carried out a smear test on their last female patient screening are in general the same as for themselves (38.4% in 2003 v 29.0% in 1998). other preventive actions: young age, absence In more than nine out of ten cases (92.2%), of complimentary medical practice, a large the smear was prescribed or performed on number of consultations, membership the GP’s own initiative. Within the last two in a professional network, referral specia-years, 15.5% of female patients between list. According to the statements of regis-50 and 60 years of age have had a test for tered dispensing pharmacists, requests occult blood in the stools for screening for information about cancer screening are purposes. In the majority of cases (73.9%), infrequent (“often”: 12.2%), with enquiries it was the GP who instigated the request. mainly relating to cancers of the breast and However, demand from women between 50 colon.
General Practitioners/Pharmacists Health Barometer 2003 Almost all dispensing pharmacists (91.0%) perceive patients’ reluctance or the medicine regularly dispense generic medicines: being in a specific therapeutic class to be an 46.3% often and 44.7% systematically. obstacle say they dispense proportionately Pharmacists under 50 years of age, who fewer generic medicines than pharmacists are satisfied with their job, participate in a who do not perceive such obstacles.
professional body or preventive organisa- tion, and perceive their role in the proper that generic medicines and prescribing in an use of medication as important, are more international common denomination (ICD) likely to report the systematic dispensing of have changed their relationship with custo-generic medicines.
mers. This change was especially perceived The obstacles to dispensing generic outside the Paris area(60.1% v 45.8% in medicines are, according to the pharmacists Ile-de-France). For 94.1% of pharmacists questioned: patients’ reluctance (86.5%), perceiving this change, generics and ICD the medicine belonging to a specific thera- peutic class (50.4%) and objection by about the cost of medicines. For 85.1% General Practitioners/Pharmacists Health Barometer 2003 of pharmacists, these changes have also in their relationship with patients following encouraged discussion about the proper the introduction of generic medicines and use of medicines.
ment more frequently report that they are medicines and ICD prescribing have changed satisfied with their profession, but do not their relationship with patients. Male GPs stand out from their colleagues with regard more frequently make this observation than to the frequency with which they dispense their female colleagues.
generic medicines.
relationship with their patients, 89.5% have Three-quarters of general practitioners prescribing have encouraged debate about (75.4%) say they are in favour of prescri- the cost and 79.0% about the proper use of bing in ICD. Those most in favour are young, medicines. GPs in favour of ICD prescribing satisfied with their job, or specialists dealing more often report more discussion about with referrals, and do not perceive changes the cost or the proper use of medicines.

Source: http://www.inpes.fr/Barometres/BaroMP2003/pdf/english.pdf