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Ingalits sociales face aux soins prventifs chez les gnralistes matres de stage Social inequalities in preventive care among GPs in training practices among GPs in training practices Laurent Rigal Paris Descartes University, Family

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Inégalités sociales face aux soins préventifs chez les généralistes maîtres de stage Social inequalities in preventive care among GPs in training practices among GPs in training practices

EQuiP spring conference, Paris, April 6, 2013

Laurent Rigal

Paris Descartes University, Family Medicine Department laurent.rigal@parisdescartes.fr

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The context of family practice and preventive care in France

An apparent consensus about preventive care dispended by general practitioners (GPs)

– GPs considered as well-placed professionals to provide preventive care – A favorable political context

Primary care organization not in favour of preventive care Primary care organization not in favour of preventive care

– Physicians working in small private offices – Fees for service – Individual and curative care, lack of public health concern – Organized screening (breast and colorectal cancers) – Payment for performance (individual contracts in 2009 and collective bargaining in 2011) – Contracts between ARS and pools of healthcare givers

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Social Inequalities in Health and Preventive care

Social Inequalities in Health

  • persist in European countries (Mackenbach 2008)
  • major challenge for countries with a public health insurance

Health care system should at least not increase and if possible reduce Social Inequalities Why focusing on preventive care provided by GPs ? Why focusing on preventive care provided by GPs ?

  • Health services (Mackenbach 2003) and particulary GPs can reduce

these social inequalities (Starfiel 2005)

  • Black Report (Townsend 1982) = behaviroural explanation : Health-

related behaviors are a potential pathway througth which the socioeconomic status affect health

  • HRB : unhealthy eating, physical activity, smoking, alcohol

consumption or cancer screening, are related to mortality, avoidable and inequally distributed across socioeconomic groups

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Objective

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Methods (1)

  • PrevQuanti Survey

– Document preventive care delivered by GPs who receive trainees in their practice – GPs belong to 2 Parisian Family Medicine Departements (Paris Descartes and Pierre et Marie Curie)

  • Population
  • Population

– 52 GPs volunteered to participate – 70 patients (35 men and 35 women), aged 40-74, taken at random in their patient list

  • Preventive care : tobacco and alcohol consumption,

gyneacological cancer screening, diet and exercise

  • Research issues : social inequalities in health (care),

practice organisation

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Method (2)

  • Data

– Collection

  • Case file: data extraction by GP trainees and validation by the

GP instructors

  • Patient : postal questionnaire

– 2 Types – 2 Types

  • Health : collected bilaterally, about prevention
  • Social : Occupation, Education, Perceived financial difficulties
  • Logistic mixed model with random intercepts
  • Stratification on patients’ sex
  • Analysis : ajusted on patient’s age, frequency and length of

relationship with the GP and BMI (except for cancer screening).

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Gynaecological cancer screening

Cervical cancer screening

Health Behavior >> Screening statut = overdue (> 3 years) GP’s Practice >> A pap smear date recorded in the case file >> GP made the last pap smear

Breast cancer screening

Health Behavior >> Screening statut = overdue (> 2 years) GP’s Practice >> A mammogram date recorded in the case file >> GP prescribed the last mammogram

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Tobacco / Alcohol

Smoking

Health Behavior >> Smoker GP’s Practice >> Smoking status recorded in the case file >> identification of smokers

Excessive alcohol consumption

Health Behavior >> Excessive drinker GP’s Practice >> Drinking status recorded in the medical case >> identification of excessive drinker

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Diet / Exercise

Diet

Health Behavior >> Eat more than 5 fruits or vegetables per day (Healthy Eating : 5 A Day) GP’s Practice >> Eating counceling

Exercise

Health Behabvior >> Has a physical activity GP’s Practice >> Exercise counceling

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Results (1)

Participation rates:

  • Patient: 71.1%
  • GP: 98.8%

Number of patients analysed:

  • 2599 Patients from both sex
  • 1340 Men & 1259 Women
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Results (2) : GPs’ characteristics (n=52)

n (%) Age (years)

<50 12 (23.1) [50-55[ 12 (23.1) [55-60[ 17 (32.7) >60 11 (21.1)

Men 33 (63.5) Group practice (vs solo) 37 (71.2) Group practice (vs solo) 37 (71.2) Unregulated fees 33 (63.5) Average consultation length (min) <20

7 (13,5) 20 28 (53.8) >20 17 (32.7)

Participation to peer groups 33 (63.5) Continuing Medical Education 14 (73.1) Electronic medical files 46 (88.5)

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Results (3) : Patients’ characteristics (n=2599)

n (%) Age (years) [40-50[ 952 (36.6) [50-60[ 815 (31.4) [60-74[ 832 (32.0) Sex Men 1340 (51.6) Women 1259 (48.4) Ancienneté du suivi (years) 370 (14.2) <2 2229 (85.8) 2 Encounters per year <3 1109 (42.7) 3 1490 (57.3) 3 1490 (57.3) Chronic disease Yes 672 (27.4) No 1783 (72.6) Occupation Professionals and Managers 105 (4.5) Intermediate white-collar workers 1085 (46.1) Shopkeepers and crafts workers 493 (21.0) Employees 453 (19.3) Manual workers 201 (8.6) Education Below High school 363 (14) High school 831 (32) Post-Secondary 1403 (54) Financial Difficulties I am not managing 125 (4.9) It’s tight, I need to be careful 2066 (81.7) It’s OK and We're comfortable 337 (13.4)

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Cervical cancer screening

Occupation Bottom Top Overdue 7.49 (2.00-28.04) 3.14 (1.81-5.45) 2.09 (1.17-3.72) 1 0.0006 Education Bottom Top Overdue 5.25 (2.73-10.10) 2.45 (1.46-4.12) 1 <0.0001

Financial Diff Bas Haut

Overdue 4.15 1.79 1 0.38 (1.71-10.08) (1.08-2.96) 0.0014 (0.13-1.11) Occupation Bottom Top Pap smear Date recorded 0.28 (0.09-0.80) 1.18 (0.82-1.70) 0.89 (0.61-1.30) 1 0.05 Education Bottom Top Gynecologist = last prescriber 0.33 (0.18-0.63) 0.67 (0.42-1.08) 1 0.0049

Occupation Bottom Top

Gynecologist = last prescriber 0.53 (0.16-1.81) 0.47 (0.30-0.75) 1.18 (0.69-2.01) 1 0.0039

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Breast cancer screening

Occupation Bottom Top Overdue 1.78 (0.74-4.33) 1.82 (1.18-2.81) 1.50 (0.94-2.37) 1 0.066

Financial sit Bottom Top

Overdue 3.24 (1.46-7.16) 1.48 (1.00-2.21) 1 0.021 1.30 (0.57-1.84) Education Bottom Top Occupation Bas Top Gyn = last prescriber 0.11 (0.04-0.30) 0.43 (0.29-0.63) 0.60 (0.40-0.90) 1 <0.0001 Mammogram Date recorded 1.93 (0.79-4.71) 1.66 (1.13-2.44) 1 0.024

Occupation Bottom Top

GP = last prescriber 1.94 (0.75-5.02) 1.67 (1.03-2.70) 1.34 (0.80-2.26) 1 0.20

Occupation Bottom Top

OS = last prescriber 4.22 (1.85-9.64) 1.91 (1.24-2.94) 1.45 (0.91-2.30) 1 0.0032

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Tobacco Consumption - Men

Occupation Bottom Top Smoker 1.33 (0.93-1.90) 1.64 (1.09-2.47) 1.45 (1.03-2.04) 1 0.044 Education Bottom Top Smoker 1.28 (0.84-1.94) 1.72 (1.29-2.29) 1 0.0022

Financial Sit Bottom Top

Smoker 2.58 1.64 1 1.21

Indentification of smokers : no social variation Women : SIH for Financial Situation / Less smoking status recorded at the bottom of the social hierarchy (occupation, education) ; Identification of smokers : no social variation

(1.38-4.79) (1.22-2.21) 0.0026 (0.82-1.76) Education Bottom Top Smoking status recorded 1.21 (0.79-1.84) 1.42 (1.04-1.93) 1 0.095

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Excessive Alcohol Consumption - Men

Health Behaviors : No social difference

Occupation Bottom Top Alcohol consumption recorded 1.64 (1.10-2.44) 1.34 (0.86-2.11) 1.74 (1.19-2.55) 1 0.018 Education Bottom Top Alcohol consumption recorded 1.47 (0.93-2.34) 1.76 (1.26-2.45) 1 0.0056

Financial Sit Bottom Top

Women : Less alcohol consumption recorded at the bottom of the social hierarchy (financial situation) => Interpretation : Stereotype, socially differenciated perception or communication

Financial Sit Bottom Top

Alcohol consumption recorded 3.22 (1.57-6.61) 1.19 (0.85-1.67) 1 0.0022 0.63 (0.40-1.00)

Financial Sit Bottom Top

Indentification of alcoholic 7.42 (1.53-36.01) 1.54 (0.70-3.40) 1 0.066 0.60 (0.15-2.36)

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Diet - Women

Occupation Bottom Top 5 fruits & vegetables per day 0.72 (0.33-1.59) 0.58 (0.43-0.79) 0.63 (0.47-0.86) 1 0.045 Education Bottom Top 5 fruits & vegetables per day 0.54 (0.37-0.80) 0.76 (0.58-0.99) 1 0.0077

Financial Sit Bottom Top

Eating counselling : no social difference

Men : same type of result (no SIH according to occupation)

5 fruits & vegetables per day 0.34 (0.18-0.65) 0.76 (0.58-1.00) 1 0.0003 1.57 (1.08-2.29)

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Exercise - Men

Occupation Bottom Top Exercise 0.58 (0.41-0.82) 0.66 (0.44-1.01) 0.90 (0.65-1.26) 1 0.017 Etudes Bottom Top Exercise 0.42 (0.29-0.61) 0.84 (0.65-1.10) 1 0.0002

Financial Sit Bottom Top

Exercise 0.79 0.76 1 1.49

Women : SI in health status only

(0.43-1.46) (0.57-1.00) 0.010 (1.04-2.12) Education Bottom Top Exercise counceling 0.54 (0.35-0.85) 0.92 (0.67-1.28) 1 0.032

Occupation Bottom Top

Exercise counceling 0.63 (0.43-0.94) 0.66 (0.42-1.04) 0.88 (0.60-1.30) 1 0.091

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Thank you for your attention !

Acknowledgments

  • participating patients
  • investigators (trainees and instructors) from Paris Descartes and

P&M Curie Universities

  • PrevQuanti Research Team
  • SFTG

Funding

  • GRSP
  • Conseil régional d’Ile-de-France
  • Inpes