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 Laurent Rigal Paris Descartes University, Family Medicine Department laurent.rigal@parisdescartes.fr EQuiP spring conference, Paris, April 6, 2013
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
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
Objective �������� ���������� ��������� ������ ��������� ����������������������� ������ ���� ��� ����� ����� ����� ���������� � ������ ������� ��������� !�"���������������������� ��������� ����� ��������������� # ���� ���������� ����������!�������� ���������� ������������������������$�����������%�������� ����������������� ��$$���������� �
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
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).
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
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
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
Results (1) Participation rates: - Patient: 71.1% - GP: 98.8% Number of patients analysed: - 2599 Patients from both sex - 1340 Men & 1259 Women
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) Group practice ( vs solo) 37 (71.2) 37 (71.2) Unregulated fees 33 (63.5) Average consultation length (min) <20 7 (13,5) 28 (53.8) 20 17 (32.7) >20 Participation to peer groups 33 (63.5) 14 (73.1) Continuing Medical Education 46 (88.5) Electronic medical files
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 � 3 1490 (57.3) 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)
Cervical cancer screening Occupation Bottom Top Overdue 7.49 3.14 2.09 1 (2.00-28.04) (1.81-5.45) (1.17-3.72) 0.0006 Education Bottom Top 5.25 2.45 1 Overdue (2.73-10.10) (1.46-4.12) <0.0001 Financial Diff Bas Haut 4.15 1.79 1 0.38 Overdue (1.71-10.08) (1.08-2.96) 0.0014 (0.13-1.11) Occupation Bottom Top Pap smear Date 0.28 1.18 0.89 1 recorded (0.09-0.80) (0.82-1.70) (0.61-1.30) 0.05 Occupation Bottom Top 0.53 0.47 1.18 1 Gynecologist = last prescriber (0.16-1.81) (0.30-0.75) (0.69-2.01) 0.0039 Education Bottom Top 0.33 0.67 1 Gynecologist = last prescriber (0.18-0.63) (0.42-1.08) 0.0049
Breast cancer screening Occupation Bottom Top Overdue 1.78 1.82 1.50 1 (0.74-4.33) (1.18-2.81) (0.94-2.37) 0.066 Financial sit Bottom Top 3.24 1.48 1 1.30 Overdue (1.46-7.16) (1.00-2.21) 0.021 (0.57-1.84) Education Bottom Top 1.93 1.66 1 Mammogram Date (0.79-4.71) (1.13-2.44) 0.024 recorded Occupation Bas Top Gyn = last 0.11 0.43 0.60 1 prescriber (0.04-0.30) (0.29-0.63) (0.40-0.90) <0.0001 Occupation Bottom Top 1.94 1.67 1.34 1 GP = last prescriber (0.75-5.02) (1.03-2.70) (0.80-2.26) 0.20 Occupation Bottom Top 4.22 1.91 1.45 1 OS = last prescriber (1.85-9.64) (1.24-2.94) (0.91-2.30) 0.0032
Tobacco Consumption - Men Occupation Bottom Top Smoker 1.33 1.64 1.45 1 (0.93-1.90) (1.09-2.47) (1.03-2.04) 0.044 Education Bottom Top 1.28 1.72 1 Smoker (0.84-1.94) (1.29-2.29) 0.0022 Financial Sit Bottom Top 2.58 1.64 1 1.21 Smoker (1.38-4.79) (1.22-2.21) 0.0026 (0.82-1.76) Education Bottom Top 1.21 1.42 1 Smoking status recorded (0.79-1.84) (1.04-1.93) 0.095 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
Excessive Alcohol Consumption - Men Health Behaviors : No social difference Occupation Bottom Top Alcohol consumption 1.64 1.34 1.74 1 recorded (1.10-2.44) (0.86-2.11) (1.19-2.55) 0.018 Education Bottom Top 1.76 1 1.47 Alcohol consumption recorded (0.93-2.34) (1.26-2.45) 0.0056 Financial Sit Financial Sit Bottom Bottom Top Top 3.22 1.19 1 0.63 Alcohol consumption recorded (1.57-6.61) (0.85-1.67) 0.0022 (0.40-1.00) Financial Sit Bottom Top 7.42 1.54 1 0.60 Indentification of alcoholic (1.53-36.01) (0.70-3.40) 0.066 (0.15-2.36) Women : Less alcohol consumption recorded at the bottom of the social hierarchy (financial situation) => Interpretation : Stereotype, socially differenciated perception or communication
Diet - Women Occupation Bottom Top 5 fruits & 0.72 0.58 0.63 1 vegetables per day (0.33-1.59) (0.43-0.79) (0.47-0.86) 0.045 Education Bottom Top 0.54 0.76 1 5 fruits & (0.37-0.80) (0.58-0.99) 0.0077 vegetables per day Financial Sit Bottom Top 0.34 0.76 1 1.57 5 fruits & (0.18-0.65) (0.58-1.00) 0.0003 (1.08-2.29) vegetables per day Eating counselling : no social difference Men : same type of result (no SIH according to occupation)
Recommend
More recommend
