BackgroundTo describe French general practioners' (GPs) adaptation strategies to ensure follow-up care of nursing home patients during the first wave of COVID-19 (May 2020) and to identify factors associated with each strategy.MethodsA national cross-sectional study was conducted with online questionnaires in May 2020 among GPs practicing in France (metropolitan and overseas) and usually providing nursing home visits before pandemic. The outcome was defined as the GPs' adaptation strategies for managing nursing home patients and was categorized into four groups: Maintenance of Nursing Home Visits NHV (reference), Stopping NHV, Numeric adaptation (teleconsultations only), Mixed adaptation (NHV and teleconsultations). The probability of adaptation strategies was analyzed by multilevel logistic models in which the GPs represented level 1 and the counties level 2. We applied three random-intercept multilevel logistic models with the county of GP's practice as random effect.ResultsThis analysis included 2,146 responses by GPs coming from 98 French counties. Overall, 40.4% of GPs maintained NHV, while other strategies were: Stopping visits (24.1%), Numeric adaptation (15.4%), Mixed adaptation (20.1%). Several individual (age, training GP, perceived status of being at high risk of severe COVID, compliance with temporary delegation of the patient's management) and territorial factors (excess mortality rate due to COVID-19, GPs' density, proportion of over-75s, presence of reinforcement measures for nursing home patients) were identified as associated with each strategy.ConclusionsThis study highlights a rapid adaptation of general practice to keep supporting nursing home patients. Heterogeneity of adaptation strategies could reflect both the lack of national guidelines and the heterogeneity among GPs' usual practices. Policymakers should take actions at a territorial level (subnational) to strengthen support to nursing home patients considering adaptations to the local context of the pandemic outbreak and perspective of local actors.

In France, towards the end of the first lockdown, COVID-19 management was largely transferred from hospitals to primary care. Primary care actors adapted their practices to ensure patients’ access to care, while limiting contamination. In this study, we aimed to identify patterns of adaptations implemented by French general practitioners (GPs) in May 2020 for outpatients with confirmed or suspected COVID-19, and factors associated with these adaptions. A French survey concerning care organization adaptations, and individual, organizational, and territorial characteristics, was sent to GPs. Data were analyzed by multiple correspondence analysis followed by agglomerative hierarchical clustering to identify GPs’ adaptation clusters. A multinomial logistic regression model estimated the associations between clusters and individual, organizational, and territorial factors. Finally, 3068 surveys were analyzed (5.8% of French GPs). Four GPs’ adaptation clusters were identified: autonomous medical reorganization (64.2% of responders), interprofessional reorganization (15.9%), use of hospital (5.1%), and collaboration with COVID-19 outpatient centers (14.8%). Age, practice type and size, and territorial features were significantly associated with adaptation clusters. Our results suggest that healthcare systems should consider organizational features of primary care to effectively deal with future challenges, including healthcare crises, such as the COVID-19 pandemic, but also those linked to epidemiologic and societal changes.

La question du nombre de médecins à former est en France, comme dans de nombreux pays, au premier plan dans le débat public à l’heure où la notion de numerus clausus a disparu et où de nombreuses voix alertent les inégalités territoriales responsables de « déserts médicaux ». La régulation purement quantitative de la démographie médicale par le numerus clausus , durant plus de quarante ans, a échoué à obtenir un niveau d’équilibre entre l’offre et les besoins. Le nombre idéal de médecins qui permet l’accès de tous, sur tout le territoire, à des soins de qualité dépend de la démographie de la population, de la démographie médicale, mais aussi de la démographie des autres professionnels de santé, et de nombreux facteurs épidémiologiques, techniques, économiques et organisationnels, qui sont par essence instables dans le temps et propres à chaque population et système de santé. Avec la suppression du numerus clausus et l’instauration d’une programmation pluriannuelle du besoin en médecins, la réforme issue de la loi de 2019 relative à l’organisation et à la transformation du système de santé replace le processus de régulation dans le temps long. L’approche par objectifs nationaux pluriannuels a ainsi marqué un pas dans la réflexion. Les travaux préparatoires à la conférence nationale tenue en mars 2021 ont conclu à la nécessité de continuer à augmenter le nombre de médecins en formation, ce qui a été acté par les ministres en charge de la Santé et de l’Enseignement supérieur qui ont arrêté des objectifs pluriannuels de formation en augmentation de près de 20 %. Mais pour répondre à l’ambition de rapprocher les besoins en professionnels de santé des besoins de soins, il faut aller encore plus loin dans la prise en compte des déterminants du besoin en ressources humaines. Tirant leçon du passé, cet article propose des voies nouvelles pour sortir de l’unique question du nombre de médecins à former, prendre en compte davantage l’organisation du système de santé et mieux approcher la réponse aux besoins territoriaux de soins.

Background. - Local governments are well-positioned to promote healthy behaviours and environments. In France, since 2009, this role can be reinforced by signature of a Local Health Contract with the Regional Health Agency. This multi-year scheme includes an action plan which may cover four areas: health promo-tion, disease prevention, health care and long-term care. Although approximately 400 Local Health Contracts had been signed by 2018, we found only sparse evidence on the context in which they were formulated and the contents of their action plans. Based on the international literature, the CLoterreS study aimed to develop an instrument characterizing the contracts' action plans, with a specific focus on prevention and health pro-motion. This paper presents an assessment and application of the CLoterreS instrument.Methods. - The instrument was developed and applied in five steps: 1) development of the contextual and thematic variables; 2) pre-testing of a coding chart and its coding guide; 3) consultation with practitioners; 4) assessment of inter-rater agreement; and 5) application of the instrument to a nationally-stratified ran-dom sample of 53 contracts.Results. - While inter-rater agreement by type of variables was satisfactory (k > 0.7), some variables had to be dis-carded due to lack of information or insufficient agreement. The analysis indicates that most of the 53 contracts studied were signed in urban areas, on the scale of a single town or a syndicate of municipalities. The action plans are clearly focused on life circumstances, health promotion and protection or primary prevention of diseases, inso-far as, on average, 73% of the contracts' action forms address at least one of these topics. The proportion of action forms dealing with at least one topic in secondary or tertiary prevention, long-term care or the organisation of health care and services is nevertheless substantial (43%). Illustrations of actions are presented.Conclusion. - Building on internationally recognized evidence-based practice, the CLoterreS instrument has proven useful in characterizing health promotion action plans at the local level. Its use by practitioners could foster a broader vision of the scope of actions that can be implemented through a Local Health Contract and in conjunction with other local prevention and access-to-care schemes.(c) 2022 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

This paper aims to identify challenges and opportunities related to the integration of social determinants of health (SDH) into primary healthcare at an international symposium in Orford, Quebec, Canada. A descriptive qualitative approach was conducted. Three focus groups on different topics were led by international facilitators. Two research team members took notes during the focus groups. All the material was analyzed using a thematic analysis according to an inductive method. Many challenges were identified, leading to the identification of potential opportunities: integrate the concept of SDH in all phases of the training curriculum for health professionals to foster interprofessional and intersectoral collaboration and sociocultural skills; organize healthcare for better outreach to vulnerable populations; organize local and regional committees to develop management frameworks to produce and use territory-specific data; develop dashboards for primary healthcare providers describing the composition of their territory’s population; work collaboratively, rallying primary healthcare providers, community organization delegates, patient partners, citizens, and municipality representatives around common projects. Discussions prompted new directions for further primary healthcare research, among which are building on best practices in the literature and in the field, and engaging various stakeholders in research, including vulnerable populations, while focusing on patient experience.

The individual and combined effects of aflatoxin B1 (AFB1) and oxytetracycline (OXT) on the synthesis and secretion of triacylglycerols in isolated rat hepatocytes maintained in suspension during 2.5 h were studied. Secretion of triacylglycerols was inhibited by both drugs when administered separately. This inhibition was accompanied by a concomitant elevation of intracellular triacylglycerols only at the highest AFB1 dose tested. Total synthesis of triacylglycerols was not inhibited by AFB1 or by OXT. When the two drugs were simultaneously added to the incubation medium, the AFB1-induced accumulation of intracellular triacylglycerols was no longer observed; the inhibition of secretion was nevertheless identical to that observed with AFB1 alone. Finally, total esterification of palmitate was inhibited by 20% compared to the AFB1-treated cells. These data suggest that OXT inhibits lipid accumulation induced by AFB1 but that this effect is due to an inhibition of total synthesis of triacylglycerols. The mechanism of AFB1's effect and of the interaction between both molecules is discussed.

Introduction : Face à la COVID-19, la plupart des pays ont d’abord réagi en associant des mesures de confinement de la population à un renforcement des soins aigus. Les soins primaires ont ensuite été mobilisés de façon variable et plus ou moins coordonnée. But de l’étude : Comparer l’implication des soins primaires dans la gestion de la pandémie de COVID pour en dégager des enseignements sur les orientations futures à donner aux systèmes sanitaires. Résultats : La mobilisation des acteurs de soins primaires a été importante, hétérogène et variait selon l’existence de dynamiques d’organisations locales préexistantes en équipes, à l’échelon territorial ou dans un cadre plus régulé comme au Québec. La spécialisation de centres COVID était soit systématique, « cliniques chaudes » au Québec, soit à l’initiative des acteurs locaux plus ou moins soutenus par les autorités de santé. La téléconsultation, largement dominée par l’usage du téléphone, a pu être mise en place partout, généralement soutenue par une tarification souple et adaptée. La réalisation des tests diagnostiques comme la vaccination par de nouveaux professionnels, dans un cadre juridique, financier, et de formation simple, est un axe d’amélioration majeur à approfondir. Les systèmes d’information pour évaluer les besoins locaux ont été partout insuffisants. Conclusion : La définition des modalités de gouvernance des soins primaires et, notamment, l’articulation des professionnels avec les opérateurs de l’action publique en santé dans les quatre pays étudiés constitue un enjeu d’amélioration prioritaire à l’échelon local comme à l’échelon national.

INTRODUCTION:The COVID-19 epidemic represented a major challenge for the primary care sector. We present the results of an interprofessional collaborative research endeavor conducted by the ACCORD network to describe primary care actors' and organizations' response to the first wave of the epidemic and national lockdown in France.METHODS:This work draws from quantitative and qualitative material. The quantitative data results from the cross-analysis of the six online surveys carried out by the ACCORD network between March and May 2020, among general practitioners, midwives, and multi-professional primary care organizations in France. This data was enriched by collective multi-professional and multi-disciplinary exchanges conducted in virtual focus groups during an online seminar.RESULTS:There was a significant decrease in primary care activity during the first wave of the epidemic. Many primary care actors adapted their organizations to lower the risk of coronavirus transmission while maintaining access and continuity of care. Professionals received and used information from multiple sources. The crisis revealed both the importance and the diversity of local networks of exchange and collaboration.CONCLUSIONS:Primary care actors adapted quickly and with important local variability to the COVID epidemic, highlighting the importance of pre-existing organizations and collaborations at the local level.

Abstract Epidemic transition, sustained costs and health workforce shortage challenges have led numerous countries to strengthen primary care (PC) and implement new models of care. Faced with declining numbers of general practitioners (GPs), France has introduced medical assistants (MAs) in 2019 to guarantee access to care and maintain workforces in deprived areas. Trained to perform administrative and clinical tasks delegated by a physician, MAs are expected to optimize medical time and improve working conditions in practices. How does French model of MAs impact quality and productivity in GPs’ practices and articulate with other policies? We conducted a qualitative case study in 6 pilot practices to explore the effects of MAs’ work (interviews with 12 GPs, 6 MAs, collection of tasks performed by 6 MAs), complemented with views from public policy makers and health professional unions (9 interviews). MA was defined as a function centered on physicians’ needs, accessible both to administrative staff and nursing professions. MAs with a clinical profile performed a wider range of tasks, were more prone to perform clinical tasks and build developed interactions with patients, and seemed better fitted for chronic disease care management. Recruitment of MAs by physicians is supported with grants that decrease yearly while practice productivity is expected to rise. In general, a gain of efficiency in daily workload enabled GPs to slightly increase their productivity. However, for most GPs, it primarily helped them to maintain high workload without burning out. Although MAs with clinical background seem better suited for patients’ needs, recent figures have shown that more than half of MAs employed are former secretaries. If in-person secretaries could be endorsed with further administrative duties, MAs could hold a more clinical role in PC teams including physicians and allied health professionals. Other aspects than productivity must be taken into account in a support policy. Key messages • Regardless of productivity objectives to attain, hiring MAs can relieve physicians’ workload and stress, preventing them from burning out and guarantee access to care in deprived areas. • MA’s clinical profile could have a stronger impact on public health issues such as chronic disease care management.

Abstract Background The incidence of skin cancer has shown an increasing trend in the world and in France over the last four decades. In this context, the delay to access a specialist opinion strongly impacts the patient outcomes. However, the medical demographics of dermatologists in France have been decreasing over the past years. Hence, a tele-expertise (TLE) experiment for skin tumors detection, which allows general practitioners to obtain feedback from a dermatologist within 7 days using a smartphone application, has been set up in the Hauts-de-France region since 2015. Thus, this study aims at understanding the advantages and drawbacks of TLE in the detection of skin tumors perceived by general practitioners. Methods Exploratory study carried out with 15 general practitioners participating in the experiment in the Hauts-de-France region. Semi-structured interviews were conducted between february and april 2021 and analyzed after transcription. Results The main advantages perceived by general practitioners are: (i) fast access to a specialized feedback; (ii) formalization of the request and commitment of the dermatologist; (iii) ease of regulating patients to a specialist; (iv) lower travel frequency and stress for patients; (v) ability to send medical information securely. The drawbacks are most related to the lack of functionalities and the graphical user interface of the application. Conclusions Tele-expertise is a well accepted technological innovation in dermatology among general practitioners, which enables the best use of the scarce medical resources available in the region and to address the needs of patients. The sustainability of TLE in dermatology and its extension to other territories is possible and desirable. Key messages Tele-expertise in dermatology has its place in enabling the early management of malignant skin tumors. The qualitative approach makes it possible to understand general practitioners visions after the introduction of a technological innovation into their practices.

Introduction: Facing COVID-19, most of health care system first responded with the confinement of the population and an increase of intensive care resources. Primary care was then mobilized variably and more or less coordinated. Purpose of research: Comparing the involvement of primary care in four francophone regions with similar primary care to draw lessons for reforms directions in light of the COVID experience. Results: Mobilization of primary care actors was important, heterogeneous and linked to local context and previous dynamics at the territorial level or the practice level except in Quebec where primary care is governed by health authorities. The creation of COVID centers was systematic as "warm practices" in Quebec or left to the initiative of local stakeholders more or less supported by health authorities. Teleconsultation, largely dominated by the use of the telephone, was implemented everywhere, generally supported by flexible and adapted pricing. The performance of diagnostic tests such as vaccination by new professionals within a legal, financial and simple training framework is a major area for improvement. Information systems to assess local needs were insufficient everywhere. Conclusion: The definition of primary care governance methods and, in particular, the link between professionals and public health operators in the four areas studied is a priority area for improvement at both local and national levels.

L’organisation des soins primaires est au cœur des reformes actuelles des systemes de sante. Souvent assimiles aux « soins de proximite » ou « de premier recours », les soins primaires concernent a la fois les soins, les acteurs et l’approche territoriale et populationnelle de la sante. Au fil de 10 questions que tout un chacun peut se poser, les auteurs detaillent l’usage recent de cette notion, les enjeux politiques qu’elle sous-tend, l’organisation territoriale de l’offre de soins primaires, le role des patients, les imperatifs de formation et de recherche, les exemples d’autres pays, les perspectives…

OBJECTIVE:The main objective of this survey was to identify how independent midwives, mainly working in primary care, adapted their practices at the beginning of the COVID-19 pandemic in France. Our assumption was that this practice adaptation would vary according to both geographical area (timing of pandemic effect) and whether they practiced alone or in a group. DESIGN:We conducted an online national survey of independent midwives in France from March 16-23, 2020. SETTING:All districts in mainland France and the overseas territories. PARTICIPANTS:Respondents from the population of all independent midwives working in France. MEASUREMENTS AND FINDINGS:The primary outcome measure was the proportion of midwives reporting that they had adapted their practices to the context of the COVID-19 pandemic, and the rank, in order of frequency, of the postponed or cancelled activities. RESULTS:Of the 1517 midwives who responded, i.e., 20.3% of the independent midwives in France, 90.6% reported adapting one or more of their practices . The main adjustment was the postponement or cancellation of consultations deemed non-essential, listed in descending order: postpartum pelvic floor rehabilitation (n = 1270, 83.7%), birth preparation (n = 1188, 78.3%), non-emergency preventive gynaecology consultation (n = 976, 64.3%), early prenatal interview (n = 170, 11.2%), and postnatal follow-up (n = 158, 10.4%). KEY CONCLUSIONS:Without guidelines, each midwife had to decide individually if and how to adapt her practice. Postpartum pelvic floor rehabilitation and birth preparation have been strongly affected. The results of this national survey indicate that a large majority of midwives have adapted their practices, independently of the local course of the pandemic, and that this reduction of contacts with women raises questions in this period of anxiety about intermediate-term adaptations to guarantee the continuity and safety of care. IMPLICATIONS FOR PRACTICE:This study's results can be used to develop tools to handle cancelled consultations. Video, also called virtual, visits and coordination between independent practitioners and hospitals are probably the major challenges in the current context.

AIM:In this paper, we report on a study investigating the involvement of primary care providers in French local health contracts.BACKGROUND:Worldwide actions are carried out to improve collaboration between primary care and public health to strengthen primary healthcare and consequently community health. In France, the local health contract is an instrument mobilising local stakeholders from different sectors to join in their actions to improve the health of the population.METHODS:We developed an instrument to analyse the frequency and nature of involvement of primary care providers in 428 action plans extracted from a sample of 17 contracts (one per French region). The number of primary care actions were counted, and thematic analyses were conducted to identify the nature and level of involvement of the professionals.FINDINGS:Primary care providers were involved in 20.1% (n = 86) of the action plans and were mostly described as a target of the action rather than leaders or partners. Within those action plans, 76.7% (n = 66) of these action plans aimed to improve access to care for local communities; an issue that appears as the main driver of collaboration between public health and primary care actors.