How to promote the prescription of evidence-based non-pharmacological treatments in France?
HTAi 2012, Bilbao
Clémence Thébaut, Olivier Scemama, Françoise Hamers, Catherine Rumeau-Pichon
Department of economic and public health evaluation
Introduction To Pharmacoeconomics, Objectives, Need of Pharmacoecomics, Four methods of Pharmaeconomics Evaluation, Basic Terminology, Importance of
Pharmacoeconomics.
Pharmacoeconomics tools will not make a decision, but are useful as an aid to decision makers regarding the appropriate use of a product. These tools can assist in selecting an area of preclinical exploration, choosing which drugs should move forward to man, and weather to progress in the phases of clinical trials.
Introduction To Pharmacoeconomics, Objectives, Need of Pharmacoecomics, Four methods of Pharmaeconomics Evaluation, Basic Terminology, Importance of
Pharmacoeconomics.
Pharmacoeconomics tools will not make a decision, but are useful as an aid to decision makers regarding the appropriate use of a product. These tools can assist in selecting an area of preclinical exploration, choosing which drugs should move forward to man, and weather to progress in the phases of clinical trials.
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Dr. Julius Ogato was aming the Ministry of Health Departmental Heads presenting at the 3rd HSDPF.
The presentation elicited interest from counties keen on adopting a single-use policy for health products and commodities.
www.interlinkconsultancy.com
Healthcare industry challenges and pharmacoeconomic solutions.The pharma industry product pipelines are drying up, leading to a high dependence on existing products for survival. The branded generic drugs segment has become commoditized due to ever increasing and fierce
competition.Price plays a major role in drug prescription and buying decisions. High price may not always assure high quality or more benefits and companies are finding it difficult to substantiate higher prices..
This presentation describes the objectives, approach and application of Drug Utilization studies in Pharmacotherapeutics. This emphasizes on how to conduct a drug utilization studies.
Successful drug developers now evaluate three-dimensional outcome data as early as possible in the product development life cycle. ECHO-Economic, Clinical and Humanistic Outcomes.
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Transitional Care for Pediatric Patients with Neuromuscular Diseases: A Healt...HTAi Bilbao 2012
Transitional Care for Pediatric Patients with Neuromuscular Diseases: A Health Technology Assessment
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HTAi 9th Annual Meeting, Bilbao
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Health products and technologies Dr. Julius Ogato, Ministry of Health. Head...Emmanuel Mosoti Machani
Dr. Julius Ogato was aming the Ministry of Health Departmental Heads presenting at the 3rd HSDPF.
The presentation elicited interest from counties keen on adopting a single-use policy for health products and commodities.
www.interlinkconsultancy.com
Healthcare industry challenges and pharmacoeconomic solutions.The pharma industry product pipelines are drying up, leading to a high dependence on existing products for survival. The branded generic drugs segment has become commoditized due to ever increasing and fierce
competition.Price plays a major role in drug prescription and buying decisions. High price may not always assure high quality or more benefits and companies are finding it difficult to substantiate higher prices..
This presentation describes the objectives, approach and application of Drug Utilization studies in Pharmacotherapeutics. This emphasizes on how to conduct a drug utilization studies.
Successful drug developers now evaluate three-dimensional outcome data as early as possible in the product development life cycle. ECHO-Economic, Clinical and Humanistic Outcomes.
Introduction to Clinical Pharmacy Practice, Definitions and Aim, Objectives, Scopes or services of Clinical Pharmacy, Functions and Roles of Clinical Pharmacy, Qualities of Clinical Pharmacy.
Outcomes, health economics and pharmacoeconomicsDureshahwar khan
Pharmacoeconomics can be regarded as a branch of health economics which deals with identifying, measuring, and comparing the costs and consequences of pharmaceutical products and services. Some of the concepts involved in pharmacoeconomic analysis include cost minimization, cost effectiveness, cost benefit, and cost utility analysis.
Transitional Care for Pediatric Patients with Neuromuscular Diseases: A Healt...HTAi Bilbao 2012
Transitional Care for Pediatric Patients with Neuromuscular Diseases: A Health Technology Assessment
Jackie Tran, MD
University of Medicine and Dentistry of New Jersey, USA
HTAi 9th Annual Meeting, Bilbao
Integrated Care for a Patient Centered System
25 June, 2012
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Health Technology Assessment (HTA) Report: Interventions to increase participation to organised cancer screening programs
Ministry of Health Grant for Applied Research
Giorgi Rossi P, Camilloni L, Ferroni E, Jimenez B, Furnari G, Guasticchi G, Borgia P.
Laziosanità – Agenzia di Sanità Pubblica della Regione Lazio
One of the most beautiful peaks in Nepal, Baruntse, can be expedited when experienced Sherpa guides lend a hand. Visit uniquetreks.com to book your Baruntse expedition.
Comprehensive and person centred approach to addressing Polypharmacy in adult...Health Innovation Wessex
The Health Innovation Network Polypharmacy programme is working with healthcare professionals to address problematic polypharmacy by supporting easier identification of patients at potential risk from harm from multiple medications.
Our evidence-based polypharmacy Action Learning Sets (ALS) are being rolled out across England to support GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely.
To drive and accelerate changes in practice, delegates complete a quality improvement project to address problematic polypharmacy in their workplace. This poster summary, Comprehensive and person centred approach to addressing Polypharmacy in adult care home residents, can be viewed here.
For more information about the polypharmacy programme, please visit https://thehealthinnovationnetwork.co.uk/programmes/medicines/polypharmacy/
Shelagh Morris, Allied Health Professions Officer of the Department of Health, talks about supplementary prescription. COT Annual Conference 2010 (22-25 June 2010)
Please share this video with anyone who may be interested!
Watch all our webinars: https://www.youtube.com/playlist?list=PL4dDQscmFYu_ezxuxnAE61hx4JlqAKXpR
In this webinar:
● Takeaways from a roundtable held on June 1st about patient-centred pharmacare in Canada
● Reports from patient groups and other subject matter experts
● A cohesive vision and set of values for national pharmacare in Canada
View the video: https://youtu.be/HMy_gsTDkfI
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Financial Protection and Improved Access to Health Care: A Spotlight on Pharm...HFG Project
Presented at “Financial Protection and Improved Access to Health Care: Peer-to-Peer Learning Workshop Finding Solutions to Common Challenges” in Accra, Ghana, February 2016. To learn more, visit: https://www.hfgproject.org/ghana-uhc-workshop
Evaluations of and Interventions for Non Adherence to Oral Medications as a P...NiyotiKhilare
The focus of this presentation will be medical non-adherence as a psychosocial issue in diabetes. The presentation will also focus elaborately on empowerment as an intervention amongst other interventions.
Social values international programme: integrating research and policy to ens...HTAi Bilbao 2012
Social values international programme: integrating research and policy to ensure fair allocation of health care resources .
HTAi Conference 2012 Panel Session
Joint chairs
Professor Peter Littlejohns and Professor Albert Weale
Challenges in commissioning research on what works in integrated careHTAi Bilbao 2012
Challenges in commissioning research on what works in integrated care.
Tara Lamont, Scientific Adviser
NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC)
www.netscc.ac.uk
EVALUATION OF PSYCHOSOCIAL FACTORS INFLUENCING HEALTHCARE PROFESSIONAL ACCEPT...HTAi Bilbao 2012
EVALUATION OF PSYCHOSOCIAL FACTORS INFLUENCING HEALTHCARE PROFESSIONAL ACCEPTANCE OF TELEMONITORING FOR CHRONIC PATIENTS
Estibalitz Orruño1, Marie-Pierre Gagnon2-3, José Asua4, Eva Reviriego1
1 Basque Office for Health Technology Assessment (Osteba), Department of Health and Consumer Affairs, Basque Government, Vitoria-Gasteiz, Spain.
2 Faculty of Nursing Sciences, Université Laval, Québec, Canada.
3 Research Centre of the Centre Hospitalier Universitaire de Québec, Québec, Canada.
4 Direction of Knowledge Management and Evaluation, Department of Health and Consumer Affairs, Basque Government, Vitoria-Gasteiz, Spain.
METHODS, MATHEMATICAL MODELS, DATA QUALITY ASSESSMENT AND RESULT INTERPRETATI...HTAi Bilbao 2012
METHODS, MATHEMATICAL MODELS, DATA QUALITY ASSESSMENT AND RESULT INTERPRETATION: SOLUTIONS DEVELOPED IN THE IFEDH FRAMEWORK
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
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Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
How to promote the prescription of evidence-based non-pharmacological treatments in France?
1. How to promote the prescription of
evidence-based non-pharmacological
treatments in France?
HTAi 2012, Bilbao
Clémence Thébaut, Olivier Scemama,
Françoise Hamers, Catherine Rumeau-Pichon
Department of economic and public health
evaluation
2. • The authors have no conflict of interest with
the subject of this presentation.
3. Background
− Clinical guidelines recommend to prescribe non-
pharmacological treatments for many conditions
− e.g. in cardiovascular diseases or insomnia the following
treatments are recommended:
− diet,
− psychological treatment,
− lifestyle changes (physical activity, sleeping habits)
− Surveys indicate a gap between these guidelines
and physicians’ prescribing habits.
* Saba et al. 2003, Chevalier et al. 2002, Cogneau et al. 2007, CNAM 2001, Briot 2006
4. Objectives
1. To identify the barriers to prescribing
non-pharmacological treatments
2. To define strategies to overcome these
barriers in France.
5. Methods
− Literature review about extra-medical factors that
influence physicians’ prescribing decisions
− Quantitative and qualitative studies
− Multidisciplinary working group and review group
− 54 experts including physicians, other health care
workers, social scientists, patients’ representatives
− To discuss the results of the literature review and
put in the perspective of the French health care
system
− To identify potential strategies to overcome these
barriers have been identified
6. Results
1. Psychosocial dimensions of drug
prescribing in physician-patient encounter
2. Perceived time pressure during medical
consultations
3. Lack of information and evidence about non
pharmacological treatments’ effectiveness
4. Economic inequalities
7. Psychosocial barriers
1. Symbolic dimension of drug prescribing
− legitimizes the pathological condition of the patient
− validates the patient’s decision to consult his
physician
− is the symbol of the medical process itself
Prescribing non-pharmacological treatment
challenges the classical physician-patient
relationship.*
* Bradley 1992, Bloor et al. 1975,Schwartz 1989,Avorn 2000 3, Fainzang 2001, Dagognet 1984 , Hall et al. 1980,
Collin et al. 1999, Beaune 1993, Collin 2005, Odier 2002
8. Strategies to overcome the barriers
► There is a need to change the collective
representations about health care
− to stop being focused on drug prescription
− to be broadened to encompass both pharmacological and non-
pharmacological treatments in a preventive-curative prospect.
► To provide patients with written prescriptions as it
is usually done for drug treatment
to give the same symbolic power
9. Perceived time pressure barriers
2. Perceived time pressure during medical
consultations
− It takes more time to prescribe non-pharmacological treatment
− Physicians most likely to report time pressure are those who prescribe
highest volume of drugs
− Economists put forward the hypothesis of « compensation patterns »
between consultation time and drug precribing
− The fee payment system increases the perceived time pressure
The impact of the payment system on « compensation patterns »
is likely to be one of the main barriers to non-pharmacological
treatments prescribing.
* Bradley 1992, Coenen 2000, Parish 1973,Wutzke 2006, Watkins 2003, Kumar 2003, Levine 1999,
Schwartz 1989, Lancry et al. 1997, Grignon 2002, Masiero et al. 2010, Rochaix 2004, Franc 2004,
Grignon 2002, Scott 2000
10. Strategies to overcome the barriers
► To change the physicians’ payement system in
France towards mixed payement system
− e.g. to include capitatio, P4P, etc. within the fee payement
system
► Such evolution is also advocated to overcome
other issues related to health care quality
− Convergence of recommandations about the necessity to
introduce other kinds of payment system beyond the sole
question of the promotion of non-pharmacological treatments
prescribing
− Experimentations are currently conducted
− Such evolutions would raise many political controversies.
11. Lack of information and evidence
about non-pharmacological treatments
3.1. Physicians and health workers are not well-
informed
− effectiveness of non-pharmacological treatments
− specific skills of the health care workers involved in non-
pharmacological treatments
− e.g. psychologist vs. psychoanalyst vs psychiatrist
− where to find health care workers to refer their patients
3.2. Physicians are not convinced about the
effectiveness of non-pharmacological treatments
− recommandations are often based on grade C or expert
consensus
− due to specific methodological issues
− due to the financing system of clinical research
* Bradley 1992, Cogneau 2007, Grol 2001, Gross 2001, Kumar 2003, Schwartz 1989, Cabana 1999, Saillour-
Glénisson 2008
12. Strategies to overcome the barriers
► To include more information about non-pharmacological
treatments in the medical education
− How to prescribe (motivational tool) ?
− To which specialized professionnal guiding the patients?
► To produce local directories of professionals specialized in
non-pharmacological treatments
to give telephone number and fees of such professionals to the
patients in order to facilitate treatment initiation and adherence
► To promote the production of scientific data about non-
pharmacological treatments
− Methodological standard : Consort group (Boutron 2008)
− Funding of clinical studies : public or private research?
13. Economic inequalities
4.1. Geographical inequality
− Heterogenity in the territorial distribution of specialized professionals
in non-pharmacological treatments
4.2. Out-of-pocket expenses
− Non-pharmacological treatments are mostly not covered by the
French national health insurance
4.3. Non-financial costs
− Initiate a psychotherapy or pratice sport take some times
− Changing his diet or his ways of thinking represent a psychological
cost
14. Strategies to overcome the barriers
► To improve the supply in terms of non-
pharmacolocical treatments
− To promote collaboration between physicians and
other health care workers (multidisciplinary group
practice, skill-mixed)
► To improve the access
− If the development of non-pharmacological
treatments prescription is really a political will, it will
be nessecary to consider to reimburse the efficient
ones after having assess cost-effectiveness
Editor's Notes
I am Clémence Thébaut, I am working at the French national authority for health and I present you today the result of an assessement we produce on the request of the ministry of health. “ how to promote…”
The request of the ministry of health was based on the following observation. … However surveys concludes that there is a gap between these guidelines and physician’s prescribing habits. True that it is not easy to quantify such gap at a national level because non pharmacological treatments are not recorded in the national health insurance database as they are not reimbursed.
Our objective was :
Now the methods. First we did a literature review about extra-medical factors that influence physician’ prescribing decision. Second, we set up multidisciplinary working and review groups. There were many non-French studies, therefore, the first objective of these groups was to put the results of the literature review in the perspective of the French health care system. Secondly, their objective was to identify potential strategies to overcome barriers that have been identified.
Now the results : We identify four categories of barriers which I present you one by one in the next slides.
So the first barrier to the prescription of non-pharmacological treatment is the symbolic dimension of drug prescribing. According to surveys, sociological and anthropological analyses: Drug prescribing has a symbolic dimension which influences both the patient and the physician. Indeed, to prescribe a drug seems to legitimize the pathological condition of the patient, it validates the patient’s decision to consult the physician, Finally it could be said that to prescribe a drug is the symbol of the medical process itself. Therefore, prescribing non-pharmacological treatment challenges the classical relationship between the physician and the patient.
How could we overcome such barriers. The main conclusions of the working group was that there is a need to change the collective representations about health care. The aim is first to stop being focused on drug prescriptions and second, to broaden the way people think about medical treatment and to encompass both pharmacological and non pharmacological treatment in a preventive-curative prospect . Ok that’s not an easy task, but we propose to give some practical advices to physicians to begin changing the way patients view non pharmacological prescription. For example we recommend that physicians provide patient with a written prescription as it is usually done for drug treatment. I don’t know how it is in your different countries, but in France, physicians are not used to write on prescriptions “do diet” or “do exercices”, and yet, it seems that such simple habits may give a more symbolic power to the prescription of non pharmacological treatment.
The second barrier to prescribing non pharmacological treatment seems to be the perceived time pressure. Indeed we have to acknowledge that to prescribe a diet or a psychological treatment takes more time than to prescribe a tranquilizer. First, there is a need to give precise advice: which food to favor, which food to avoid. Moreover there is a need for the physician to explain why it is important to follow their advice because non pharmacological treatments often imply big changes in lifestyle. Surveys show that lack of time was often the reason why physicians declare not prescribe non pharmacological treatments. Indeed, other studies show that physicians who are most likely to report time pressure are those who are prescribing the highest volume of drug. This correlation leads some economists to put forward the hypothesis of “compensation patterns” : some physicians would exchange time of consultation with drug prescription. This phenomenon is likely to be encouraged by the physician fee payment system which is prevailing in France . This could somehow be one of the main barriers to non pharmacological treatment prescription in France.
How could we overcome these barriers? It would be relevant to change the physician’s payment system to go toward a more mixed payment system: we could for example include some capitatio or¨P4P within a fee payment system. Such evolution could seem to be a little bit too much compared with the sole question of non pharmacological treatment prescription. Yet we see that the evolution of the fee payment system is advocated to overcome other issues related to health care quality. The objective of the promotion of non pharmacological treatment would be one more reason to change the actual fee payment system in France. However you could easily imagine that it raises many political controversies.
The third categories of barriers is the lack of information. It is interesting to note that the working group underlined some barriers that have not been identified in the literature, maybe the reason is they are specific to France: According to them, physicians are not well-informed about the specific skills of the different health care workers that are involved in non pharmacological treatment : what is the difference between a psychologist, a psychoanalyst or a psychiatrist? Secondly, they don’t’ know where to find such health care workers were they could refer their patients. Another barrier is the lack of confidence of physicians about non pharmacological treatment effectiveness due weak evidence that can be explained by methodological issues. Indeed, compared with drug treatment, it is more difficult to describe, standardize and administer consistently non pharmacological treatment. Moreover we have to acknowledge that there is a problem du to the financing system of clinical research. Who’s gonna pay for producing studies about non-pharmacological treatment?
In order to overcome these barriers, the working group recommend some improvements in the medical education and to produce local directories of specialized workers. Other recommendations are put forward about the methodological issues. In particular we underlined the work of the Consort group and the need to apply their recommendations. Regarding the question of who should fund the clinical studies, frankly we don not have answer. How could private organizations would be interested in funding these studies and, at the same time, public resources are, nowedays, lacking.
Finally, economic inequalities may be a barrier to the promotion of non pharmacological treatments prescriptions. There are geographical inequality, there are issues raised by out-of pocket expenses because such treatment (like dietician consultation, psychological treatment) are not reimbursed by the national health insurance. Finally there is some non financial costs that could induce inequality. It take some times to practice a sport or to initiate a psychotherapy. Everyone is not equal in their capacity to provide such time.
To overcome these barrier, it is advocated to promote collaboration between physicians and other health care workers (for example multidisciplinary group practice). This is almost not existing in France. Finally if the development of non pharmacological treatment is indeed a political will, then it would be necessary to consider to reimburse efficient ones, after having assessed their cost/effectiveness. It is true that we will be limited by the methodological issues about the assessment of their effectiveness.