Michel Amouyal

How representative are clinical study patients with allergic rhinitis in primary care

BACKGROUND Guidelines are the cornerstone of health care decision making and are based on the best available evidence, ideally large randomized controlled trials (RCTs). Although guidelines target typical patients, RCTs are often based on narrow inclusion and exclusion criteria. OBJECTIVES We explored to what extent typical patients, such as those consulting general practitioners for allergic rhinitis, differ from patients enrolled in RCTs. METHODS We conducted a prospective cohort study including all the consecutive patients with allergic rhinitis cared for by general practitioners in the Languedoc-Roussillon region of France within 2 weeks during the grass pollen season. We evaluated how the characteristics of these patients differed from those of patients included in the 4 largest placebo-controlled RCTs of persistent and intermittent allergic rhinitis. RESULTS Three hundred eleven patients seen by 48 general practitioners were enrolled in this study. Only 7.4% (95% CI, 4.5% to 10.3%) of the patients would have been enrolled in the RCTs. The primary reasons for this difference were as follows: diagnosis of allergy based on skin test results, serum specific IgE levels, or both (20.4%); severity of allergic rhinitis (11.5%); other chronic diseases (11.4%); history of sinusitis (10.4%); and asthma comorbidity (10.1%). A sensitivity analysis excluding contraception and the diagnosis of allergy showed that the percentage of representative patients increased to 20.2% (95% CI, 15.8% to 24.7%). CONCLUSION Only a small proportion of patients with allergic rhinitis seen in the primary care setting for allergic rhinitis would be eligible for RCTs. Thus guideline developers and health decision makers need to make careful judgments about the directness of the evidence from RCTs conducted in highly controlled settings.

[Determinants of support for dementia patients in general practice: a qualitative approach based on an epidemiological cohort].

BACKGROUND the analysis of access to diagnosis and care pathway for dementia patients shows that the disease is not considered as a priority for the general practitioner (GP). Different studies have point out under diagnosis of dementia. PURPOSE the purpose of this qualitative study was to document the determinants of the diagnosis and management of dementia by GP. METHODS recruitment of GPs (n = 12) was made from incident cases of dementia who were identified during the follow-up of subject enrolled in the 3 Cities cohort study. A semi-structured interview was conducted with an interview guide focused on the experience of the doctors. A phenomenological and pragmatic analysis, taking into account all the linguistic and extra linguistic evidence contained in the transcript was conducted. RESULTS several emerging categories have been described: the doctors believe that the management of Alzheimers disease is a public health problem and not an individual, the positioning of the GP in the care system is central. Determinants that influence the management are the identity of the physician, the impression of a fuzzy nosology, the finding of a therapeutic ineffectiveness, the priority given to severe co-morbidities and the workload of the general practitioner. However, the ordering of these categories according to the pragmatic phenomenological approach showed that the identity of the doctor, professional and personal, is at the origin of behavioral variability in their medical care. CONCLUSION in a context of increased workload, the GP favors the assumption of comorbidities in the elderly given fuzzy nosology of dementia and uncertainty about the therapeutic efficacy. The phenomenological approach allows understanding that the human identity of the doctor, personal and professional identity, is the major factor that influence its care attitude for demented patients.

Living Lab MACVIA-LR Équilibre et prévention des chutes

La Presse Medicale - In Press.Proof corrected by the author Available online since vendredi 16 octobre 2015