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

• The authors have no conflict of interest with the subject of this presentation.

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

Objectives

1. To identify the barriers to prescribing non-pharmacological treatments

2. To define strategies to overcome these barriers in France.

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

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

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

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

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

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.

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

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?

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

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