How to promote the prescription of evidence-based non-pharmacological treatments in France?
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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
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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
Notes de l'éditeur
- 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.