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General practitioners’ preferences with regard to colorectal cancer screening organisation Colon cancer screening medico-legal aspects
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Original article
General practitioners’ preferences with regard to colorectal cancer screening organisation Colon cancer screening medico-legal aspects Frédérique Papin-Lefebvre a,b,c , Elodie Guillaume b , Grégoire Moutel c , Guy Launoy b , Célia Berchi b,∗ a
Caen University Hospital (CHU), Forensic Institute, Côte de Nacre Hospital, Caen, F-14000, France INSERM, U1086 “Cancers and Prevention”, Normandie University, Centre Franc¸ois Baclesse, Caen, F-14076, France c Paris Descartes University, EA4569, Medical Ethics and Forensic Medicine Laboratory, Faculty of Medicine, Paris V, F-75005, France b
a r t i c l e
i n f o
Article history: Received 31 May 2016 Received in revised form 21 August 2017 Accepted 30 August 2017 Keywords: Colorectal cancer screening General practitioner Preferences Rights of patients Discrete choice method
a b s t r a c t Objective: French health authorities put general practitioners at the heart of the colorectal cancer screening. This position raises organisational issues and poses medico-legal problems for the professionals and institutions involved in these campaigns, related to the key concepts of medical decisions and suitability of standards. The objective of our study is to reveal the preferences of general practitioners related to colorectal cancer screening organisation with regard to the medico-legal risk Methods: A discrete choice questionnaire presenting hypothetical screening scenarios was mailed to 2114 physicians from 20 French different areas. The preferences of 358 general practitioners were analysed using logistic regression models. Results: The factors that have significant impact on the preferences of general practitioners are the capacity of the primary care professional in the procedure, the manner in which pre-screening information is given to patients, the manner in which screening results are given to patients, the number of reminders sent to patients who test positive and who do not undergo a colonoscopy and the remuneration of the attending physician. Conclusions: Our results reveals that current colorectal cancer screening organisation is not adapted to general practitioners preferences. This work offers the public authorities avenues for reflection on possible developments in order to optimize the involvement of general practitioners in the promotion of cancer screening programme. © 2017 Elsevier B.V. All rights reserved.
1. Introduction In France, colorectal cancer mass screening has been implemented since 2008 [1]. The State and the health insurance Fund delegate the organization and the promotion of this screening to local associations. More precisely, these management structures are operational bodies under the authority of the Ministry of Health which are responsible for identifying the target population and inviting them by mail to carry out the screening. Decrees published in the French Official Journal of Legislation define the resources and tasks of the management structures, in particular in terms of programme evaluation and compliance with regulatory and ethical aspects (quality assurance, consent, confidentiality [2,3]). The
∗ Corresponding author at: U1086 INSERM “Cancers and prevention” Centre Franc¸ois Baclesse, Avenue du Général Harris, BP 5026 14 076 CAEN Cedex 5–France. E-mail address: [email protected] (C. Berchi).
French colorectal cancer screening programme targets people in the 50–74 years old age group with average risk. The management structure invites people by a personal letter to go to their general practitioner to give them a screening test. The screening test for occult blood in faeces must be done at home. Once the test has been completed, it is sent to a laboratory using a prepaid envelope provided with the test. Patients, their doctor and the management structure are informed of the result by the laboratory. If the result is positive, a colonoscopy will be required to confirm. To reduce colorectal cancer mortality estimated at some 17,500 deaths in 2011 [4], French health authorities set a level of participation of the population concerned above 50% (with a European expected participation objective at 45%) [5]. During the period from 2011 to 2012, the participation rate was only 31.7% [6]. Several studies revealed numerous inequalities in terms of screening participation linked to socio-demographic variables [7,8] and showed that the level of screening participation is closely related to the degree of involvement of the general practitioners. This is not particular to France.
http://dx.doi.org/10.1016/j.healthpol.2017.08.013 0168-8510/© 2017 Elsevier B.V. All rights reserved.
Please cite this article in press as: Papin-Lefebvre F, et al. General practitioners’ preferences with regard to colorectal cancer screening organisation Colon cancer screening medico-legal aspects. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.08.013
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An Australian study also showed that compliance was higher when patients received an invitation to screening signed by their general practitioner rather than receiving an invitation signed by the promoter centre without mention of the GP’s name [9]. General practitioners appear to play a major role for improving participation in the screening programme by sending a final reminder to their patients. The 2009–2013 Cancer Plan launched by the French government in order to reduce cancer incidence and mortality and improve the care of the sick, therefore placed the attending physician at the heart of the cancer mass screening process [10]. Laid down in measure 14 of the 2009–2013 Cancer Plan, the involvement of attending physicians in colorectal cancer mass screening is aimed at fighting inequalities in access to and use of screening. Involving attending physicians in national screening programmes is even the core issue of measure 16 of the Cancer Plan, with the objective of facilitating inclusion of the target patients by general practitioners [11] and therefore increases screening participation. The position of general practitioners at the heart of the system, however, raises organisational issues and poses medico-legal problems for the professionals and institutions involved in these campaigns, related to the key concepts of medical decisions and implementation and suitability of standards. Focused on the specific relationship between doctors and patients in preventive action, these issues refer to notions of terms and scope of information, obtaining the consent of patients, data confidentiality, professional liability. . . Indeed, given the fact that our society is becoming ever more litigious, there is reason to fear an increase in the questioning of the legal responsibility of doctors by patients detected false positives or false negatives or not detected but suffering from cancer on the grounds for insufficient information on screening. The objective of our study was to reveal the preferences of general practitioners related to colorectal cancer mass screening organisation especially with regard to the medico-legal risk. This work deals with the balance of the current screening organisation modalities (such as patient information before and after screening, the number of reminders to undergo a colonoscopy sent to patients . . .) and the general practitioners requirements concerning both the respectful of the rights of patients and their degree of professional liability exposure.
2. Material and methods 2.1. Sample selection The study population was selected from the 216,450 general practitioners registered with the French Medical Association in 2011. The sample size was based upon a rule of thumb usually applied in discrete choice experiment. It was determined on the basis of the analysis of sub-groups with a minimum figure of between 30 and 100 individuals for each sub-group of interest i.e. in this study for each socio-professional characteristics of respondents [12]. Then, estimating between 15 and 20% the a priori proportion of questionnaires accepted and exploitable among the persons contacted, we have fixed the population to be contacted at 2114. A sample of 2114 general practitioners broken down by gender, French département and locality of practice was selected. 20 départements (9 in the south of France, 9 in the north of France, 1 in the Paris region and 1 overseas département) were selected based on the density of general practitioners in the département: low (LD), medium (MD) or high density (HD). Depending on the locality in which their practice was located, the doctors were broken down into three zones: rural (population below 2000), intermediate or urban (population of over 10,000), based on the census taken by the French statistics office INSEE as of 1 January 2010.
2.2. Method of analysis The method of analysis chosen to reveal the preferences of general practitioners was the discrete choice method [13]. Initially used in environmental economics and marketing, this method has been applied to health for some twenty years now as a decision-making support tool for public health choices and as a tool to prepare best practice recommendations [14]. It refers to a set of experimental methods making it possible to determine the preferences of an individual for different alternatives. Observing the choices made by individuals makes it possible to deduce an estimation of utility (i.e. economic indicator of the individuals’ satisfaction) derived from consumption of a product, use of a service or taking a given action. The value of these methods is that they make it possible to estimate the contribution of each component to the choice made (still called attribute). Applied to ethical aspects of colorectal cancer mass screening, the discrete choice method indicates, for example, the utility of doctors associated with means of providing information, medical monitoring of the patient, or the remuneration of doctors. 2.3. Attributes and scenarios By means of questionnaires, use of the discrete choice method leads to presentation of a series of scenarios for organisation of screening to each doctor, so that the practitioner can choose the alternative that offers the highest level of utility. Each hypothetical scenario was composed of specific levels of each attribute representing a specific CRC screening organization modality. The choice of attributes was based on the work done by the French National Institute of Cancer Research Group on Ethics in Screening aimed at identifying ethical issues related to cancer mass screening in France [15]. Five interest attributes were chosen corresponding to the most debated modalities related to ethical aspects of the colorectal cancer mass screening procedure and general practitioners practice (Table 1). The first attribute was the manner in which pre-screening information is given to the patient.,. Screening information is currently given to the patient by a brochure sent by post by the management structure. This mode of information is certainly quick and economical but does not guarantee the patient’s good understanding of the benefits and risks of screening. This is why some doctors claim in France that the information must be issued exclusively by a healthcare professional during a dedicated consultation. The second attribute was the way in which screening results are given to the patient. The current organization of screening provides that the results are communicated to the patient by standard mail. This method carries a double risk: that the patient does not receive the mail and that he does not understand the contents of the mail. Other modalities such as communicating the results in an interview with a health professional would provide better information for the patient and protection of the physician against possible legal action by an uninformed patient. The third attribute was the capacity of the primary care professional from the screening procedure to the diagnosis. Currently in the hands of the management structures, it could be transferred to the general practitioner or the gastroenterologist. However, the medical shortage that is waiting for France is also pushing some politicians to consider entrusting this mission to nurses. The fourth attributes was the remuneration of the attending physician. This attribute does not deal directly with the ethical aspect of screening but is concerned with a highly debated modality. Indeed, French fee-for-service system favours consultations for curative treatments rather than prevention. Therefore, when French general practitioners provide faecal occult blood tests, they
Please cite this article in press as: Papin-Lefebvre F, et al. General practitioners’ preferences with regard to colorectal cancer screening organisation Colon cancer screening medico-legal aspects. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.08.013
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Table 1 Attributes and terms of the fictitious colorectal cancer screening programmes. Attributes
Terms
1. How screening information is given to the patient (SUPPORTinfo)
(a) Document given during consultation for another reason (b) Brochure sent by posta (c) Specific consultation by a healthcare professional (a) Standard lettera (b) Registered letter with acknowledgement of receipt (c) Private interview (a) Nurse
2. How screening results are returned to the patient (MODrendu)
3. Primary care professional in charge of monitoring the screening procedure until the diagnosis, as required (PROFref)
(b) Management structurea (c) General practitioner (d) Specialist (a) None (b) Annual lump suma (c) On a per-medical-service basis (a) None
4. Remuneration of the attending physician (REMUN)
5. Number of reminders sent to patients who test positive and who have not undergone a colonoscopy (NBrelance)
(b) One (c) Severala a
Terms of the national programme.
receive an annual progressive lump sum based on the number of tests performed by patients. But this method of remuneration does not gain the adhesion of all the doctors and could slow down the involvement of certain doctors very attached to the fee-for-service. The last attribute was the number of reminders sent to patients who test positive and who have not undergone a colonoscopy. Patients are currently receiving several stimulus letters to perform their colonoscopy. If this modality optimizes the information, its repeated character is considered by some to be an impediment to the patient’s free will. For each attribute, the value corresponding to the terms of the national programme was included. The scenarios were then built, with the combination of values of each attribute. The number of possible combinations with all the attribute values was 324 (34 × 41 ). To reduce the number of experiments, a fractional orthogonal design was built using the SAS software (version 9.3). Among the 12 scenarios chosen, a reference scenario was selected by draw. 2.4. Preparation of the questionnaire The binary choice technique was used rather than ranking technique since it is easier to understand. It consisted of presenting the physician with several pairs of scenarios for organisation of screening, asking the following question: “Of these 2 fictitious colorectal cancer screening programmes, which would you prefer to propose to your patients to avoid professional liability exposure and to better protect the interests of your patients?” (Fig. 1). At the end of the questionnaire, several socio-professional characteristics likely to influence the preferences of general practitioners were recorded: age, gender, locality of the practice, type of practice (in a group, alone), fee category (contracted – category 1, contracted – category 2, non-contracted), prior training in legal issues or in organisation of cancer screening. The questionnaire was completed by two questions on support of the physician for the national screening programme and his opinion on the medico-legal risk arising from his practice. To minimise the size of the questionnaire, not all 11 pair-wise choices were presented in the same questionnaire but were shared out over 2 different questionnaires (1 questionnaire with 5 pairwise choices and 1 questionnaire with 6 pair-wise choices). These questionnaires were piloted on a sample of 20 general practitioners randomly selected from the 216,450 general practitioners registered with the French Medical Association. This confirmed the questions were understood and physicians were able to consider
6 choice sets in the same questionnaire. Their responses were not included in the final analysis. The questionnaire was approved by the National Data Protection Authority. 2.5. Data collection and analysis Data were collected by sending questionnaires by post. Supposing that attributes have an independent influence on the physician’s preference, the following equation was estimated by means of logistic regression, using the SAS software (version 9.3): U = Pr[Y = 1] = ˇ0 + ˇ1 × SUPPORTinfo + ˇ2 × MODrendu + ˇ3 × PROFref + ˇ4 × REMUN + ˇ5 × NBrelance + Where U represents the utility associated with the terms of colorectal cancer mass screening 1 to 5 are the coefficients indicating the relative utility of each attribute. The sign of the coefficient reflects the positive or negative impact of the attribute on the preference of the physician. The value of the coefficient indicates the relative importance of the corresponding attribute. The attribute influences the preference of the physician if it has a coefficient with a statistically significant threshold. The influence of the socio-professional characteristics of the general practitioners was tested by including the interactions between the attributes and these characteristics in the main model. 3. Results Of the 2114 physicians to whom questionnaires were sent, 358 replied (17%). Of 358 questionnaires received, 326 could be analysed (91%). Thirty-five questionnaires were incomplete regarding choices, 44 regarding the other data collected. The socio-professional characteristics of the physicians are presented in Table 2. A majority of women (54.6%) answered the questionnaire. The average age of the respondents was 53.6. The breakdown of physicians according to the French département of practice and the density of doctors were not significantly different between respondents and non-respondents (X 2 test, p = 0.41 and p = 0.50). However, the proportion of respondents practising in urban areas was significantly lower compared to non-respondents (X 2 test, p < 0.01). 82.2% of respondents indicated that they were in favour of organisation of colorectal screening by the public authorities. Regarding the medico-legal risk involved in the programme,
Please cite this article in press as: Papin-Lefebvre F, et al. General practitioners’ preferences with regard to colorectal cancer screening organisation Colon cancer screening medico-legal aspects. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.08.013
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Fig. 1. Example of choices proposed in the questionnaire.
Table 2 Socio-professional characteristics of respondents (n = 326). Characteristics
N
(%)
Gender Male Age (in years)
148
(45.4)
53.6 8.95 (33–72) 62 257 7
(19.1) (78.8) (2.1)
French département where the doctor practises North South Paris region Overseas
168 143 7 8
(51.5) (43.9) (2.2) (2.4)
Density of doctors Low (LD) Medium (MD) High (HD)
111 105 110
(34.1) (32.2) (33.7)
Practice location Rural Intermediate Urban
126 117 83
(38.6) (35.9) (25.5)
Fee category Contracted – Category 1 Category 2 or non-contracted Not indicateda
304 12 10
(93.3) (3.7) (3)
Practice organisation Alone In a group Not indicateda
167 153 6
(51.3) (46.9) (1.8)
Legal training Yes Not indicateda
30 8
(9.2) (2.5)
Training in mass screening Yes Not indicateda
171 11
(52.5) (3.4)
Average Standard deviation (minimum-maximum) 45 or below Above 45 Not indicateda
a
Not indicated.
67.2% considered that it did not modify the risk of disputes with their patients, 4.9% considered that it increased the risk, 15.6% that it decreased the risk and 8.6% had no opinion (3.7% nonrespondents).
In the main model (Table 3), all attributes appear as factors significantly impacting the utility of the general practitioner (p < 0.01), except remuneration by means of an annual lump sum. The participating physicians prefered scenarios that establish the general practitioner as the primary care physician, where the patients who test positive and who have not undergone a colonoscopy are reminded several times, where screening results are given to the patient during a private interview, where information prior to mass screening is given to the patient by means of written documents (sent by post or given when the patient comes in for a consultation on another issue) and where the attending physician is paid on a per-service basis. They preferentially reject scenarios where screening results are sent by post, in particular by registered mail with acknowledgement of receipt, and where no reminders are sent following a positive test result. The results of the final model, with interactions, are also presented in Table 3. Remuneration of the attending physician for participation in the mass screening on a per-service basis (compared to no remuneration) appeared to be the preference among the respondents, even taking potential confounding factors such as socio-professional characteristics into account. The area of practice, fee category, existence of legal training or training specific to mass screening and opinion on the medico-legal risk of the programme did not influence the preferences of respondents. On the other hand, gender, age, density of doctors and support for the national programme appeared to be interaction factors in the final model, emphasising their importance for certain subgroups of professionals. Women practitioners and practitioners below the age of 46 preferred to give pre-screening information during a medical consultation organised for that purpose. Majority of women rejected mass screening without reminders sent to patients who test positive. Younger practitioners rejected remuneration on a permedical-service basis for their participation in mass screening. In areas with a low medical density, practitioners preferred to send the results by registered letter with acknowledgement of receipt more than in areas with a medium medical density. Physicians who were not in favour of mass screening would rather opt for a programme with a general practitioner as the primary-care professional in the system and without reminders following positive tests and tended to reject the idea of private interviews to give screening results.
Please cite this article in press as: Papin-Lefebvre F, et al. General practitioners’ preferences with regard to colorectal cancer screening organisation Colon cancer screening medico-legal aspects. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.08.013
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Table 3 Results of the final model: Main effects and interactions. Attributes
Terms
Constant
Main model (n = 326) 3306 observations
Model with interactions (n = 326) 3162 observations
Coefficients 
p
Coefficients 
p
0.4047
<0.0001
0.3838
<0.0001
Type of pre-screening information provided
Document given during another examination Brochure sent by post Specific consultation by a healthcare professional a
0.1494 0.1482 0.00001
<0.0001 <0.0001
0.2389 0.2124
<0.0001 <0.0001
How results are given
Private interview e Standard letter Registered letter with acknowledgement of receipt d
0.00001 −0.1705 −0.2598
<0.0001 <0.0001
−0.2108 −0.2902
<0.001 <0.0001
Primary care professional entrusted with monitoring
General practitioner f Management structure Specialist Nurse
0.3990 0.1086 0.0921 0.00001
<0.0001 <0.001 <0.01
0.3363 0.1155 0.0731
<0.0001 <0.001 <0.05
Remuneration
Per medical service c None Annual lump sum
0.0952 0.00001 −0.0067
<0.01
0.1292
<0.001
0.85
0.0078
0.84
Number of reminders
Several One None b
0.3032 0.00001 −0.1378
<0.0001
0.2972
<0.0001
<0.0001
−0.1130
<0.01
Interactions
Women × Specific consultation a Women × No reminder b Less than 46 years of age × Specific consultation a Less than 46 years of age × Per-medical-service remuneration c LD × Registered letter d Not in favour of mass screening × Private interview e Not in favour of mass screening × No reminder b Not in favour of mass screening × General practitioner f
0.0760 −0.1463 0.0563 −0.1347 0.0992 −0.0831 0.3842 0.3260
<0.01 <0.01 <0.05 <0.05 <0.05 <0.05 <0.0001 <0.01
Likelihood logarithm
−2165.6474
n = Number of respondents; p = Significance threshold; 1 Reference value.
4. Discussion The results of the study show that issues related to patient information and to the manner in which consent is obtained, as well as monitoring of patients taking part in the programme, have a clear impact on support for screening campaigns among general practitioners. The general practitioners who responded to this survey are in favour of mass screening (over 80% of respondents) and are keen to assert their role with the public authorities, placing themselves at the heart of the system as primary care professionals. On the other hand, the issue of remuneration does not appear to play a major role in their choice. The preferences of general practitioners appear to differ from the current organisation of colorectal cancer mass screening. Regarding pre-screening information, although general practitioners express a preference for written documents to be given to the patient, they prefer to have a private interview with their patient and to give such documents when the patient comes in for another medical consultation, rather than having the documents sent by post, which is the procedure under the national programme. This preference is even more clearly expressed when it comes to informing the patient of the result of the screening test, as general practitioners significantly reject the hypothesis of sending test results by post, whether by standard letter as it is the case in the current programme, or by registered letter with acknowledgement of receipt. Through these results, general practitioners show the support role they intend to play with their patients, both in terms of obtaining informed consent and when positive test results are announced. These results highlight their choice of being primary care professionals responsible for monitoring the screening procedure from the outset. Although they do not reject the role of the management structure, they wish to play a major role by assert-
ing their difference thanks to the privileged trust relationship they have with their patients. Contrary to the situation in England or in the United States [16], general practitioners do not wish to delegate that duty to a nurse despite the fact that there is a lack of general practitioners in some French areas. Concerning remuneration, a majority of doctors choose a fee-for-service rather than an annual lump sum, as laid down in the programme. Their reply concerning the number of reminders is the only aspect where they confirm the provisions of the current programme (the regulation was modified by order in 2013 [3]) which stipulate that if the test has not been performed, there will be at least two reminders: one 3 months later followed by a second reminder, preferably 6 months later, if there is no response. Although few respondents had benefited from legal training (less than 10%), the choices made reflect their knowledge of the rules of deontology regarding information and expression of patient wishes. These rules, enshrined in the Code of Medical Deontology (CDM), were also included in the Law of 4 March 2002 on the rights of patient [17] and were included in the regulatory section of the French Public Health Code [18]. Placing the general practitioner at the heart of the system, as recommended by the 2009–2013 Cancer Plan, therefore appears to ensure enhanced protection of patient interests and to reduce professional liability exposure for health professionals. In this way, the general practitioner is able to give the patient “accurate, clear and appropriate information” (art. 35 of the Code of Medical Deontology – art. R4127-35 of the Public Health Code) on the screening procedure. The general practitioner is in a position to specify “the usefulness, urgency, if any, consequences and normally foreseeable frequent or serious risks involved” (art L1111-2 of the Public Health Code). In case of positive test, the general practitioner is able to inform the patient of the consequences of refusal to undergo a colonoscopy (art. 36 of the Code of Deontology) and
Please cite this article in press as: Papin-Lefebvre F, et al. General practitioners’ preferences with regard to colorectal cancer screening organisation Colon cancer screening medico-legal aspects. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.08.013
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to suggest other solutions if they are possible (art L1111-2 of the Public Health Code). If new risks are identified at a later stage, he is able to contact the person again, as the Law of 4 March 2002 specifies that such information must be given during a private interview. More particularly, the long-term follow-up of the patient also allows the general practitioner to identify any changes in his state of health, making him ineligible for organised screening (persons who have a high or very high risk of colorectal cancer or who have undergone a colonoscopy in the last five years) and to inform the patient of this evolution. This pivotal role appears to be easier for general practitioners than for a management structure, which is an operational body that has no close contact with patients. To assess the reliability of results, certain limitations of the study should be taken into consideration. The major limitation of the study is the low response rate. This weakness could call into question the representativeness of the sample compared with all general practitioners, in particular given that those who responded are overwhelmingly in favour of mass screening. This means that caution should be exercised in generalising the results obtained. In our study, for example, the gender ratio of respondents is reversed compared with that of French general practitioners as a whole (approximately 54.8% are men), given that the majority of our respondents were women. The average age of respondents was also slightly above the average age of general practitioners (52) in 2010. On the other hand, the breakdown by departement of practice and density of doctors is identical to that of general practitioners as a whole. Despite the low response rate, there is no problem related to the statistical power of the study. 5. Conclusion Finally, this study reveals the preferences of the general practitioners who are most involved in participation in colorectal cancer mass screening campaigns. The results show that general practitioners fully assume the central role assigned to them by the authorities and wish to play a more important role in informing patients both upstream and downstream of screening. They are in favour of delivering the information in a single colloquium during dedicated consultations rather than by simple letters sent by the management structures currently in force. They are also in favour of maximising the number of reminders when the test has not been performed (at least two reminders: one 3 months later followed by a second reminder, preferably 6 months later, if there is no response). Finally, without this being a primary element, the study reveals an increased preference for fee-for-service payment. This result suggests that doctors have not fully adhered to the lump sum payment system adopted to compensate for their involvement in screening since 2008 and remain strongly attached to fee-forservice payment. This work suggests that general practitioners could increase their involvement in colorectal cancer screening if they were more associated with patient information at different stages of screening (inclusion in screening, announcement of the result of the test and its consequences, reminders in case of non-completion of the test or the confirmation colonoscopy).Their privileged mode of communication remains the face-to-face consultation with the patient. In a fee-for-service environment where GPs do not have any incentives for prevention related consultations, it is necessary to adjust financial incentives for screening. Further studies on the influence
of general practitioners’ remuneration mode on their involvement in the promotion of cancer screening should be conducted. This work offers avenues for reflection for improving GP’s involvement in promoting cancer screening programmes. Declaration of conflict of interest No conflict of interest declared. Acknowledgements The authors thank Marie Ingouf and Catherine Grain for entering the data. This work was supported financially by the Inca. References [1] Viguier J. L’organisation du dépistage du cancer colorectal en France (Organisation of colorectal cancer screening in France). BEH 2009; 2–3: 19–22 (www. invs.sante.fr/beh/2009). [2] French Republic Order of 29 September 2006 on cancer screening programmes. Official Journal of 21 December 2006. [3] French Republic Order of 15 April 2013 amending the Order of 29 September 2006 on mass cancer screening programmes. Official Journal of 27 April 2013. [4] InVS/Francim/Inserm/Hospices Civils de Lyon/INCa. Estimation nationale de l’incidence et de la mortalité par cancer en Franceentre 1980 et 2012. (National estimate of the impact of and mortality due to cancer in France between 1980 and 2012). July 2013. [5] European Commission European guidelines for quality assurance in colorectal cancer screening and diagnosis, 4th ed. Luxembourg: Publications Office of the European Union; 2010 www.kolorektum.cz/res/file/guidelines-EC-201102-03.pdf. [6] InVS. Taux de participation au programme de dépistage organise du cancercolorectal 2011–2012 (Level of participation in the colorectal cancer mass screening programme for 2011–2012), 26/02/2013. [7] Pornet C, Dejardin O, Morlais F, Bouvier V, Launoy G. Socioeconomic determinants for compliance to colorectal cancer screening. Journal of Epidemiology and Community Health 2010;64:318–24. [8] Poncet F, Delafosse P, Seigneurin A, Exbrayat C, Colonna M. Determinants of participation in organized colorectal cancer screening in Isère (France). Clinics and Research in Hepatology and Gastroenterology 2013;37:193–9. [9] Cole SR, Young GP, Byrne D, Guy JR, Morcom J. Participation in screening for colorectal cancer based on a faecal occult blood test is improved by endorsement by the primary care practitioner. Journal of Medical Screening 2002;9:147–52. [10] Grünfeld JP. Recommandations pour le Plan Cancer 2009–2013. Pour un nouvel élan. Rapport au Président de la République. (Recommendations for the 2009–2013 Cancer Plan. For new impetus. Report to the French President). 14 February 2009. (www.sante.gouv.fr/IMG/pdf/Rapport Grunfeldrecommandations pour la plan cancer 2009 2013 -mars 2009.pdf). [11] French Republic 2009–2013 Cancer Plan (www.plan-cancer.gouv.fr). [12] Permain D, Swanson J, Kroes E, Bradley M. Stated preferences techniques: a guide to practice. Steer Davis Gleave and Hague Consulting group; 1991. [13] Berchi C, Launoy G. Principle, strengths and weaknesses of discrete choice modelling for eliciting public preferences for health care. Revue d’Épidémiologie et de Santé Publique 2007;55:133–9. [14] Ryan M, Gerard K, Amya-Amaya M. Using discrete choice experiments to value health and health care, 1st ed. Springer: Houten (The Netherlands); 2008. [15] Moutel G, Duchange N, Jullian O, de Montgolfier S, Papin-Lefebvre F, SanchoGarnier H. Ethique et dépistage organisé du cancer du sein en France –Rapport du Groupe de réflexion sur l’éthique du dépistage (GRED). (Ethics and mass screening for breast cancer in France – Report of the Think Tank on screening ethics (GRED)). Boulogne-Billancourt: INCa – Collection Etats des lieux & des connaissances, 2012. [16] Leconte C. La place du médecin généraliste dans le dépistage des cancers de l’intestin, du sein, du col de l’utérus et de la prostate; 2011. Thèse de Doctorat en Médecine (Role of general practitioners in screening for bowel, breast, cervical and prostate cancer. Thesis for a Doctorate in Medicine). Caen. [17] French Republic Law 2002-303 of 4 March 2002 on the rights of patients and the quality of the healthcare system. Official Journal of 5 March 2002. [18] French Republic Decree 2004-802 of 29 July 2004 on parts IV and V (regulatory provisions) of the Public Health Code amending certain provisions of the code. Official Journal of 8 August 2004.
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Original article
General practitioners’ preferences with regard to colorectal cancer screening organisation Colon cancer screening medico-legal aspects Frédérique Papin-Lefebvre a,b,c , Elodie Guillaume b , Grégoire Moutel c , Guy Launoy b , Célia Berchi b,∗ a
Caen University Hospital (CHU), Forensic Institute, Côte de Nacre Hospital, Caen, F-14000, France INSERM, U1086 “Cancers and Prevention”, Normandie University, Centre Franc¸ois Baclesse, Caen, F-14076, France c Paris Descartes University, EA4569, Medical Ethics and Forensic Medicine Laboratory, Faculty of Medicine, Paris V, F-75005, France b
a r t i c l e
i n f o
Article history: Received 31 May 2016 Received in revised form 21 August 2017 Accepted 30 August 2017 Keywords: Colorectal cancer screening General practitioner Preferences Rights of patients Discrete choice method
a b s t r a c t Objective: French health authorities put general practitioners at the heart of the colorectal cancer screening. This position raises organisational issues and poses medico-legal problems for the professionals and institutions involved in these campaigns, related to the key concepts of medical decisions and suitability of standards. The objective of our study is to reveal the preferences of general practitioners related to colorectal cancer screening organisation with regard to the medico-legal risk Methods: A discrete choice questionnaire presenting hypothetical screening scenarios was mailed to 2114 physicians from 20 French different areas. The preferences of 358 general practitioners were analysed using logistic regression models. Results: The factors that have significant impact on the preferences of general practitioners are the capacity of the primary care professional in the procedure, the manner in which pre-screening information is given to patients, the manner in which screening results are given to patients, the number of reminders sent to patients who test positive and who do not undergo a colonoscopy and the remuneration of the attending physician. Conclusions: Our results reveals that current colorectal cancer screening organisation is not adapted to general practitioners preferences. This work offers the public authorities avenues for reflection on possible developments in order to optimize the involvement of general practitioners in the promotion of cancer screening programme. © 2017 Elsevier B.V. All rights reserved.
1. Introduction In France, colorectal cancer mass screening has been implemented since 2008 [1]. The State and the health insurance Fund delegate the organization and the promotion of this screening to local associations. More precisely, these management structures are operational bodies under the authority of the Ministry of Health which are responsible for identifying the target population and inviting them by mail to carry out the screening. Decrees published in the French Official Journal of Legislation define the resources and tasks of the management structures, in particular in terms of programme evaluation and compliance with regulatory and ethical aspects (quality assurance, consent, confidentiality [2,3]). The
∗ Corresponding author at: U1086 INSERM “Cancers and prevention” Centre Franc¸ois Baclesse, Avenue du Général Harris, BP 5026 14 076 CAEN Cedex 5–France. E-mail address: [email protected] (C. Berchi).
French colorectal cancer screening programme targets people in the 50–74 years old age group with average risk. The management structure invites people by a personal letter to go to their general practitioner to give them a screening test. The screening test for occult blood in faeces must be done at home. Once the test has been completed, it is sent to a laboratory using a prepaid envelope provided with the test. Patients, their doctor and the management structure are informed of the result by the laboratory. If the result is positive, a colonoscopy will be required to confirm. To reduce colorectal cancer mortality estimated at some 17,500 deaths in 2011 [4], French health authorities set a level of participation of the population concerned above 50% (with a European expected participation objective at 45%) [5]. During the period from 2011 to 2012, the participation rate was only 31.7% [6]. Several studies revealed numerous inequalities in terms of screening participation linked to socio-demographic variables [7,8] and showed that the level of screening participation is closely related to the degree of involvement of the general practitioners. This is not particular to France.
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An Australian study also showed that compliance was higher when patients received an invitation to screening signed by their general practitioner rather than receiving an invitation signed by the promoter centre without mention of the GP’s name [9]. General practitioners appear to play a major role for improving participation in the screening programme by sending a final reminder to their patients. The 2009–2013 Cancer Plan launched by the French government in order to reduce cancer incidence and mortality and improve the care of the sick, therefore placed the attending physician at the heart of the cancer mass screening process [10]. Laid down in measure 14 of the 2009–2013 Cancer Plan, the involvement of attending physicians in colorectal cancer mass screening is aimed at fighting inequalities in access to and use of screening. Involving attending physicians in national screening programmes is even the core issue of measure 16 of the Cancer Plan, with the objective of facilitating inclusion of the target patients by general practitioners [11] and therefore increases screening participation. The position of general practitioners at the heart of the system, however, raises organisational issues and poses medico-legal problems for the professionals and institutions involved in these campaigns, related to the key concepts of medical decisions and implementation and suitability of standards. Focused on the specific relationship between doctors and patients in preventive action, these issues refer to notions of terms and scope of information, obtaining the consent of patients, data confidentiality, professional liability. . . Indeed, given the fact that our society is becoming ever more litigious, there is reason to fear an increase in the questioning of the legal responsibility of doctors by patients detected false positives or false negatives or not detected but suffering from cancer on the grounds for insufficient information on screening. The objective of our study was to reveal the preferences of general practitioners related to colorectal cancer mass screening organisation especially with regard to the medico-legal risk. This work deals with the balance of the current screening organisation modalities (such as patient information before and after screening, the number of reminders to undergo a colonoscopy sent to patients . . .) and the general practitioners requirements concerning both the respectful of the rights of patients and their degree of professional liability exposure.
2. Material and methods 2.1. Sample selection The study population was selected from the 216,450 general practitioners registered with the French Medical Association in 2011. The sample size was based upon a rule of thumb usually applied in discrete choice experiment. It was determined on the basis of the analysis of sub-groups with a minimum figure of between 30 and 100 individuals for each sub-group of interest i.e. in this study for each socio-professional characteristics of respondents [12]. Then, estimating between 15 and 20% the a priori proportion of questionnaires accepted and exploitable among the persons contacted, we have fixed the population to be contacted at 2114. A sample of 2114 general practitioners broken down by gender, French département and locality of practice was selected. 20 départements (9 in the south of France, 9 in the north of France, 1 in the Paris region and 1 overseas département) were selected based on the density of general practitioners in the département: low (LD), medium (MD) or high density (HD). Depending on the locality in which their practice was located, the doctors were broken down into three zones: rural (population below 2000), intermediate or urban (population of over 10,000), based on the census taken by the French statistics office INSEE as of 1 January 2010.
2.2. Method of analysis The method of analysis chosen to reveal the preferences of general practitioners was the discrete choice method [13]. Initially used in environmental economics and marketing, this method has been applied to health for some twenty years now as a decision-making support tool for public health choices and as a tool to prepare best practice recommendations [14]. It refers to a set of experimental methods making it possible to determine the preferences of an individual for different alternatives. Observing the choices made by individuals makes it possible to deduce an estimation of utility (i.e. economic indicator of the individuals’ satisfaction) derived from consumption of a product, use of a service or taking a given action. The value of these methods is that they make it possible to estimate the contribution of each component to the choice made (still called attribute). Applied to ethical aspects of colorectal cancer mass screening, the discrete choice method indicates, for example, the utility of doctors associated with means of providing information, medical monitoring of the patient, or the remuneration of doctors. 2.3. Attributes and scenarios By means of questionnaires, use of the discrete choice method leads to presentation of a series of scenarios for organisation of screening to each doctor, so that the practitioner can choose the alternative that offers the highest level of utility. Each hypothetical scenario was composed of specific levels of each attribute representing a specific CRC screening organization modality. The choice of attributes was based on the work done by the French National Institute of Cancer Research Group on Ethics in Screening aimed at identifying ethical issues related to cancer mass screening in France [15]. Five interest attributes were chosen corresponding to the most debated modalities related to ethical aspects of the colorectal cancer mass screening procedure and general practitioners practice (Table 1). The first attribute was the manner in which pre-screening information is given to the patient.,. Screening information is currently given to the patient by a brochure sent by post by the management structure. This mode of information is certainly quick and economical but does not guarantee the patient’s good understanding of the benefits and risks of screening. This is why some doctors claim in France that the information must be issued exclusively by a healthcare professional during a dedicated consultation. The second attribute was the way in which screening results are given to the patient. The current organization of screening provides that the results are communicated to the patient by standard mail. This method carries a double risk: that the patient does not receive the mail and that he does not understand the contents of the mail. Other modalities such as communicating the results in an interview with a health professional would provide better information for the patient and protection of the physician against possible legal action by an uninformed patient. The third attribute was the capacity of the primary care professional from the screening procedure to the diagnosis. Currently in the hands of the management structures, it could be transferred to the general practitioner or the gastroenterologist. However, the medical shortage that is waiting for France is also pushing some politicians to consider entrusting this mission to nurses. The fourth attributes was the remuneration of the attending physician. This attribute does not deal directly with the ethical aspect of screening but is concerned with a highly debated modality. Indeed, French fee-for-service system favours consultations for curative treatments rather than prevention. Therefore, when French general practitioners provide faecal occult blood tests, they
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Table 1 Attributes and terms of the fictitious colorectal cancer screening programmes. Attributes
Terms
1. How screening information is given to the patient (SUPPORTinfo)
(a) Document given during consultation for another reason (b) Brochure sent by posta (c) Specific consultation by a healthcare professional (a) Standard lettera (b) Registered letter with acknowledgement of receipt (c) Private interview (a) Nurse
2. How screening results are returned to the patient (MODrendu)
3. Primary care professional in charge of monitoring the screening procedure until the diagnosis, as required (PROFref)
(b) Management structurea (c) General practitioner (d) Specialist (a) None (b) Annual lump suma (c) On a per-medical-service basis (a) None
4. Remuneration of the attending physician (REMUN)
5. Number of reminders sent to patients who test positive and who have not undergone a colonoscopy (NBrelance)
(b) One (c) Severala a
Terms of the national programme.
receive an annual progressive lump sum based on the number of tests performed by patients. But this method of remuneration does not gain the adhesion of all the doctors and could slow down the involvement of certain doctors very attached to the fee-for-service. The last attribute was the number of reminders sent to patients who test positive and who have not undergone a colonoscopy. Patients are currently receiving several stimulus letters to perform their colonoscopy. If this modality optimizes the information, its repeated character is considered by some to be an impediment to the patient’s free will. For each attribute, the value corresponding to the terms of the national programme was included. The scenarios were then built, with the combination of values of each attribute. The number of possible combinations with all the attribute values was 324 (34 × 41 ). To reduce the number of experiments, a fractional orthogonal design was built using the SAS software (version 9.3). Among the 12 scenarios chosen, a reference scenario was selected by draw. 2.4. Preparation of the questionnaire The binary choice technique was used rather than ranking technique since it is easier to understand. It consisted of presenting the physician with several pairs of scenarios for organisation of screening, asking the following question: “Of these 2 fictitious colorectal cancer screening programmes, which would you prefer to propose to your patients to avoid professional liability exposure and to better protect the interests of your patients?” (Fig. 1). At the end of the questionnaire, several socio-professional characteristics likely to influence the preferences of general practitioners were recorded: age, gender, locality of the practice, type of practice (in a group, alone), fee category (contracted – category 1, contracted – category 2, non-contracted), prior training in legal issues or in organisation of cancer screening. The questionnaire was completed by two questions on support of the physician for the national screening programme and his opinion on the medico-legal risk arising from his practice. To minimise the size of the questionnaire, not all 11 pair-wise choices were presented in the same questionnaire but were shared out over 2 different questionnaires (1 questionnaire with 5 pairwise choices and 1 questionnaire with 6 pair-wise choices). These questionnaires were piloted on a sample of 20 general practitioners randomly selected from the 216,450 general practitioners registered with the French Medical Association. This confirmed the questions were understood and physicians were able to consider
6 choice sets in the same questionnaire. Their responses were not included in the final analysis. The questionnaire was approved by the National Data Protection Authority. 2.5. Data collection and analysis Data were collected by sending questionnaires by post. Supposing that attributes have an independent influence on the physician’s preference, the following equation was estimated by means of logistic regression, using the SAS software (version 9.3): U = Pr[Y = 1] = ˇ0 + ˇ1 × SUPPORTinfo + ˇ2 × MODrendu + ˇ3 × PROFref + ˇ4 × REMUN + ˇ5 × NBrelance + Where U represents the utility associated with the terms of colorectal cancer mass screening 1 to 5 are the coefficients indicating the relative utility of each attribute. The sign of the coefficient reflects the positive or negative impact of the attribute on the preference of the physician. The value of the coefficient indicates the relative importance of the corresponding attribute. The attribute influences the preference of the physician if it has a coefficient with a statistically significant threshold. The influence of the socio-professional characteristics of the general practitioners was tested by including the interactions between the attributes and these characteristics in the main model. 3. Results Of the 2114 physicians to whom questionnaires were sent, 358 replied (17%). Of 358 questionnaires received, 326 could be analysed (91%). Thirty-five questionnaires were incomplete regarding choices, 44 regarding the other data collected. The socio-professional characteristics of the physicians are presented in Table 2. A majority of women (54.6%) answered the questionnaire. The average age of the respondents was 53.6. The breakdown of physicians according to the French département of practice and the density of doctors were not significantly different between respondents and non-respondents (X 2 test, p = 0.41 and p = 0.50). However, the proportion of respondents practising in urban areas was significantly lower compared to non-respondents (X 2 test, p < 0.01). 82.2% of respondents indicated that they were in favour of organisation of colorectal screening by the public authorities. Regarding the medico-legal risk involved in the programme,
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Fig. 1. Example of choices proposed in the questionnaire.
Table 2 Socio-professional characteristics of respondents (n = 326). Characteristics
N
(%)
Gender Male Age (in years)
148
(45.4)
53.6 8.95 (33–72) 62 257 7
(19.1) (78.8) (2.1)
French département where the doctor practises North South Paris region Overseas
168 143 7 8
(51.5) (43.9) (2.2) (2.4)
Density of doctors Low (LD) Medium (MD) High (HD)
111 105 110
(34.1) (32.2) (33.7)
Practice location Rural Intermediate Urban
126 117 83
(38.6) (35.9) (25.5)
Fee category Contracted – Category 1 Category 2 or non-contracted Not indicateda
304 12 10
(93.3) (3.7) (3)
Practice organisation Alone In a group Not indicateda
167 153 6
(51.3) (46.9) (1.8)
Legal training Yes Not indicateda
30 8
(9.2) (2.5)
Training in mass screening Yes Not indicateda
171 11
(52.5) (3.4)
Average Standard deviation (minimum-maximum) 45 or below Above 45 Not indicateda
a
Not indicated.
67.2% considered that it did not modify the risk of disputes with their patients, 4.9% considered that it increased the risk, 15.6% that it decreased the risk and 8.6% had no opinion (3.7% nonrespondents).
In the main model (Table 3), all attributes appear as factors significantly impacting the utility of the general practitioner (p < 0.01), except remuneration by means of an annual lump sum. The participating physicians prefered scenarios that establish the general practitioner as the primary care physician, where the patients who test positive and who have not undergone a colonoscopy are reminded several times, where screening results are given to the patient during a private interview, where information prior to mass screening is given to the patient by means of written documents (sent by post or given when the patient comes in for a consultation on another issue) and where the attending physician is paid on a per-service basis. They preferentially reject scenarios where screening results are sent by post, in particular by registered mail with acknowledgement of receipt, and where no reminders are sent following a positive test result. The results of the final model, with interactions, are also presented in Table 3. Remuneration of the attending physician for participation in the mass screening on a per-service basis (compared to no remuneration) appeared to be the preference among the respondents, even taking potential confounding factors such as socio-professional characteristics into account. The area of practice, fee category, existence of legal training or training specific to mass screening and opinion on the medico-legal risk of the programme did not influence the preferences of respondents. On the other hand, gender, age, density of doctors and support for the national programme appeared to be interaction factors in the final model, emphasising their importance for certain subgroups of professionals. Women practitioners and practitioners below the age of 46 preferred to give pre-screening information during a medical consultation organised for that purpose. Majority of women rejected mass screening without reminders sent to patients who test positive. Younger practitioners rejected remuneration on a permedical-service basis for their participation in mass screening. In areas with a low medical density, practitioners preferred to send the results by registered letter with acknowledgement of receipt more than in areas with a medium medical density. Physicians who were not in favour of mass screening would rather opt for a programme with a general practitioner as the primary-care professional in the system and without reminders following positive tests and tended to reject the idea of private interviews to give screening results.
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Table 3 Results of the final model: Main effects and interactions. Attributes
Terms
Constant
Main model (n = 326) 3306 observations
Model with interactions (n = 326) 3162 observations
Coefficients 
p
Coefficients 
p
0.4047
<0.0001
0.3838
<0.0001
Type of pre-screening information provided
Document given during another examination Brochure sent by post Specific consultation by a healthcare professional a
0.1494 0.1482 0.00001
<0.0001 <0.0001
0.2389 0.2124
<0.0001 <0.0001
How results are given
Private interview e Standard letter Registered letter with acknowledgement of receipt d
0.00001 −0.1705 −0.2598
<0.0001 <0.0001
−0.2108 −0.2902
<0.001 <0.0001
Primary care professional entrusted with monitoring
General practitioner f Management structure Specialist Nurse
0.3990 0.1086 0.0921 0.00001
<0.0001 <0.001 <0.01
0.3363 0.1155 0.0731
<0.0001 <0.001 <0.05
Remuneration
Per medical service c None Annual lump sum
0.0952 0.00001 −0.0067
<0.01
0.1292
<0.001
0.85
0.0078
0.84
Number of reminders
Several One None b
0.3032 0.00001 −0.1378
<0.0001
0.2972
<0.0001
<0.0001
−0.1130
<0.01
Interactions
Women × Specific consultation a Women × No reminder b Less than 46 years of age × Specific consultation a Less than 46 years of age × Per-medical-service remuneration c LD × Registered letter d Not in favour of mass screening × Private interview e Not in favour of mass screening × No reminder b Not in favour of mass screening × General practitioner f
0.0760 −0.1463 0.0563 −0.1347 0.0992 −0.0831 0.3842 0.3260
<0.01 <0.01 <0.05 <0.05 <0.05 <0.05 <0.0001 <0.01
Likelihood logarithm
−2165.6474
n = Number of respondents; p = Significance threshold; 1 Reference value.
4. Discussion The results of the study show that issues related to patient information and to the manner in which consent is obtained, as well as monitoring of patients taking part in the programme, have a clear impact on support for screening campaigns among general practitioners. The general practitioners who responded to this survey are in favour of mass screening (over 80% of respondents) and are keen to assert their role with the public authorities, placing themselves at the heart of the system as primary care professionals. On the other hand, the issue of remuneration does not appear to play a major role in their choice. The preferences of general practitioners appear to differ from the current organisation of colorectal cancer mass screening. Regarding pre-screening information, although general practitioners express a preference for written documents to be given to the patient, they prefer to have a private interview with their patient and to give such documents when the patient comes in for another medical consultation, rather than having the documents sent by post, which is the procedure under the national programme. This preference is even more clearly expressed when it comes to informing the patient of the result of the screening test, as general practitioners significantly reject the hypothesis of sending test results by post, whether by standard letter as it is the case in the current programme, or by registered letter with acknowledgement of receipt. Through these results, general practitioners show the support role they intend to play with their patients, both in terms of obtaining informed consent and when positive test results are announced. These results highlight their choice of being primary care professionals responsible for monitoring the screening procedure from the outset. Although they do not reject the role of the management structure, they wish to play a major role by assert-
ing their difference thanks to the privileged trust relationship they have with their patients. Contrary to the situation in England or in the United States [16], general practitioners do not wish to delegate that duty to a nurse despite the fact that there is a lack of general practitioners in some French areas. Concerning remuneration, a majority of doctors choose a fee-for-service rather than an annual lump sum, as laid down in the programme. Their reply concerning the number of reminders is the only aspect where they confirm the provisions of the current programme (the regulation was modified by order in 2013 [3]) which stipulate that if the test has not been performed, there will be at least two reminders: one 3 months later followed by a second reminder, preferably 6 months later, if there is no response. Although few respondents had benefited from legal training (less than 10%), the choices made reflect their knowledge of the rules of deontology regarding information and expression of patient wishes. These rules, enshrined in the Code of Medical Deontology (CDM), were also included in the Law of 4 March 2002 on the rights of patient [17] and were included in the regulatory section of the French Public Health Code [18]. Placing the general practitioner at the heart of the system, as recommended by the 2009–2013 Cancer Plan, therefore appears to ensure enhanced protection of patient interests and to reduce professional liability exposure for health professionals. In this way, the general practitioner is able to give the patient “accurate, clear and appropriate information” (art. 35 of the Code of Medical Deontology – art. R4127-35 of the Public Health Code) on the screening procedure. The general practitioner is in a position to specify “the usefulness, urgency, if any, consequences and normally foreseeable frequent or serious risks involved” (art L1111-2 of the Public Health Code). In case of positive test, the general practitioner is able to inform the patient of the consequences of refusal to undergo a colonoscopy (art. 36 of the Code of Deontology) and
Please cite this article in press as: Papin-Lefebvre F, et al. General practitioners’ preferences with regard to colorectal cancer screening organisation Colon cancer screening medico-legal aspects. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.08.013
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to suggest other solutions if they are possible (art L1111-2 of the Public Health Code). If new risks are identified at a later stage, he is able to contact the person again, as the Law of 4 March 2002 specifies that such information must be given during a private interview. More particularly, the long-term follow-up of the patient also allows the general practitioner to identify any changes in his state of health, making him ineligible for organised screening (persons who have a high or very high risk of colorectal cancer or who have undergone a colonoscopy in the last five years) and to inform the patient of this evolution. This pivotal role appears to be easier for general practitioners than for a management structure, which is an operational body that has no close contact with patients. To assess the reliability of results, certain limitations of the study should be taken into consideration. The major limitation of the study is the low response rate. This weakness could call into question the representativeness of the sample compared with all general practitioners, in particular given that those who responded are overwhelmingly in favour of mass screening. This means that caution should be exercised in generalising the results obtained. In our study, for example, the gender ratio of respondents is reversed compared with that of French general practitioners as a whole (approximately 54.8% are men), given that the majority of our respondents were women. The average age of respondents was also slightly above the average age of general practitioners (52) in 2010. On the other hand, the breakdown by departement of practice and density of doctors is identical to that of general practitioners as a whole. Despite the low response rate, there is no problem related to the statistical power of the study. 5. Conclusion Finally, this study reveals the preferences of the general practitioners who are most involved in participation in colorectal cancer mass screening campaigns. The results show that general practitioners fully assume the central role assigned to them by the authorities and wish to play a more important role in informing patients both upstream and downstream of screening. They are in favour of delivering the information in a single colloquium during dedicated consultations rather than by simple letters sent by the management structures currently in force. They are also in favour of maximising the number of reminders when the test has not been performed (at least two reminders: one 3 months later followed by a second reminder, preferably 6 months later, if there is no response). Finally, without this being a primary element, the study reveals an increased preference for fee-for-service payment. This result suggests that doctors have not fully adhered to the lump sum payment system adopted to compensate for their involvement in screening since 2008 and remain strongly attached to fee-forservice payment. This work suggests that general practitioners could increase their involvement in colorectal cancer screening if they were more associated with patient information at different stages of screening (inclusion in screening, announcement of the result of the test and its consequences, reminders in case of non-completion of the test or the confirmation colonoscopy).Their privileged mode of communication remains the face-to-face consultation with the patient. In a fee-for-service environment where GPs do not have any incentives for prevention related consultations, it is necessary to adjust financial incentives for screening. Further studies on the influence
of general practitioners’ remuneration mode on their involvement in the promotion of cancer screening should be conducted. This work offers avenues for reflection for improving GP’s involvement in promoting cancer screening programmes. Declaration of conflict of interest No conflict of interest declared. Acknowledgements The authors thank Marie Ingouf and Catherine Grain for entering the data. This work was supported financially by the Inca. References [1] Viguier J. L’organisation du dépistage du cancer colorectal en France (Organisation of colorectal cancer screening in France). BEH 2009; 2–3: 19–22 (www. invs.sante.fr/beh/2009). [2] French Republic Order of 29 September 2006 on cancer screening programmes. Official Journal of 21 December 2006. [3] French Republic Order of 15 April 2013 amending the Order of 29 September 2006 on mass cancer screening programmes. Official Journal of 27 April 2013. [4] InVS/Francim/Inserm/Hospices Civils de Lyon/INCa. Estimation nationale de l’incidence et de la mortalité par cancer en Franceentre 1980 et 2012. (National estimate of the impact of and mortality due to cancer in France between 1980 and 2012). July 2013. [5] European Commission European guidelines for quality assurance in colorectal cancer screening and diagnosis, 4th ed. Luxembourg: Publications Office of the European Union; 2010 www.kolorektum.cz/res/file/guidelines-EC-201102-03.pdf. [6] InVS. Taux de participation au programme de dépistage organise du cancercolorectal 2011–2012 (Level of participation in the colorectal cancer mass screening programme for 2011–2012), 26/02/2013. [7] Pornet C, Dejardin O, Morlais F, Bouvier V, Launoy G. Socioeconomic determinants for compliance to colorectal cancer screening. Journal of Epidemiology and Community Health 2010;64:318–24. [8] Poncet F, Delafosse P, Seigneurin A, Exbrayat C, Colonna M. Determinants of participation in organized colorectal cancer screening in Isère (France). Clinics and Research in Hepatology and Gastroenterology 2013;37:193–9. [9] Cole SR, Young GP, Byrne D, Guy JR, Morcom J. Participation in screening for colorectal cancer based on a faecal occult blood test is improved by endorsement by the primary care practitioner. Journal of Medical Screening 2002;9:147–52. [10] Grünfeld JP. Recommandations pour le Plan Cancer 2009–2013. Pour un nouvel élan. Rapport au Président de la République. (Recommendations for the 2009–2013 Cancer Plan. For new impetus. Report to the French President). 14 February 2009. (www.sante.gouv.fr/IMG/pdf/Rapport Grunfeldrecommandations pour la plan cancer 2009 2013 -mars 2009.pdf). [11] French Republic 2009–2013 Cancer Plan (www.plan-cancer.gouv.fr). [12] Permain D, Swanson J, Kroes E, Bradley M. Stated preferences techniques: a guide to practice. Steer Davis Gleave and Hague Consulting group; 1991. [13] Berchi C, Launoy G. Principle, strengths and weaknesses of discrete choice modelling for eliciting public preferences for health care. Revue d’Épidémiologie et de Santé Publique 2007;55:133–9. [14] Ryan M, Gerard K, Amya-Amaya M. Using discrete choice experiments to value health and health care, 1st ed. Springer: Houten (The Netherlands); 2008. [15] Moutel G, Duchange N, Jullian O, de Montgolfier S, Papin-Lefebvre F, SanchoGarnier H. Ethique et dépistage organisé du cancer du sein en France –Rapport du Groupe de réflexion sur l’éthique du dépistage (GRED). (Ethics and mass screening for breast cancer in France – Report of the Think Tank on screening ethics (GRED)). Boulogne-Billancourt: INCa – Collection Etats des lieux & des connaissances, 2012. [16] Leconte C. La place du médecin généraliste dans le dépistage des cancers de l’intestin, du sein, du col de l’utérus et de la prostate; 2011. Thèse de Doctorat en Médecine (Role of general practitioners in screening for bowel, breast, cervical and prostate cancer. Thesis for a Doctorate in Medicine). Caen. [17] French Republic Law 2002-303 of 4 March 2002 on the rights of patients and the quality of the healthcare system. Official Journal of 5 March 2002. [18] French Republic Decree 2004-802 of 29 July 2004 on parts IV and V (regulatory provisions) of the Public Health Code amending certain provisions of the code. Official Journal of 8 August 2004.
Please cite this article in press as: Papin-Lefebvre F, et al. General practitioners’ preferences with regard to colorectal cancer screening organisation Colon cancer screening medico-legal aspects. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.08.013