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Theses

Les déterminants de la prescription médicamenteuse en médecine générale

Abstract : Drug prescription is associated with health benefits but also iatrogenic, economic, environmental and ecological consequences. It plays a central role in the relationship between patient and physician. In general practice in France, 78 % to 90 % of consultations result in a drug prescription versus 72 % in Germany and 43 % in the Netherlands. The drug is a complex product subjected to contradictory industrial and public health logics. Its prescription is the result of a medical decision which takes into account, according to the evidence-basedmedicine, information science, experience of the physician and patient choices. Other determinants may influence drug prescription, as some characteristics of the disease, patients, physicians and the healthcare system. To identify these determinants, we conducted a systematic literature review searching for factors associated with the number of drugs prescribed in general practice. Then, from a nationwide epidemiological study (ECOGEN), we identified the factors related to drug prescription in general practice in France. To explore more precisely the drug prescription in patients with chronic diseases, we conducted an epidemiological study to assess the factors associated with the prescription of antibiotics and anxiolytics/hypnotics to patients with asthma in general practice in France and Italy. Finally, we studied the place of functionalities related to drug prescription in electronic health record systems in France. The literature review showed that the determinants of the number of drugs prescribed in general practice were often related to the existence of a chronic disease, the sociodemographic characteristics of patients (elderly, female gender, low socioeconomic status, low education level) and some characteristics of the physician’s such as the number of consultations per day. The epidemiological study conducted in general practice in France showed that a drug prescription was more common in women (OR: 1.12 [1.04 to 1.20]), patients aged over 60 years (OR: 1.35 [1.20 to 1.53]) or below 15 years (OR: 1.51 [1.29 to 1.78]. General practitionners receiving pharmaceutical sales representative visits were also more likely to prescribe a drug (OR: 1.19 [1.01 to 1.41]). The study comparing Italy to France showed that the French general practitioners (GPs) prescribed more anxiolytics/hypnotics (17.8% vs. 6.9%, p <0.0001) but fewer antibiotics (37.1% vs. 42.2%, p <0.00001) than the Italian GPs to asthmatic patients. This study also showed that both in France and Italy, women with asthma were more likely to be prescribed with antibiotics (OR: 1.5 [1.3-1.7]) and anxiolytics/hypnotics (OR: 1.8 [1.5-2.1]) than men with asthma. Finally the study of electronic health record systems of French GPs showed that the function for drug prescription was particularly facilitated by a structured and standardized access to drug databases, in contrast to non-drug treatments. Thus, interventions aimed at changing drug prescription in general practice must be multifaceted on patients, doctors and the environment in which they operate
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David Darmon. Les déterminants de la prescription médicamenteuse en médecine générale. Santé. Université Claude Bernard - Lyon I, 2014. Français. ⟨NNT : 2014LYO10318⟩. ⟨tel-02467763⟩

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