Comportements et pratiques des médecins : exercer dans les zones les moins dotées, cela fait-il une différence ?

Abstract

Selon les projections récentes, les effectifs de médecins libéraux diminueront de 30 % d'ici à 2027 et la densité standardisée diminuerait jusqu'en 2023, créant des poches de sous-densité relativement nombreuses sur le territoire français métropolitain. L'article s'intéresse aux ajustements que les médecins généralistes de ville mettent en oeuvre lorsque, sur leur territoire, ils sont d'ores et déjà confrontés à cette raréfaction. Les données utilisées sont celles du troisième panel des médecins généralistes enrichies d'indicateurs fournies par la CNAMTS. Nous nous sommes appuyés sur l'indicateur d'accessibilité potentielle localisé, développé par l'IRDES et la DREES pour définir les zones les moins dotées en généralistes. En comparant les comportements des généralistes exerçant dans les zones les moins dotées à leurs homologues des zones mieux dotées, il est apparu d'abord que le planning d'activité du médecin s'intensifie : nos données semblent en effet montrer que les rythmes de consultation dans les zones les moins dotées sont plus élevés, alors que le temps de travail global des généralistes s'avère peu réactif à la densité en médecins alentour. On note aussi quelques différences statistiquement significatives sur les pratiques médicales : usage de certains médicaments, renvoi vers des soins paramédicaux, suivis gynécologique probablement un peu moins réguliers, etc. Cependant, il semble que les différences ne sont pas statistiquement significatives pour les indicateurs de qualité des pratiques rattachés au dispositif de rémunération sur objectifs de santé publique (ROSP).

Can General Practitioners Be More Productive? The Impact of Teamwork and Cooperation with Nurses on GP Activities

“…Based on the theoretical literature and considering some specifics of the Asalée pilot experiment, such as the heterogeneity in the intensity and nature of cooperation between GP-AN pairs, we consider the following hypotheses concerning the impact of teamwork, skill mixing and cooperation between GPs and ANs: � GPs reallocate any medical time saved due to cooperation with ANs to address unmet healthcare needs, either by providing new care and services to new patients or to patients with chronic diseases or high needs. Indeed, the documentation of adverse consequences on GPs' workloads of the primary healthcare supply shortage and geographic imbalance in France supports this assumption: in underserved areas, quality of care, including for prevention, is lower than that in other areas (Chaput et al, 2020;Silhol, Ventelou, Zaytseva, & Marbot, 2019). On average, visits are shorter and end with less education and counseling, the waiting time between appointments is longer (lower temporal accessibility of GPs), and patients have much more difficulty in registering with a GP gatekeeper or benefiting from unplanned visits when the workload for GPs is very high; � The impact on GPs' activities is larger in underserved areas, where the demand is more constrained; � The impact is larger for GP-AN pairs for which cooperation is effective; � In addition, since we cannot observe the duration of the visit, which may be influenced by the pilot experiment, we assume a constant visit duration over the period to test these hypotheses.…”

“…GPs reallocate any medical time saved due to cooperation with ANs to address unmet healthcare needs, either by providing new care and services to new patients or to patients with chronic diseases or high needs. Indeed, the documentation of adverse consequences on GPs' workloads of the primary healthcare supply shortage and geographic imbalance in France supports this assumption: in underserved areas, quality of care, including for prevention, is lower than that in other areas (Chaput et al., 2020; Silhol, Ventelou, Zaytseva, & Marbot, 2019). On average, visits are shorter and end with less education and counseling, the waiting time between appointments is longer (lower temporal accessibility of GPs), and patients have much more difficulty in registering with a GP gatekeeper or benefiting from unplanned visits when the workload for GPs is very high;…”

How French general practitioners respond to declining medical density: a study on prescription practices, with an insight into opioids use

“…It is therefore vital to better understand how GPs located in relatively underserved areas are adapting their practices. Despite numerous studies comparing healthcare access in rural and urban settings [13][14][15], both in low-and high-income countries, there have been very few comprehensive quantitative studies linking healthcare professional shortages with the quantity and quality of care received by local populations [16][17][18].…”