Critères qualités de la gestion des visites à domicile du médecin généraliste : revue systématique de la littérature

Abstract : Background: In 2001, France was the largest consumer of physician-conducted home visits in Europe. Between 2002 and 2003, France witnessed a reduction of 20% of physicians home visits. GP committed to reduce the number of their home visits in return of a fee increase. Home visit can offer a valuable supplement to the informations collected at the medical office. Nonetheless, physicians consider it as a time consuming and a low-profitable care.
Objective: To identify the elements that improve the quality of healthcare delivered by the GPs in home visits, and their alternatives.The secondary objectives are: propose home visit’s quality criteria to improve home health care management and to propose a quality framework for home care visits.
Methods: Literature review using the PRISMA method by querying 2 databases (Medline, Cochrane) with no time limit until October 2017. References of the included articles and of the grey literature were examined manually. The European and anglo-saxon institutional databases were handsearched.
Results: 37 documents were identified. The majority were randomized controller (n= 12), followed by systematic reviews (n= 11), expert guidelines (n= 8), observational studies (n= 4), cross-sectional mail surveys (n= 2). Telephone counselling and nurse triage reduced the number of GP visits by 39% (p<0.001). Home follow-up for people over 65 years of age after a hospitalization by a general practitioner and/or a nurse led to a decrease in admissions to retirement homes (p<0.05) and decrease in the number of re-hospitalizations (p= 0.03, RRR 23%). Seniors refusing "preventive" home visits had a higher mortality and admission rate to retirement homes ((RR= 1,5 (IC 95%= 1,3-1,7, p<0,0001)). Telemonitoring is an alternative to home visiting, reducing mortality from all causes (RR 0.66, 95% CI (0.54 - 0.81) p<0.0001)). Telemonitoring (p = 0.008) and telephone support (p <0.0001), reduced the rate of hospitalization for chronic heart failure. Systematic visits after hospital discharges did not significatly improve the patients quality of life, neither influenced the use of emergency services and/or hospitalizations.
Conclusion: We have identified different criteria to improve the quality of home visits. Those allowing to reduce the workload of the general practitioner, such as the use of online appointment services, the telephone triage delegated to a trained nurse under medical supervision. Communicating effectively the reason behind home visits demands allows the GP to optimize his activity. The coordinated home monitoring between a general practitioner and a nurse reduces the rate of readmissions to retirement homes, the rate of re-hospitalization and the number of emergency services. Moreover, assessing patients home-based lifestyle completes the data collected during the consultations in the office. In France, there is a lack of home visits guidelines. The evidence provided by this work remains weak. Thus, the repository proposed by this review should be evaluated to prove its usefulness in the management of home visits.
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Master Thesis
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Leslie Rogeau. Critères qualités de la gestion des visites à domicile du médecin généraliste : revue systématique de la littérature. Médecine humaine et pathologie. 2018. ⟨dumas-01975649⟩

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