title: Determinants of preventive services in general practice. A multilevel approach in cardiovascular domain and vaccination in France.
abstract: BACKGROUND
  France is in Europe, the country in which the mortality due to potentially preventable causes is the highest. At the same time, French doctors receive no incentives to undertake prevention activities. This article examined the general practitioners' (GPs) determinants (characteristics, patient list and contextual factors) of cardiovascular prevention and vaccination carried out by GPs in their offices.
  
  
  METHODS
  Data were collected from 105,726 patients followed by 86 GPs (observational study). A multilevel analysis with two levels: GP and patient (HLM) was performed.
  
  
  RESULTS
  A high between-GP variability of the prevention activity is underlined in both domains. After controlling for patient characteristics, we observed a positive effect of the GP's workload (ORa=1.03) and of an elderly GP's patient list (ORa=1.04) on cardiovascular prevention, a positive effect of a patient list with a high level of health care consumption on vaccination activity (ORa=1.04). The significant influence of contextual factors is ever more demonstrative: the ORa is 1.3 times lower in cardiovascular prevention and 1.6 in vaccination when the density of GPs in the local community of the doctor's practice grows of one-point (1/1000); the ORa is two times lower in both cardiovascular prevention and vaccination for GPs having an urban practice.
  
  
  CONCLUSIONS
  These results emphasize the need for taking into account contextual factors to implement prevention policies in primary care. But further studies of this type should be conducted by taking other variables into account in order to improve the proportion of variance explained in our models.
authors.affiliation: CERMES, INSERM U 750 (National Institute of Health and Medical Research), 80 rue du Général Leclerc, 94276 Le Kremlin Bicêtre Cedex, France. fleury@kb.inserm.fr
authors.forename: Nathalie
authors.initials: N
authors.lastname: Pelletier-Fleury
authors.forename: Marc
authors.initials: M
authors.lastname: Le Vaillant
authors.forename: Gilles
authors.initials: G
authors.lastname: Hebbrecht
authors.forename: Philippe
authors.initials: P
authors.lastname: Boisnault
mesh_terms: D000293:Adolescent; D000328:Adult; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D005194:Family Practice; D005260:Female; D005602:France; D006801:Humans; D008297:Male; D032541:Mass Vaccination / Q000706:statistics & numerical data*; D008875:Middle Aged; D019370:Observation; D011315:Preventive Medicine