Standard strategies for diagnosis and treatment of patients with newly diagnosed Parkinson disease

In France, newly diagnosed patients with Parkinson disease (PD) are mostly referred by a general practitioner (GP) to a public (hospital-based) or private practice neurologist for confirmation of the diagnosis and treatment initiation. Most neurologists rely on a clinical evaluation according to National Health Authority (HAS) recommendations and guidelines.1 MRI scans and dopamine transporter imaging are increasingly being performed for the differential diagnosis of atypical parkinsonism, for drug-induced parkinsonism and tremor, in early-onset patients, or to deal with the anxiety of patients and their families. Clinical scales such as the Unified Parkinson's Disease Rating Scale are scarcely used in routine practice. Therapeutic strategies are not or little affected by who is covering the cost of treatment or by how medical facilities and professionals are reimbursed, ensuring that health care guidelines are usually respected. Indeed, the expenses for drugs and other inpatient and ambulatory health care are almost fully covered by the health insurance within the frame of chronic diseases (“Affection de longue durée n°16”), providing that the parkinsonian syndrome is irreversible and requires the administration of antiparkinsonian drugs for at least 6 months. Some newly diagnosed patients, before being registered by the free care system for chronic diseases, may only have partial coverage of costs (65%). However, most of them have complementary private insurance allowing full reimbursement of their expenses.

There may be some disparities between patients living in urban vs rural areas regarding the ease or delay of being referred to a neurologist or tertiary center, particularly in remote rural areas. Treatment initiation by French neurologists depends upon age, severity, comorbidities, and the neurologist's own experience and beliefs. A direct influence of the marketing of drug companies may exist, but things are changing with new laws emerging that regulate the relationship between the industry and doctors. Most neurologists follow national guidelines (HAS 2000, 2012) recommending that young patients (<60–65 years old) be started with dopamine agonists or monoamine oxidase B inhibitors and older patients be started with standard levodopa + dopa decarboxylase inhibitor. Recent concerns about behavioral side effects of dopamine agonists and the broadcasting of related medicolegal issues have certainly had an effect on the neurologist's choice for treatment initiation.

Follow-up is usually performed every 3 to 6 months in outpatient hospital-based or private practice neurology clinics depending on the therapeutic strategy, the drug response, and side effects. When a patient with PD is followed by a neurologist, the GP usually does not interfere too much with the antiparkinsonian treatment besides minor adjustments or emergencies.

The landscape of medico-social care for PD is currently changing in France with the recent funding of 24 regional expert and 7 interregional coordinating centers that cover the entire national territory. The mission of the expert centers is to organize and coordinate multidisciplinary and personalized care, to implement patient education, and to disseminate good practice tools for improving the care of PD beyond the expert centers and their networks.

Correspondence to: francois.tison@chu-bordeaux.fr