Balancing Equity and Efficiency in Kidney Allocation: An Overview.

Organs for transplantation are a scarce resource. Markedly, the transplant community's primary challenge is the stark disparity between the number of patients awaiting deceased donor organ transplants and the rate at which organs become available. However, the allocation of a limited number of organs poses another constant challenge: maintaining an equilibrium between renal transplant utility and equity, that is, striking a balance between the utilitarian argument of medical efficiency and the principle of equity. In this comprehensive overview, the authors delve into the challenge of maintaining an acceptable balance between equity and efficiency and elaborate on some of the factors that might inform a decisionmaker's evaluation of the extent to which a given allocation scheme is efficient or equitable.

Patient-initiated second medical consultations-patient characteristics and motivating factors, impact on care and satisfaction: a systematic review.

OBJECTIVES: To review the characteristics and motivations of patients seeking second opinions, and the impact of such opinions on patient management, satisfaction and cost effectiveness. DATA SOURCES: Embase, Medline, PsycINFO and Health Management Information Consortium (HMIC) databases. STUDY DESIGN: A systematic literature search was performed for terms related to second opinion and patient characteristics. Study quality was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. DATA COLLECTION/EXTRACTION METHODS: We included articles focused on patient-initiated second opinions, which provided quantitative data on their impact on diagnosis, treatment, prognosis or patient satisfaction, described the characteristics or motivating factors of patients who initiated a second opinion, or the cost-effectiveness of patient-initiated second opinions. PRINCIPAL FINDINGS: Thirty-three articles were included in the review. 29 studies considered patient characteristics, 19 patient motivating factors, 10 patient satisfaction and 17 clinical agreement between the first and second opinion. Seeking a second opinion was more common in women, middle-age patients, more educated patients; and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain more information or reassurance about their diagnosis or treatment. While many second opinions confirm the original diagnosis or treatment, discrepancies in opinions had a potential major impact on patient outcomes in up to 58% of cases. No studies reported on the cost effectiveness of patient initiated second opinions. CONCLUSIONS: This review identified several demographic factors associated with seeking a second opinion, including age, gender, health status, and socioeconomic status. Differences in opinion received, and in the impact of change in opinion, varies significantly between medical specialties. More research is needed to understand the cost effectiveness of second opinions and identify patient groups most likely to benefit from second opinions.

Attitudes, knowledge, and preferences of the Israeli public regarding the allocation of donor organs for transplantation.

BACKGROUND: There is a stark disparity between the number of patients awaiting deceased-donor organ transplants and the rate at which organs become available. Though organs for transplantation are assumed to be a community resource, and the organ supply depends on public willingness to donate, current allocation schemes do not explicitly incorporate public priorities and preferences. This paper seeks to provide insights regarding the Israeli public's preferences regarding criteria for organ (specifically, kidney) allocation, and to determine whether these preferences are in line with current allocation policies. METHODS: A market research company administered a telephone survey to 604 adult participants representing the Jewish-Israeli public (age range: 18-95; 50% male). The questionnaire comprised 39 questions addressing participants' knowledge, attitudes, and preferences regarding organ donation and criteria for organ allocation, including willingness to donate. RESULTS: The criteria that respondents marked as most important in prioritizing waitlist candidates were maximum medical benefit (51.3% of respondents) and waiting time (21%). Donor status (i.e., whether the candidate is registered as an organ donor) was ranked by 43% as the least significant criterion. Most participants expressed willingness to donate the organs of a deceased relative; notably, they indicated that they would be significantly more willing to donate if organ allocation policies took their preferences regarding allocation criteria into account. Unlike individuals in other countries (e.g., the UK, the US, and Australia) who responded to similar surveys, Israeli survey respondents did not assign high importance to the candidate's age (24% ranked it as the least important factor). Interestingly, in some cases, participants' declared preferences regarding the importance of various allocation criteria diverged from their actual choices in hypothetical organ allocation scenarios. CONCLUSIONS: The findings of this survey indicate that Israel's citizens are willing to take part in decisions about organ allocation. Respondents did not seem to have a strict definition or concept of what they deem to be just; yet, in general, their preferences are compatible with current policy. Importantly, participants noted that they would be more willing to donate organs if their preferences were integrated into the allocation policy. Accordingly, we propose that allocation systems must strive to respect community values and perceptions while maintaining continued clinical effectiveness.

Second opinion utilization by healthcare insurance type in a mixed private-public healthcare system: a population-based study.

OBJECTIVES: To evaluate the utilisation (overall and by specialty) and the characteristics of second-opinion seekers by insurance type (either health fund or supplementary insurance) in a mixed private-public healthcare. DESIGN: An observational study. SETTING: Secondary care visits provided by a large public health fund and a large supplementary health insurance in Israel. PARTICIPANTS: The entire sample included 1 392 907 patients aged 21 years and above who visited at least one specialist over an 18 months period, either in the secondary care or privately via the supplementary insurance. OUTCOMES MEASURES: An algorithm was developed to identify potential second-opinion instances in the dataset using visits and claims data. Multivariate logistic regression was used to identify characteristics of second-opinion seekers by the type of insurance they used. RESULTS: 143 371 (13%) out of 1 080 892 patients who had supplementary insurance sought a single second opinion, mostly from orthopaedic surgeons. Relatively to patients who sought second opinion via the supplementary insurance, second-opinion seekers via the health fund tended to be females (OR=1.2, 95% CI 1.17 to 1.23), of age 40-59 years (OR=1.36, 95% CI 1.31 to 1.42) and with chronic conditions (OR=1.13, 95% CI 1.08 to 1.18). In contrast, second-opinion seekers via the supplementary insurance tended to be native-born and established immigrants (OR=0.79, 95% CI 0.76 to 0.84), in a high socioeconomic level (OR=0.39, 95% CI 0.37 to 0. 4) and living in central areas (OR=0.88, 95% CI 0.85 to 0.9). CONCLUSIONS: Certain patient profiles tended to seek second opinions via the supplementary insurance more than others. People from the centre of the country and with a high socioeconomic status tended to do so, as medical specialists tend to reside in central urban areas. Further research is recommended to examine the availability of medical specialists by specialty and residence.

Reasons, perceived outcomes and characteristics of second-opinion seekers: are there differences in private vs. public settings?

BACKGROUND: In most countries, patients can get a second opinion (SO) through public or private healthcare systems. There is lack of data on SO utilization in private vs. public settings. We aim to evaluate the characteristics of people seeking SOs in private vs. public settings, to evaluate their reasons for seeking a SO from a private physician and to compare the perceived outcomes of SOs given in a private system vs. a public system. METHODS: A cross-sectional national telephone survey, using representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, on the same medical concern. We modeled SO utilization in a public system vs. a private system by patient characteristics using a multivariate logistic regression model. RESULTS: 214 of 339 respondents who obtained a SO during the study period, did so in a private practice (63.1%). The main reason for seeking a SO from a private physician rather than a physician in the public system was the assumption that private physicians are more professional (45.7%). However, respondents who obtained a private SO were neither more satisfied from the SO (p = 0.45), nor felt improvement in their perceived clinical outcomes after the SO (p = 0.37). Low self-reported income group, immigrants (immigrated to Israel after 1989) and religious people tended to seek SOs from the public system more than others. CONCLUSIONS: The main reason for seeking a SO from private physicians was the assumption that they are more professional. However, there were no differences in satisfaction from the SO nor perceived clinical improvement. As most of SOs are sought in the private system, patient misconceptions about the private market superiority may lead to ineffective resource usage and increase inequalities in access to SOs. Ways to improve public services should be considered to reduce health inequalities.

Seeking a second medical opinion: composition, reasons and perceived outcomes in Israel.

BACKGROUND: Seeking a second-opinion (SO) is a common clinical practice that can optimize treatment and reduce unnecessary procedures and risks. We aim to characterize the composition of the population of SO seekers, their reasons for seeking a SO and choosing a specific physician, and their perceived outcomes following the SO. METHODS: A cross-sectional national telephone survey, using a representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, for the same medical concern. We describe the characteristics of respondents who obtained SOs, their reasons for doing so and their perceived outcomes: (1) Satisfaction with the SO; (2) Experiencing health improvement after receiving a SO; (3) A difference in the diagnosis or treatment suggested in the first opinions and the second opinions; (4) Preference of the SO over the first one. RESULTS: Most of the respondents who sought a SO (n = 344) were above 60 years old, secular, living with a partner, perceived their income to be above average and their health status to be not so good. For the patients who utilized SOs, orthopedic surgeons were sought out more than any other medical professional.Reasons for seeking a SO included doubts about diagnosis or treatment (38%), search for a sub-specialty expert (19%) and dissatisfaction with communication (19%). SO seekers most frequently chose a specific specialist based on a recommendation from a friend or a relative (33%). About half of the SO seekers also searched for information on the internet. Most of the respondents who sought a SO mentioned that they were satisfied with it (84%), felt health improvement (77%), mentioned that there was a difference between the diagnosis or treatment between the first opinion and the SO (56%) and preferred the SO over the first one (91%). CONCLUSIONS: Clinical uncertainty or dissatisfaction with patient-physician communication were the main reasons for seeking a SO. Policy makers should be aware that many patients choose a physician for a SO based on recommendations made outside the medical system. We recommend creating mechanisms that help patients in the complicated process of seeking a SO, suggest specialists who are suitable for the specific medical problem of the patient, and provide tools to reconcile discrepant opinions.

Second Medical Opinion: Utilization Rates and Characteristics of Seekers in a General Population.

BACKGROUND: Second opinion (SO) is common in medical practice and can reduce unnecessary risks and costs. To date, there is no population-based estimation of how many people seek SOs and what the characteristics of second-opinion seekers are. OBJECTIVES: To estimate how many people seek SOs, and what the characteristics of second-opinion seekers are. METHODS: We conducted both a medical records analysis (n=1,392,907) and a cross-sectional national telephone survey with a representative sample of the general Israeli population (n=848, response rate=62%). In the medical records analysis, we linked consultations with specialists at community secondary care and private consultations using claims data. We developed a time-sensitive algorithm that identified potential SO instances. In both methods, we predicted the characteristics of second-opinion seekers using multivariate logistic regressions. RESULTS: The medical records analysis and the survey findings were highly consistent, and showed that about sixth (14.9% in the medical records vs. 17.2% in the survey) of a general population sought a SO, mostly from orthopedic surgeons. Women, native-born, and established immigrants, people living in central urban areas or close to central urban areas, people with chronic conditions, and those who perceived their health status as not very good, were more likely to seek SOs than others. CONCLUSIONS: A considerable amount of people sought a SO. Certain patient profiles tended to seek SOs more than others. Such utilization patterns are important to devise policy regarding SOs, due to their implications on expenditure, policy, clinical outcomes, and patient satisfaction.

Enhancing patient-doctor-computer communication in primary care: towards measurement construction.

OBJECTIVE: The traditional dyadic dynamics of the medical encounter has been altered into a triadic relationship by introducing the computer into the examination room. This study defines Patient-Doctor-Computer Communication (PDCC) as a new construct and provides an initial validation process of an instrument for assessing PDCC in the computerized exam room: the e-SEGUE. MATERIAL AND METHODS: Based on the existing literature, a new construct, PDCC, is defined as the physician's ability to provide patient-centered care while using the computer during the medical encounter. This study elucidates 27 PDCC-related behaviors from the relevant literature and state of the art models of PDCC. These were embedded in the SEGUE communication assessment framework to form the e-SEGUE, a communication skills assessment tool that integrates computer-related communication skills. Based on Mackenzie et al.'s methodological approach of measurement construction, we conducted a two-phased content validity analysis by a general and expert panels of the PDCC behaviors represented in the e-SEGUE. This study was carried out in an environment where EMR use is universal and fully integrated in the physicians' workflow. RESULTS: The panels consisted of medical students, residents, primary care physicians, healthcare leaders and faculty of medicine members, who rated and provided input regarding the 27 behaviors. Overall, results show high level of agreement with 23 PDCC-related behaviors. CONCLUSION: The PDCC instrument developed in this study, the e-SEGUE, fared well in a rigorous, albeit initial, validation process has a unique potential for training and enhancing patient-doctor communication (PDC) in the computerized examination room pending further development.

Role of intervention programs to increase influenza vaccination in Israel.

BACKGROUND: Influenza vaccination is the most efficient and cost-effective method to prevent influenza. To increase vaccination coverage, health authorities use various intervention programs (IPs), such as cost subsidies or placing vaccination centers in malls to make vaccination more accessible. Nevertheless, vaccination coverage has been sub-optimal in most developed countries, including in Israel. METHODS: To determine possible drivers of individual vaccination uptake and to examine the effectiveness of different IPs in increasing vaccination, we analyzed a telephone survey of a representative sample of the Israeli population conducted in March 2011 (n = 470), and paper questionnaires at the work place and at homes during April-July 2011 to several sub-populations : soldiers (n = 81), medical staff (n = 107), ultra-orthodox Jews (n = 72), Israeli Arabs (n = 87) and students (n = 85). RESULTS: The population can be stratified into three sub-groups: Acceptors, who receive vaccination regardless of IPs (22%), Conditional Acceptors, who are only vaccinated because of IP implementation (44%) and Non-Acceptors, who are not vaccinated despite IP implementation (34%). Our analysis shows that the risk perception towards influenza relative to vaccination is higher in the Acceptors than in the Conditional Acceptors, with the Non-Acceptors showing the lowest risk perception (P < 0.01). For Conditional Acceptors, physician recommendation is the most effective IP, regardless of the sub-population tested (P = 0.04). Students and low-income participants were more prone than any others to be persuaded to receive vaccination following IPs. In addition, financial incentives were more effective for ultra-religious orthodox Jews and students; vaccinations in more accessible areas were more effective for the ultra-religious orthodox, soldiers, and medical personnel; and TV and radio advertisements were more effective for people above 50 relative to other age groups. CONCLUSIONS: Risk perception of influenza and vaccination governs the likelihood of successful implementation of IPs. Policy makers in Israel should invest efforts to increase the knowledge regarding influenza and vaccination, and should apply specific interventions customized to the preferences and diverse perceptions among the Israeli sub-populations.

An innovative influenza vaccination policy: targeting last season's patients.

Influenza vaccination is the primary approach to prevent influenza annually. WHO/CDC recommendations prioritize vaccinations mainly on the basis of age and co-morbidities, but have never considered influenza infection history of individuals for vaccination targeting. We evaluated such influenza vaccination policies through small-world contact networks simulations. Further, to verify our findings we analyzed, independently, large-scale empirical data of influenza diagnosis from the two largest Health Maintenance Organizations in Israel, together covering more than 74% of the Israeli population. These longitudinal individual-level data include about nine million cases of influenza diagnosed over a decade. Through contact network epidemiology simulations, we found that individuals previously infected with influenza have a disproportionate probability of being highly connected within networks and transmitting to others. Therefore, we showed that prioritizing those previously infected for vaccination would be more effective than a random vaccination policy in reducing infection. The effectiveness of such a policy is robust over a range of epidemiological assumptions, including cross-reactivity between influenza strains conferring partial protection as high as 55%. Empirically, our analysis of the medical records confirms that in every age group, case definition for influenza, clinical diagnosis, and year tested, patients infected in the year prior had a substantially higher risk of becoming infected in the subsequent year. Accordingly, considering individual infection history in targeting and promoting influenza vaccination is predicted to be a highly effective supplement to the current policy. Our approach can also be generalized for other infectious disease, computer viruses, or ecological networks.

Existing instruments for assessing physician communication skills: are they valid in a computerized setting?

OBJECTIVES: This study aims to highlight the differences in physicians' scores on two communication assessment tools: the SEGUE and an EMR-specific communication skills checklist. The first tool ignores the presence of the EMR in the exam room and the second, though not formally validated, rather focuses on it. METHODS: We use the Wilcoxon Signed Ranks Test to compare physicians' scores on each of the tools during 16 simulated medical encounters that were rated by two different raters. RESULTS: Results show a significant difference between physicians' scores on each tool (z=-3.519, p<0.05 for the first rater, and z=-3.521, p<0.05 for the second rater), while scores on the EMR-specific communication skills checklist were significantly and consistently lower. CONCLUSION: These results imply that current communication assessment tools that do not incorporate items that are relevant for communication tasks during EMR use may produce inaccurate results. PRACTICE IMPLICATIONS: We therefore suggest that a new instrument, possibly an extension of existing ones, should be developed and empirically validated.

Orthopedic surgeons' and neurologists' attitudes towards second opinions in the Israeli healthcare system: a qualitative study.

BACKGROUND: Second opinion is a treatment ratification tool that may critically influence diagnosis, treatment, and prognosis. Second opinions constitute one of the largest expenditures of the supplementary health insurance programs provided by the Israeli health funds. The scarcity of data on physicians' attitudes toward second opinion motivated this study to explore those attitudes within the Israeli healthcare system. METHODS: We interviewed 35 orthopedic surgeons and neurologists in Israel and qualitatively analyzed the data using the Grounded Theory approach. RESULTS: As a common tool, second opinion reflects the broader context of the Israeli healthcare system, specifically tensions associated with health inequalities. We identified four issues: (1) inequalities between central and peripheral regions of Israel; (2) inequalities between private and public settings; (3) implementation gap between the right to a second opinion and whether it is covered by the National Health Insurance Law; and (4) tension between the authorities of physicians and religious leaders. The physicians mentioned that better mechanisms should be implemented for guiding patients to an appropriate consultant for a second opinion and for making an informed choice between the two opinions. CONCLUSIONS: While all the physicians agreed on the importance of the second opinion as a tool, they raised concerns about the way it is provided and utilized. To be optimally implemented, second opinion should be institutionalized and regulated. The National Health Insurance Law should strive to provide the mechanisms to access second opinion as stipulated in the Patient's Rights Law. Further studies are needed to assess the patients' perspectives.

Patient-physician relationships in second opinion encounters - the physicians' perspective.

Theories on the patient-physician relationship have evolved within the last decades to portray a nuanced picture of the traditional patient-physician "dyad". Shifts in social, economic, and technological contexts in which the physician-patient encounters are taking place raised the need for more complex frameworks to study patient-physician encounters. One example of a change to this dyad is the increasing use of second opinions. The second opinion is a ratification tool that critically influences diagnosis, treatment, and prognosis. There are scarce data on the patient-physician relationship in second opinions, specifically from the physician's perspective. We studied the physicians' attitudes toward second opinion encounters. We interviewed 35 orthopedic surgeons and neurologists in Israel, and performed a qualitative analysis of the data using the Grounded Theory approach. The findings exemplify how physicians struggle between their perceived professional image and their vulnerability, as they are sometimes disappointed, offended, embarrassed and resent their patients, and how they strive to preserve their professional authority and autonomy through allegedly 'paternalistic' behavior. The physicians portrayed their patients as striving to conceal the two physicians from each other, creating two dyads that rarely develop into a triad. Along the asymmetry inherent to the patient-physician relationship, we found that physicians and assumedly their patients share symmetric motives and behaviors. We identify two continuums that physicians, and apparently their patients, experience between their different sources of power (whether professional or consumerist), creating a covert conflict over power and control, and between loyalty and autonomy. Finally, we suggested a humanistic approach to understanding physician and patient behavior, based on mutual recognition of needs. Physicians and patients can benefit from communicating openly, positively and respectfully in second opinion encounters. Perceiving the second opinion as a legitimate and empowering tool, that strengthens and widens the patient-physician relationship, instead of weakening it, may result in greater satisfaction on both sides, both for the clinical decision and for a healthy patient-physician relationship.

Do first opinions affect second opinions?

BACKGROUND: Second medical opinions have become commonplace and even mandatory in some health-care systems, as variations in diagnosis, treatment or prognosis may emerge among physicians. OBJECTIVE: To evaluate whether physicians' judgment is affected by another medical opinion given to a patient. DESIGN: Orthopedic surgeons and neurologists filled out questionnaires presenting eight hypothetical clinical scenarios with suggested treatments. One group of physicians (in each specialty) was told what the other physician's opinion was (study group), and the other group was not told what it was (control group). PARTICIPANTS: A convenience sample of 332 physicians in Israel: 172 orthopedic surgeons (45.9% of their population) and 160 neurologists (64.0% of their population). MEASUREMENTS: Scoring was by choice of less or more interventional treatment in the scenarios. We used χ(2) tests and repeated measures ANOVA to compare these scores between the two groups. We also fitted a cumulative ordinal regression to account for the dependence within each physician's responses. RESULTS: Orthopedic surgeons in the study group chose a more interventionist treatment when the other physician suggested an intervention than those in the control group [F (1, 170) =4.6, p=0.03; OR=1.437, 95% CI 1.115-1.852]. Evaluating this effect separately in each scenario showed that in four out of the eight scenarios, they chose a more interventional treatment when the other physician suggested an intervention (scenario 1, p=0.039; scenario 2, p<0.001; scenario 3, p=0.033; scenario 6, p<0.001). These effects were insignificant among the neurologists [F (1,158) =0.44, p=0.51; OR=1.087, 95% CI 0.811-1.458]. In both specialties there were no differences in responses by level of clinical experience [orthopedic surgeons: F (2, 166) =0.752, p=0.473; neurologists: F (2,154) =1.951, p=0.146]. CONCLUSIONS: The exploratory survey showed that in some cases physicians' judgments may be affected by other physicians' opinions, but unaffected in other cases. Weighing previous opinions may yield a more informed clinical decision, yet physicians may be unintentionally influenced by previous opinions. Second opinion has the potential to improve the clinical decision-making processes, and mechanisms are needed to reconcile discrepant opinions.

[Second medical opinions].

Second opinion is a decision-support tool for ratification or modification of a suggested treatment, by another physician. Second opinion may have a critical influence on the diagnosis, treatment and prognosis. The patient can benefit from treatment optimization and avoid unnecessary risks. The physician can benefit from less exposure to legal claims, and healthcare organizations can benefit from increased treatment, quality assurance and costs saving from unnecessary surgery and treatments. Nevertheless, injudicious use of this tool can provoke unnecessary medical costs. In recent years, many patients prefer to seek a second opinion on their disease and available treatments. Private and public insurance companies are trying to control surgery costs by urging and even demanding a second opinion before surgery. Although second opinions are common in medical practice, relatively little is known on this subject. Most of the studies reviewed in this article evaluated the clinical benefit of second opinions, the reasons patients seek a second opinion and the characteristics of these patients, as well as technological interventions to promote second opinions, and ethical or legal issues related to second opinions. Yet, there are opportunities for further studies about physicians attitudes and barriers towards second opinions, their effect on patient-physician communication and cost-effectiveness analyses of second opinions. Due to the relevance of second opinions for public heath, this review aims to summarize the current research on second opinions.

Optimal timing of joint replacement using mathematical programming and stochastic programming models.

The optimal timing for performing radical medical procedures as joint (e.g., hip) replacement must be seriously considered. In this paper we show that under deterministic assumptions the optimal timing for joint replacement is a solution of a mathematical programming problem, and under stochastic assumptions the optimal timing can be formulated as a stochastic programming problem. We formulate deterministic and stochastic models that can serve as decision support tools. The results show that the benefit from joint replacement surgery is heavily dependent on timing. Moreover, for a special case where the patient's remaining life is normally distributed along with a normally distributed survival of the new joint, the expected benefit function from surgery is completely solved. This enables practitioners to draw the expected benefit graph, to find the optimal timing, to evaluate the benefit for each patient, to set priorities among patients and to decide if joint replacement should be performed and when.

Electronic notifications about drug substitutes can change physician prescription habits: a cross-sectional observational study.

BACKGROUND: A health maintenance organization (HMO) provides physicians with electronic notifications regarding HMO-recommended drug substitutes. OBJECTIVE: Investigating factors affecting physicians' compliance and evaluating associated cost savings. DESIGN: A cross-sectional observational study of all physicians in the HMO's clinics from June 2005 to February 2006. SETTING: Recording physician ID, initial drug choice, final drug choice, elapsed time between initial and final choices, and pharmacological details. PARTICIPANTS: Out of 2120 physicians, 647 physicians met the inclusion criteria. They prescribed 1.21 million prescriptions. INTERVENTION: Transparently recording physicians' response to HMO-recommended drug substitutes within a drug-prescription sub-system of an electronic medical record. MEASUREMENTS: Compliance pattern, factors affecting compliance, and cost savings associated with compliance. RESULTS: Thirty percent of prescriptions did not comply with substitute recommendations. Compliance was most strongly affected by the substitute type, whether generic or therapeutic. Physician workload and age were found second and third in effect magnitude. Compliance was found to be non-automatic, selective and deliberate, suggesting that maintaining quality of care guides physicians in the prescription process. At least 4% of costs for prescribed drugs were saved as a result of compliance with substitute recommendations. CONCLUSIONS: Physicians selectively complied with electronic recommendations to substitute less costly for more costly drugs. Compliance was neither automatic nor thoughtless and entailed cost containment with possibly marginal compromise on quality of care or none at all, as compliance mostly involved substituting generic for patent drugs. We strongly feel that the results can be generalized to other HMOs as well.

[Can linking co-payment for drugs to evidence on treatment value improve health outcomes and contain healthcare costs?].

Co-payment strategies are frequently used by health insurers as a measure of containing healthcare costs. However, co-payments may reduce the use of essential drugs in chronically-ill patients. Recently, value-based insurance designs, where co-payments rates are determined by the value of the treatment, have been introduced in the United States. This review summarizes the results of recent studies in the United States, suggesting that reducing co-payments for highly valued treatments and raising co-payments for less effective treatments can lead to better compliance and better outcomes, with the potential of reducing long-term costs. Further research is needed to examine the feasibility of this approach and the long-term impact on quality of care and treatment costs in other healthcare systems, including Israel.

The process of updating the National List of Health Services in Israel: is it legitimate? Is it fair?

OBJECTIVE: The Israeli National Health Insurance Law stipulates a National List of Health Services (NLHS) to which all residents are entitled from their HMOs. This list has been updated annually for almost a decade using a structured review and decision-making process. Although this process has been described in detail in previous papers, none of these have fully addressed legitimacy and fairness. We examine the legitimacy and fairness of the process of updating the NLHS in Israel. METHODS: We assessed the priority-setting process for compliance with the four conditions of accountability for reasonableness outlined by Daniels and Sabin (relevance, publicity, appeals, and enforcement). These conditions emphasize transparency and stakeholder engagement in democratic deliberation. RESULTS: Our analysis suggests that the Israeli process for updating the NLHS does not fulfill the appeals and enforcement conditions, and only partially follows the publicity and relevance conditions, outlined in the accountability for reasonableness framework. The main obstacles for achieving these goals may relate to the large number of technologies assessed each year within a short time frame, the lack of personnel engaged in health technology assessment, and the desire for early adoption of new technologies. CONCLUSIONS: The process of updating the NLHS in Israel is unique and not without merit. Changes in the priority-setting process should be made to increase its acceptability among the different stakeholders.

Peer review in publication: factors associated with the full-length publication of studies presented in abstract form at the annual meeting of the Society for Medical Decision Making.

BACKGROUND: : Many studies are presented at scientific meetings and are summarized in abstract form prior to their full-length publication. Publication rates of these studies may be an indicator in judging their quality. OBJECTIVES: To determine the rate at which studies reported in an abstract form are subsequently published in full length and identify factors associated with publication success. METHODS: : All abstracts presented at the 25th Annual Meeting of SMDM in October 2003 were reviewed and assessed for subsequent publication in peer-reviewed journals through December 31, 2007. For each abstract we recorded the presenting author's affiliation, presentation mode, and country of origin. For published articles, we recorded the publication date, type of journal, and the journal's impact factor. We calculated the mean and median time from conference presentation to publication using a Kaplan-Meier survival analysis. RESULTS: : Of 239 presented abstracts, 64 (27%) were subsequently published in full-length, including 39% of podium, and 20% of poster presentations (P = 0.002). Mean and median times from presentation to publication were 20.5 and 19.0 months, respectively. There was no significant difference in mean publication lag for podium and poster presentations. CONCLUSIONS: : A significant proportion of studies presented at the SMDM meeting are not published in full length. This failure to publish is substantially higher as compared with findings from other medical and biomedical meetings. A further study is needed to explore the reasons for this low publication rate and to compare the fate of SMDM meeting abstracts to those of similar conferences.