Medical Practice Variation Among Primary Care Physicians: 1 Decade, 14 Health Services, and 3,238,498 Patient-Years.

PURPOSE: Variation in medical practice is associated with poorer health outcomes, increased costs, disparities in care, and increased burden on the public health system. In the present study, we sought to describe and assess inter- and intra-primary care physician variation, adjusted for patient and clinic characteristics, over a decade of practice and across a broad range of health services. METHODS: We assessed practice patterns of 251 primary care physicians in southern Israel. For each of 14 health services (imaging tests, cardiac tests, laboratory tests, and specialist visits) we described interphysician and intraphysician variation, adjusted for patient case mix and clinic characteristics, using the coefficient of variation. The adjusted rates were assessed by generalized linear negative-binomial mixed models. RESULTS: The variation between physicians was on average 3-fold greater than the variation of individual physician practice over the years. Services with low utilization were associated with greater inter- and intraphysician variation: rs = (-0.58), P = .03 and rs = (-0.39), P = .17, respectively. In addition, physician utilization ranks averaged over all health services were consistent across the 14 health services (intraclass correlation coefficient, 0.94; 95% CI, 0.93-0.95). CONCLUSIONS: Our results show greater variation in practice patterns between physicians than for individual physicians over the years. It appears that the variation remains high even after adjustment for patient and clinic characteristics and that the individual physician utilization patterns are stable across health services. We propose that personal behavioral characteristics of medical practitioners might explain this variation.

Balancing volume and duration of information consumption by physicians: The case of health information exchange in critical care.

BACKGROUND: The realization of the potential benefits of health information exchange systems (HIEs) for emergency departments (EDs) depends on the way these systems are actually used. The attributes of volume of information and duration of information processing are important for the study of HIE use patterns in the ED, as cognitive load and time constraints may result in a trade-off between these attributes. Experts and non-experts often use different problem-solving strategies, which may be consequential for their system use patterns. Little previous research focuses on the trade-off between volume and duration of system use or on the factors that affect it, including user expertise. OBJECTIVES: This study aims at exploring the trade-off of volume and duration of use, examining whether this relationship differs between experts and non-experts, and identifying factors that are associated with use patterns characterized by volume and duration. METHODS: The research objectives are pursued in the context of critically-ill patients, treated at a busy ED in the period 2010-2012. The primary source of internal and external data is an HIE linked to 14 hospitals, over 1300 clinics, and other clinical facilities. We define four use profiles based on the attributes of duration and volume: quick and basic, quick and deep, slow and basic, and slow and deep. The volume and duration of use are computed using HIE log files as the number of screens and the time per screen, respectively. Each session is then classified into a specific profile based on distances from predefined profile centroids. Experts are physicians that are board-certified in emergency medicine. We test the distribution of use profiles and their associations with multiple variables that describe the patient, physician, situation, information available in the HIE system, and use dynamics within the encounter. RESULTS: The quick and basic profile is the most prevalent. While available admission summaries are associated with quick and basic use, lab and imaging results are associated with slower or deeper use. Physicians who are the first to use the system or are sole users during an encounter are less inclined to quick and deep use. These effects are intensified for experts. DISCUSSION: A trade-off between volume and duration is identified. While system use is overall similar for experts and non-experts, the circumstances in which a certain profile is more likely to be observed vary across these two groups. Information availability and multiple-physician dynamics within the encounter emerge as important for the prediction of use profiles. The findings of this study provide implications for the design, implementation, and research of HIE use.

[COMMUNITY, HOSPITAL AND IN-BETWEEN: QUALITY MEASURES FOR THE CONTINUITY OF CARE].

INTRODUCTION: The southern district of Clalit Health Services and Soroka University Medical Center are combined in an organizational configuration: the Southern Region. The Region has developed joint programs in order to advance the quality of medical care whilst optimizing the utilization of available resources. An objective continuous method of assessment was needed to evaluate the continuity of care between the community and the hospital. AIMS: To produce objective tools for quantification based on pre-existing data systems, which enable ongoing assessment of the quality of continuity of care between the community and hospital, and the impact of the introduction of novel means of improvement. METHODS: We defined a set of measurements that exemplify continuity of care in different areas of transition between community and hospital, all directly retrievable from existing computerized data sources. RESULTS: About forty different measurements have been defined, in different clinical areas. Of these, a dozen have already been implemented by mapping the process and the main obstacles that the patient goes through, followed by implementation of appropriate solutions. CONCLUSIONS: The application of an objective system of assessment of the results of continuity of care, utilizing pre-existing data sources, is essential for advancing the initiative, and is a breakthrough in the quantification of continuity of care. DISCUSSION: Continuity of care between community and hospital has been applied in the Southern Region to dozens of quality measurements. This is a novel project developing an objective system of measurement, directly assessing the quality of continuity of care for the individual patient.

Prognostic Value of Glycated Hemoglobin for One Year Mortality Following Hospitalization in the Internal Medicine Ward.

BACKGROUND: The impact of admission glycated hemoglobin (HbA1c) on hospital outcome is controversial. OBJECTIVES: To evaluate the association between admission glucose and HbA1c levels and mortality 1 year after hospitalization in the internal medicine ward. METHODS: HbA1c level of consecutive patients was measured during the first 24 hours of admission to the internal medicine ward and divided at the cutoff point of 6.5%. Three groups of patients were prospectively identified: patients with preexisting diabetes mellitus (DM), patients with glucose > 140 mg/dl (hyperglycemia) on admission and no known diabetes (H), and patients without diabetes or hyperglycemia (NDM). The primary end-point was 1 year all-cause mortality. RESULTS: A total of 1024 patients were enrolled, 592 (57.8%) belonged to the DM group, 119 (11.6/6) to the H group and 313 (30.6%) to the NDM group. At 1 year, death occurred in 70 (11.9%) in the DM group, 12 (10.0%) in the H group and 15 (4.8%) in the NDM group (P = 0.002). Elevated admission glucose levels did not influence outcome in any of the groups. HbA1c levels were similar for survivors and non-survivors (P = 0.60). Within-group multivariate analysis adjusted for comorbidities and age showed that in the H group HbA1C levels of 6.5% or above were associated with increased mortality risk [hazard ratio (HR) 8.25, 95% confidence interval (CI) 1.93-35.21]. In the DM group, HbA1c levels below 6.5% were associated with increased mortality risk (HR = 2.05, 95% CI 1.25-3.36). CONCLUSIONS: Glucose levels upon admission did not affect mortality. However, HbA1c levels below 6.5% had opposite effects on 1 year mortality in diabetes patients and patients with hyperglycemia.

Use patterns of health information exchange through a multidimensional lens: conceptual framework and empirical validation.

Insights about patterns of system use are often gained through the analysis of system log files, which record the actual behavior of users. In a clinical context, however, few attempts have been made to typify system use through log file analysis. The present study offers a framework for identifying, describing, and discerning among patterns of use of a clinical information retrieval system. We use the session attributes of volume, diversity, granularity, duration, and content to define a multidimensional space in which each specific session can be positioned. We also describe an analytical method for identifying the common archetypes of system use in this multidimensional space. We demonstrate the value of the proposed framework with a log file of the use of a health information exchange (HIE) system by physicians in an emergency department (ED) of a large Israeli hospital. The analysis reveals five distinct patterns of system use, which have yet to be described in the relevant literature. The results of this study have the potential to inform the design of HIE systems for efficient and effective use, thus increasing their contribution to the clinical decision-making process.

Emergency Department Admission Rates, Waiting Times, and Mortality: An Observational Study in the Tertiary Center Most Proximal to Gaza During a Military Conflict.

OBJECTIVES: Military conflicts may be ongoing and encompass multiple medical facilities. This study investigated the impact of a military conflict ("Protective Edge" PE) on emergency department (ED) function in a tertiary medical center. METHODS: Visits to the ED during PE (July-August 2014) were compared with ED visits during July-August 2013 and 2015 with regard to admission rates, waiting times and 30-d mortality. Odds ratios (ORs) adjusted for confounders were used for the multivariable regression models. RESULTS: There were 32,343 visits during PE and 74,279 visits during the comparison periods. A 13% decrease in the daily number of visits was noted. During PE, longer waiting times were found, on average 0.25 h longer, controlling for confounders. The difference in waiting times was greater in medicine and surgery. Admission rates were on average 10% higher during PE military conflict, controlling for confounders. This difference decreased to 7% controlling for the daily number of visits. Thirty-day mortality was significantly increased during PE (OR = 1.42; 95% CI: 1.18-1.70). ORs for mortality during PE were significantly higher in medicine (OR = 1.45; 95% CI: 1.15-1.81) and pediatrics (OR = 4.40; 95% CI: 1.33-14.5). CONCLUSIONS: During an ongoing military conflict, waiting times, admission rates, and mortality were statistically significantly increased.

Unravelling the determinants of medical practice variation in referrals among primary care physicians: insights from a retrospective cohort study in Southern Israel.

OBJECTIVES: Reducing medical practice variation (MPV) is a central theme of system improvement because it is associated with poor health outcomes, increased costs and disparities in care. This study aimed to estimate the extent to which each determinant (patient, physician, clinic) explains MPV among primary care physicians and to identify the characteristics of health services with a greater explained variance. METHODS: A retrospective cohort study of primary care physicians practising in non-private clinics of Clalit Health Services in Southern Israel, for longer than a year between 2011 and 2017 and with more than 100 adult patients per practice. We assessed the variation in referral rates among 17 health services and the proportion explained by each domain (patient, physician and clinic). We used generalised linear negative binomial mixed models and the Nakagawa's R2, computing the marginal r2. RESULTS: The study included 243 physicians working in 295 practices and 139 clinics. The mean-explained variance was 28.5%±10.0%, where physician characteristics explained 4.5% of the variation. The intrapractice variation (within a single physician between the years) was explained better than the interphysician (between physicians). Health services with high explained variation were blood tests characterised by both low intrapractice variation (Rs=-0.65, p value=0.005) and high referral rates (Rs=0.46, p value=0.06). CONCLUSION: Over 70% of MPV is not explained by the patient, clinic and physician demographic and professional characteristics. Future research should focus on the fraction of MPV that is explained by the physicians' psychological characteristics, and thus potentially identify psychological targets for behavioural modifications aimed at reducing MPV.

Beating the clock: Reduced time to first antibiotic dose administration following an audit and feedback intervention.

OBJECTIVE: Quality improvement interventions and policy revisions have been shown to improve clinical practice and patient outcomes. This study evaluated an intervention to shorten the time from the first antibiotic dose ordering to its administration in patients hospitalised with bacterial infections. METHODS: An intervention consisting of a weekly email report to nurse and physician leaders in hospital departments was introduced. The report included the percentage of patients who received their first antibiotic dose within 3 hours and details of those who did not. Interrupted time series analysis was used to compare the delay between the order and administration of antibiotics in various wards (surgical and medical) and daily nursing shifts. RESULTS: The total number of orders pre-intervention and post-intervention was 58 320 and 52 127, respectively. The most protracted delays were observed during the morning shift in the surgical and medical wards (161 and 100 minutes, respectively). Comparing the pre- to post-intervention time to the first antibiotic dose (TTFAD), a reduction in the morning shift was noted both in the surgical wards (87 minutes, 55%) and medical wards (37 minutes, 37%) and with a preserved trend (P < 0.001). The slope's angle before and after the intervention was not affected. CONCLUSION: Using an audit and feedback automatic weekly report significantly reduced TTFAD in hospitalised patients. This intervention proved to be simple and sustainable over time. Raising staff awareness of current medical care practices is an effective way of improving performance.

Temporal trends in patient characteristics and survival of intensive care admissions with sepsis: a multicenter analysis*.

OBJECTIVE: To estimate in-hospital, 1-yr, and long-term mortality and to assess time trends in incidence and outcomes of sepsis admissions in the intensive care unit. DESIGN: A population-based, multicenter, retrospective cohort study. PATIENTS: Patients hospitalized with sepsis in the intensive care unit in seven general hospitals in Israel during 2002-2008. INTERVENTIONS: None. MEASUREMENTS: Survival data were collected and analyzed according to demographic and background clinical characteristics, as well as features of the sepsis episode, using Kaplan-Meier approach for long-term survival. MAIN RESULTS: A total of 5,155 patients were included in the cohort (median age: 70, 56.3% males; median Charlson comorbidity index: 4). The mean number of intensive care unit admissions per month increased over time, while no change in in-hospital mortality was observed. The proportion of patients surviving to hospital discharge was 43.9%. The 1-, 2-, 5-, and 8-yr survival rates were 33.0%, 29.8%, 23.3%, and 19.8%, respectively. Mortality was higher in older patients, patients with a higher Charlson comorbidity index, and those with multiorgan failure, and similar in males and females. One-year age-standardized mortality ratio was 21-fold higher than expected, based on the general population rates. CONCLUSIONS: Mortality following intensive care unit sepsis admission remains high and is correlated with underlying patients' characteristics, including age, comorbidities, and the number of failing organ systems.

[The Dead Sea--a unique resort for patients suffering from joint diseases].

The Dead Sea area is an excellent and unique resort for patients suffering from a wide range of inflammatory and non-inflammatory joint diseases. Factors contributing to the beneficial effect are the high concentration of salts and minerals in the Dead Sea water and in the water from springs in the area, medical mud, and the unique climatic conditions including high barometric pressure, relative low humidity and high temperatures. This review describes the various balneotherapy modalities and the existing body of research describing their utility. Balneotherapy significantly improves most patients' conditions and in some cases leads to complete remission of several months duration. Although of importance, balneotherapy is not curative. An important advantage of balneotherapy is the lack of serious adverse effects, and, in contrast to some physicians' beliefs, the scarcity of contraindications for therapy at the Dead Sea area.

Determinants of Medical Practice Variation Among Primary Care Physicians: Protocol for a Three Phase Study.

BACKGROUND: One of the greatest challenges of modern health systems is the choice and use of resources needed to diagnose and treat patients. Medical practice variation (MPV) is a broad term which entails the differences between health care providers inclusive of both the overuse and underuse. In this paper, we describe a 3-phase research protocol examining MPV in primary care. OBJECTIVE: We aim to identify the potential targets for behavioral modification interventions to reduce the variation in practice patterns and thus improve health care, decrease costs, and prevent disparities in care. METHODS: The first phase will delineate the variation in primary care practice over a wide range of services and long follow-up period (2003-2017), the second will examine the 3 determinants of variation (ie, patient, physician, and clinic characteristics), and attempt to derive the unexplained variance. In the third phase, we will assess a novel component that might contribute to the previously unexplained variance - the physicians' personal behavioral characteristics (such as risk aversion, fear of malpractice, stress from uncertainty, empathy, and burnout). RESULTS: This work was supported by the research grant from Israel National Institute for Health Policy Research (Grant No. 2014/134). Soroka University Medical Center Institutional Ethics Committee has approved the updated version of the study protocol (SOR-14-0063) in February 2019. All relevant data for phases 1 and 2, including patient, physician, and clinic, were collected from the Clalit Health Services data set in 2019 and are currently being analyzed. The evaluation of the individual physician characteristics (eg, risk aversion) by the face-to-face questionnaires was started on 2018 and remains in progress. We intend to publish the results during 2020-2021. CONCLUSIONS: Based on the results of our study, we aim to propose a list of potential targets for focused behavioral intervention. Identifying new targets for such an intervention can potentially lead to a decrease in the unwarranted variation in the medical practice. We suggest that such an intervention will result in optimization of the health system, improvement of health outcomes, reduction of disparities in care and savings in cost. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18673.

The association between an increase in glucose levels and armed conflict-related stress: A population-based study.

Studies have shown stress may lead to diabetes-related morbidities. In recent years during enhanced hostility periods, the population of Southern Israel experienced alert sirens and rocket fire on a daily basis. We investigated whether the exposure to these stressful circumstances, which peaked during three large military operations (MO), was associated with increased glucose levels among the civilian population. We included all fasting serum glucose tests taken between 2007-2014, of Clalit Health Services members in Southern Israel who had at least one fasting glucose test during an MO period and at least one test drawn at other times. We analyzed the association between MO periods and glucose using linear mixed-effects models. We included 408,706 glucose tests (10% during MO periods). Among subjects who reside in proximity to Gaza, glucose levels were 2.10% (95% CI 1.24%; 2.97%) higher in MO days compared to other times. A weaker effect was observed among subjects in more remote locations. In conclusion, we found stress to be associated with increased fasting glucose levels, especially among those who reside in locations in which the intensity of the threat is higher. Since glucose may be a marker of the population at cardiovascular risk, further studies are required.

Improvement of Blood Samples Preanalytic Management Alters the Clinical Results of Glucose Values: Population Study.

BACKGROUND: Prolonged time elapsing between the blood drawing and separation of the cell mass may result in decreased sample glucose levels due to continuous glycolysis. This can lead to underdiagnoses of hyperglycemic states and overdiagnosis of hypoglycemia. We aimed to evaluate the clinical impact of shortened transit time and earlier centrifugation of laboratory specimens on reported glucose results and diagnosis of clinically significant hypoglycemia (<50 mg/dL) or elevated glucose levels (>100 mg/dL). METHODS: We assessed all fasting-serum glucose tests from the adult population (190 767 subjects) without known diabetes residing in Southern Israel. Before and after intervention periods were compared: 268 359 blood tests were performed during 2009-2010, and 317 336 during 2012-2013. RESULTS: While glucose levels were 94.17 mg/dL ± 14.12 in 2012-2013 versus 83.53 mg/dL ± 14.50 in 2009-2010 (12.75% ± 0.88 increase, P < .001), the difference in glycated hemoglobin levels was statistically significant but clinically negligible: 5.84% ± 0.56 in 2012-2013 versus 5.88% ± 0.56 in 2009-2010 (0.53% ± 0.78 decrease, P < .01). There was an increased likelihood of a glucose result to be above 100 mg/dL following intervention: 9.80% versus 25.90%, P < .001. For clinics distanced over 40 km from the laboratory, age-adjusted odds ratio value was 1.26 (95% CI 1.13, 1.41). The proportion of samples with hypoglycemia values decreased from 0.33% to 0.03% (P < .001). CONCLUSIONS: We demonstrated an important change in glucose values over a two-year period following an improvement of the preanalytic processes. The intervention was related to an increase in the frequency of hyperglycemia results and a decrease in the number of hypoglycemia results. Future administrative projects should consider clinical consequences with involvement of all relevant stakeholders.

Atherosclerotic cardiovascular disease in systemic lupus erythematosus: the Beer Sheva experience.

Atherosclerotic disease is common in systemic lupus erythematosus and is the result of multiple pathogenic mechanisms that include traditional risk factors as well as SLE-related factors. Endothelial dysfunction and arterial stiffness contribute significantly to the atherogenic process. Dobutamine stress echocardiogram has not been shown to detect subclinical coronary artery disease; however, the high percentage of left ventricular outflow gradient requires further evaluation and follows-up studies.

Characteristics and outcomes of critically-ill medical patients admitted to a tertiary medical center with restricted ICU bed capacity.

BACKGROUND: In the emergency department (ED) critically-ill medical patients are treated in the resuscitation room (RR). No studies described the outcomes of critically-ill RR patients admitted to a hospital with low capacity of intensive care unit (ICU) beds. METHODS: We included all medical patients above 18 who were admitted to a RR of a tertiary hospital during 2011-2012. We conducted multivariate logistic and Cox regressions and propensity score (PS) matched analysis to analyze parameters associated with the study outcomes. RESULTS: In-hospital mortality rate was 32.4% in ICU admitted patients compared to 52.0% of the non-ICU critically-ill patients (p<0.001). Age above 80, female and recent ED encounters were associated with non-ICU admissions (p<0.05 for all). ICU admission had a statistically significant effect on in-hospital mortality in PS matched analysis (OR 0.36, 95% CI 0.21-0.61). A marginal effect was evident in one-year survival in PS matched landmark analysis (HR 0.50 95% CI 0.23-1.06). CONCLUSION: ED critically-ill medical patients who were treated in the RR had high mortality rates in an institute with restricted ICU beds availability. However, those who were admitted to an ICU showed prolonged short and perhaps long term survival compared to those who were not.

Validation of Contact-Free Sleep Monitoring Device with Comparison to Polysomnography.

STUDY OBJECTIVES: To validate a contact-free system designed to achieve maximal comfort during long-term sleep monitoring, together with high monitoring accuracy. METHODS: We used a contact-free monitoring system (EarlySense, Ltd., Israel), comprising an under-the-mattress piezoelectric sensor and a smartphone application, to collect vital signs and analyze sleep. Heart rate (HR), respiratory rate (RR), body movement, and calculated sleep-related parameters from the EarlySense (ES) sensor were compared to data simultaneously generated by the gold standard, polysomnography (PSG). Subjects in the sleep laboratory underwent overnight technician-attended full PSG, whereas subjects at home were recorded for 1 to 3 nights with portable partial PSG devices. Data were compared epoch by epoch. RESULTS: A total of 63 subjects (85 nights) were recorded under a variety of sleep conditions. Compared to PSG, the contact-free system showed similar values for average total sleep time (TST), % wake, % rapid eye movement, and % non-rapid eye movement sleep, with 96.1% and 93.3% accuracy of continuous measurement of HR and RR, respectively. We found a linear correlation between TST measured by the sensor and TST determined by PSG, with a coefficient of 0.98 (R = 0.87). Epoch-by-epoch comparison with PSG in the sleep laboratory setting revealed that the system showed sleep detection sensitivity, specificity, and accuracy of 92.5%, 80.4%, and 90.5%, respectively. CONCLUSIONS: TST estimates with the contact-free sleep monitoring system were closely correlated with the gold-standard reference. This system shows good sleep staging capability with improved performance over accelerometer-based apps, and collects additional physiological information on heart rate and respiratory rate.

Sensitive Molecular Diagnostics for Cutaneous Leishmaniasis.

BACKGROUND: Rapid diagnosis of cutaneous leishmaniasis (CL) and identification of Leishmania species is highly important for the disease management. In Israel, CL is caused mainly by Leishmania major and Leishmania tropica species. METHODS: We established an easy to handle point of care lesion-swabbing, combined with a highly sensitive multiplex real time PCR (multiplex qPCR) for accurate and rapid diagnosis of Leishmania species. RESULTS: Using three probes: one general for: Leishmania species, and two specific for L major, and L tropica, we screened 1783 clinical samples collected during two years. Leishmania species was found in 1086 individuals, 1008 L major, and 70 L tropica. Eight samples positive for Leishmania species only, were further tested using a second set of multiplex qPCR developed, and were found positive for Leishmania braziliensis and Leishmania infantum/donovani (2 and 6 samples, concomitantly). CONCLUSIONS: Taken together, the test enabled diagnostics and better treatment of Leishmania infections from the Old World (1078 samples) and the New World (8 samples), and the subtyping of the dominant strains in the region, as well as in returning travelers'.

The role of cardiac troponin I as a prognosticator in critically ill medical patients: a prospective observational cohort study.

INTRODUCTION: Myocardial injury is frequently unrecognized in intensive care unit (ICU) patients. Cardiac troponin I (cTnI), a surrogate of myocardial injury, has been shown to correlate with outcome in selected groups of patients. We wanted to determine if cTnI level measured upon admission is an independent predictor of mortality in a heterogeneous group of critically ill medical patients. METHODS: We conducted a prospective observational cohort study; 128 consecutive patients admitted to a medical ICU at a tertiary university hospital were enrolled. cTnI levels were measured within 6 h of admission and were considered positive (>0.7 ng/ml) or negative. A variety of clinical and laboratory variables were recorded. RESULTS: Both cTnI positive and negative groups were similar in terms of age, sex and pre-admission co-morbidity. In a univariate analysis, positive cTnI was associated with increased mortality (OR 7.0, 95% CI 2.44-20.5, p < 0.001), higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores and a higher rate of multi-organ failure and sepsis. This association between cTnI and mortality was more pronounced among elderly patients (>65 years of age). Multivariate analysis controlling for APACHE II score revealed that elevated cTnI levels are not independently associated with 28-day mortality. CONCLUSION: In critically ill medical patients, elevated cTnI level measured upon admission is associated with increased mortality rate. cTnI does not independently contribute to the prediction of 28-day mortality beyond that provided by APACHE II.

Spa therapy for ankylosing spondylltis at the Dead Sea.

BACKGROUND: The efficacy of spa therapy in ankylosing spondylitis has not been investigated extensively. OBJECTIVE: To study the efficacy of balneotherapy and climatic therapy (climatotherapy) at the Dead Sea area in patients with ankylosing spondylitis. METHODS: In a single-blind randomized controlled study, 28 patients suffering from ankylosing spondylitis were allocated into two groups of 14 patients each. The first group (the combined treatment group) received balneotherapy (mud packs and sulfur pool) and exposure to the unique climatic conditions of the Dead Sea. The second group (the climatotherapy group) used the fresh water pool and experienced the same climatic conditions. The duration of treatment was 2 weeks and the follow-up period 3 months. RESULTS: For both patient groups a significant improvement was found in the outcome measures: Bath AS Disease Activity Index (P = 0.002), VisuarAnalog Scale for pain (P = 0.002) and VAS for spinal movement (P = 0.011). The variability was explained by the effect of time (within group effect) rather than the type of treatment (between group effect). Quality of life, assessed by the SF-36 questionnaire, was very low prior to the study, but improved in terms of pain amelioration in the combined treatment group. CONCLUSIONS: Climatotherapy at the Dead Sea area can improve the condition of patients suffering from long-standing ankylosing spondylitis.