Unstructured brainstorming is not enough: structured brainstorming based on four verification and validation questions yields better hazard identification in healthcare.

OBJECTIVES: (1) To introduce the Methodical Hazard Identification Checklist (MHIC) for structured brainstorming and the four V&V categories on which it is based, and (2) to compare its efficacy with that of brainstorming (BS) in identifying hazards in healthcare. DESIGN: Comparative analysis of MHIC and team BS results. SETTING: Baruch Padeh Medical Center, Poriya, Israel. STUDY PARTICIPANTS: Quality engineering students, facilitators, validation teams and hospital staff who were familiar with the specific processes. INTERVENTION(S): The number of hazards identified by team BS were compared with those deduced by applying the four V&V hazard categories to each step (the MHIC) of 10 medical and 12 administrative processes. MAIN OUTCOME MEASURE(S): The total number of hazards (1) identified by BS, (2) identified by MHIC, (3) validated by the validation team and (4) hazards identified by both methods that the validation team deemed unreasonable. RESULTS: MHIC was significantly more successful than BS in identifying all hazards for the 22 processes (P < 0.0001). The estimated probabilities of success for BS for administrative and medical processes were 0.4444, 95%CI = [0.3506, 0.5424] and 0.3080, 95%CI = [0.2199, 0.4127], respectively. The estimated probabilities of success for MHIC for administrative and medical processes were 0.9885, 95%CI = [0.9638, 0.9964] and 0.9911, 95%CI = [0.9635, 0.9979], respectively. CONCLUSIONS: Compared to traditional BS, MHIC performs much better in identifying prospective hazards in the healthcare system. We applied MHIC methodology to administrative and medical processes and believe it can also be used in other industries that require hazard identification.

Frequent Surfing on Social Health Networks is Associated With Increased Knowledge and Patient Health Activation.

BACKGROUND: The advent of the Internet has driven a technological revolution that has changed our lives. As part of this phenomenon, social networks have attained a prominent role in health care. A variety of medical services is provided over the Internet, including home monitoring, interactive communications between the patient and service providers, and social support, among others. This study emphasizes some of the practical implications of Web-based health social networks for patients and for health care systems. OBJECTIVE: The objective of this study was to assess how participation in a social network among individuals with a chronic condition contributed to patient activation, based on the Patient Activation Measure (PAM). METHODS: A prospective, cross-sectional survey with a retrospective component was conducted. Data were collected from Camoni, a Hebrew-language Web-based social health network, participants in the diabetes mellitus, pain, hypertension, and depression/anxiety forums, during November 2012 to 2013. Experienced users (enrolled at least 6 months) and newly enrolled received similar versions of the same questionnaire including sociodemographics and PAM. RESULTS: Among 686 participants, 154 of 337 experienced and 123 of 349 newly enrolled completed the questionnaire. Positive correlations (P<.05) were found between frequency and duration of site visits and patient activation, social relationships, and chronic disease knowledge. Men surfed longer than women (χ²3=10.104, P<.05). Experienced users with diabetes surfed more than those with other illnesses and had significantly higher PAM scores (mean, M=69.3, standard deviation, SD=19.1, PAM level 4; Z=-4.197, P<.001) than new users (M=62.8, SD=18.7, PAM level 3). Disease knowledge directly predicted PAM for all users (ß=.26 and .21, respectively). Frequency and duration of social health network use were correlated with increased knowledge about a chronic disease. Experienced surfers had higher PAM than newly enrolled, suggesting that continued site use may contribute to increased activation. CONCLUSIONS: Web-based social health networks offer an opportunity to expand patient knowledge and increase involvement in personal health, thereby increasing patient activation. Further studies are needed to examine these changes on other aspects of chronic illnesses such as quality of life and costs.

Defensive Medicine Among Plastic and Aesthetic Surgeons in Israel.

BACKGROUND: Defensive medicine (DM) includes medical practices that are aimed at avoiding liability rather than benefitting the patient. DM has not been well characterized among plastic surgeons. OBJECTIVES: The authors examined the extents of intended and unintended DM among members of the Israeli Society of Plastic and Aesthetic Surgery (ISPAS) and identified risk factors for DM. METHODS: A total of 108 ISPAS members were asked to complete a questionnaire that addressed physician attitudes toward DM and intended or unintended DM practices. RESULTS: Seventy-eight surgeons (72.2% response rate) returned the questionnaire, although some questionnaires were returned incomplete. Forty respondents acknowledged practicing DM (ie, DM group), and 33 respondents did not (ie, non-DM group). There were no between-group differences in gender, years of practice, or number of previous litigations. Thirty-one percent of respondents in the DM group indicated that they avoid certain surgical procedures, compared with 6% of respondents in the non-DM group (P = .008). In private practice, 66.2% of respondents stated that they obtain written informed consent twice before surgery, and 100% request preoperative blood-coagulation testing. In contrast, 40% and 74% of respondents in public practice, respectively, acknowledged these behaviors (for consent, P = .027; for testing, P = .0059). Sixty-three percent of respondents prescribe antibiotics for more than 24 hours postoperatively, and this practice was slightly more common in the DM group (34 prescribe antibiotics vs 21 in the non-DM group; P = .079). CONCLUSIONS: DM is highly integrated into the daily medical practices of plastic surgeons in Israel.

[WELL-CHILD VISITS REGARDING GROWTH AND DEVELOPMENT OF INFANTS: A CROSS-CULTURAL COMPARISON].

AIMS: 1. To examine the rate of WCV among mothers in four ethno-cultural groups: native-born Jewish, Bedouin and immigrants from the Former Soviet Union (FSU) and Ethiopia; 2. to test the relationship between WCV in the first and second year of the infant's life; 3. to assess the effect of sociodemographic variables on WCV. BACKGROUND: Consistent infant well-child visits (WCV) have been found to be related to better health status and a decrease in visits to the emergency room and hospitalizations. METHODS: The data were collected in the Beer Sheva district among community-dwelling women in the years 2010-2012. The quota sample comprised of 400 mothers: 100 from each group. The inclusion criteria were: age (18-35 years old), either first or second child, or age of the youngest child between 18- 24 months. Immigrant mothers lived in Israel for at least 10 years. The monitoring of WCV was evaluated according to the registered number of visits in the well-baby clinic registration card. RESULTS: Mothers from all groups completed fewer WCV than the recommended number. The highest rate of visits was observed among the immigrants from the FSU, and the lowest rate among the Bedouin mothers (p<.001). Mothers of higher economic status had a higher rate of WCV (b = 0.38, p < 0.001). The rate of WCV in the second year was a function of the rate of WCV in the first year (b = 0.51, p < 0.001). CONCLUSIONS: Medical personnel treating infants should address the ethno-cultural and economic background of mothers. It is important to give mothers information about preventive medicine at an early stage in the infant's life and to encourage mothers in general and Bedouin mothers in particular to comply with recommendations regarding WCV.

Increased prevalence of obstructive lung disease in patients with obstructive sleep apnea.

STUDY PURPOSES: This study aims to determine whether there is an increased prevalence of obstructive lung diseases (OLDs) in patients with obstructive sleep apnea (OSA). We also determined whether among the OLD patients there is a difference in the prevalences of specific chronic disease co-morbidities between patients with and without OSA. METHODS: The prevalences of COPD, asthma, and COPD combined with asthma (ICD-9 coding) were compared between 1,497 adult OSA patients and 1,489 control patients, who were matched for age, gender, geographic location, and primary care physician. The prevalences of specific co-morbidities were measured in the OLD groups between patients with OSA and the matched control group. RESULTS: COPD, asthma, and COPD combined with asthma were found to be more prevalent among OSA patients compared to the matched controls. Prevalences among patients with and without OSA, respectively, were COPD-7.6 and 3.7 % (P<0.0001), asthma-10.4 and 5.1 % (P<0.0001), COPD plus asthma-3.3 and 0.9 % (P<0.0001). The Charlson Comorbidity Index was greater for OSA patients (2.3 ± 0.2) than for controls (1.9 ± 1.8; P<0.0001). These trends held for all severity ranges of OSA. Patients with OSA and COPD were characterized by more severe hypoxia at night compared with the OSA patients without OLD. CONCLUSION: OSA was associated with an increased prevalence of OLDs.

The economic impact of obstructive sleep apnea.

PURPOSE OF REVIEW: Obstructive sleep apnea (OSA) has a substantial economic impact on healthcare systems. We reviewed parameters affecting healthcare costs (race, low education, and socioeconomic status) on OSA comorbidity, and costs and the effect of OSA treatment on medical costs. RECENT FINDINGS: OSA is associated with increased cardiovascular disease (CVD) morbidity and substantially increased medical costs. Risk for OSA and resulting CVD are associated with obesity, tobacco smoking, black race, and low socioeconomic status; all these are associated with poor continuous positive airway pressure (CPAP) adherence. Healthcare costs are not normally distributed, that is, the costliest and the sickest upper third of patients consume 65-82% of all medical costs. Only a limited number of studies have explored the effect of CPAP on medical costs. SUMMARY: Costs of untreated OSA may double the medical expenses mainly because of CVD. Identifying the costliest, sickest upper third of OSA patients will reduce expenses to healthcare systems. Studies exploring the effect of CPAP on medical costs are essential. In addition, tailoring intervention programs to reduce barriers to adherence have the potential to improve CPAP treatment, specially in at-risk populations that are sicker and consume more healthcare costs.

Acute pharyngitis: low adherence to guidelines highlights need for greater flexibility in managing paediatric cases.

AIM: To describe how physicians manage acute pharyngitis with respect to the clinical guidelines. METHODS: The computerized medical records of 105 961 children in one district of a large health maintenance organization were analysed, to identify children aged 0-18 years with a diagnosis of pharyngitis and paying their first visit for pharyngitis. Main outcome variables were whether a throat culture was performed and the time between their medical consultation and purchasing any antibiotics, if at all. RESULTS: A total of 28 511 episodes of pharyngitis in 19 865 children aged 0-18, recorded by 125 physicians, were analysed (average of 1.4 episodes per child). Throat cultures were performed in 14 847 episodes (52%), with tests more common among paediatricians and younger physicians. Antibiotics were purchased in 24.8% of these cases, without knowing the result, and were more commonly associated with male physicians, family practitioners, children living in rural areas and drugs bought before the weekend. CONCLUSION: About 50% of the physicians did not adhere to the guidelines. Factors influencing adherence included physician training, years in practice and patients' nonmedical characteristics. It is suggested that the existing clinical guidelines should address additional modifiers that will make the more applicable in practice.

Determinants of elevated healthcare utilization in patients with COPD.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) imparts a substantial economic burden on western health systems. Our objective was to analyze the determinants of elevated healthcare utilization among patients with COPD in a single-payer health system. METHODS: Three-hundred eighty-nine adults with COPD were matched 1:3 to controls by age, gender and area of residency. Total healthcare cost 5 years prior recruitment and presence of comorbidities were obtained from a computerized database. Health related quality of life (HRQoL) indices were obtained using validated questionnaires among a subsample of 177 patients. RESULTS: Healthcare utilization was 3.4-fold higher among COPD patients compared with controls (p < 0.001). The "most-costly" upper 25% of COPD patients (n = 98) consumed 63% of all costs. Multivariate analysis revealed that independent determinants of being in the "most costly" group were (OR; 95% CI): age-adjusted Charlson Comorbidity Index (1.09; 1.01-1.2), history of: myocardial infarct (2.87; 1.5-5.5), congestive heart failure (3.52; 1.9-6.4), mild liver disease (3.83; 1.3-11.2) and diabetes (2.02; 1.1-3.6). Bivariate analysis revealed that cost increased as HRQoL declined and severity of airflow obstruction increased but these were not independent determinants in a multivariate analysis. CONCLUSION: Comorbidity burden determines elevated utilization for COPD patients. Decision makers should prioritize scarce health care resources to a better care management of the "most costly" patients.

[Obstetrics and gynecology workforce planning: the Israeli experience 1995-2025].

BACKGROUND: Currently, there is no current obstetricians and gynecologists' workforce (OBGW) planning in Israel. Forecasting the OBGW is a challenge in order to achieve optimal obstetrics and gynecology care in the next decades. OBJECTIVE: To examine the current Israeli OBGW and to describe, using an equation, the future supply of OBGW, until 2025. METHODS: A descriptive study of past (1995-2006) and future (through 2025) OBGW trends in Israel. An equation was developed to project physician supply until 2025. RESULTS: No "optimal ratio" exists regarding OBGW to female population ratio. In addition, information regarding OBGW planning is scarce. In Israel, the ratio of OBGW aged < 65 years per 1000 females aged > or = 15 years, was 0.35 in 2006, 23% more than the higher projected ratio from USA for 2005. In 2020, for comparison, the ratio in Israel will be 18% higher than the US ratio. The ratio calculated by the equation presents a plateau of the supply of Ob-Gyn specialists in Israel until 2025. A continued significant growth in the number of Ob-Gyn female specialists, compared with males, is noted. The interpretation of this data requires further evaluation. CONCLUSIONS: In order to preserve the quality of care, there is a need for continuous monitoring and structured planning of health care human resources and OBGW in particular. Research and data in this field are scarce and, therefore, there is a need to conduct many additional research studies. Furthermore, additional data collection is needed to evaluate quality of care and its availability according to the relation between manpower needs and expected demands in Israel's health system.

Low socioeconomic status is a risk factor for CPAP acceptance among adult OSAS patients requiring treatment.

STUDY OBJECTIVE: To evaluate whether socioeconomic status (SES) has a role in obstructive sleep apnea syndrome (OSAS) patients' decision to accept continuous positive airway pressure (CPAP) treatment. DESIGN: Cross-sectional study; patients were recruited between March 2007 and December 2007. SETTING: University-affiliated sleep laboratory. PATIENTS: 162 consecutive newly diagnosed (polysomnographically) adult OSAS patients who required CPAP underwent attendant titration and a 2-week adaptation period. RESULTS: 40% (n = 65) of patients who required CPAP therapy accepted this treatment. Patients accepting CPAP were older, had higher apnea-hypopnea index (AHI) and higher income level, and were more likely to sleep in a separate room than patients declining CPAP treatment. More patients who accepted treatment also reported receiving positive information about CPAP treatment from family or friends. Multiple logistic regression (after adjusting for age, body mass index, Epworth Sleepiness Scale, and AHI) revealed that CPAP purchase is determined by: each increased income level category (OR, 95% CI) (2.4; 1.2-4.6), age + 1 year (1.07; 1.01-1.1), AHI ( > or = 35 vs. < 35 events/hr) (4.2, 1.4-12.0), family and/or friends with positive experience of CPAP (2.9, 1.1-7.5), and partner sleeps separately (4.3, 1.4-13.3). CONCLUSIONS: In addition to the already known determinants of CPAP acceptance, patients with low SES are less receptive to CPAP treatment than groups with higher SES. CPAP support and patient education programs should be better tailored for low SES people in order to increase patient treatment initiation and adherence.

[Work satisfaction, quality of life and leisure time of residents at the Soroka University Medical Center, Beer Sheba, Israel].

BACKGROUND: Work dissatisfaction among physicians worldwide continues to rise over the last few decades, mainly due to declining professional prestige, tack of self fulfillment, time pressure and tack of leisure time. Physicians' burnout is a major result of dissatisfaction, causing doctors to leave the medical profession, and to provide lower quality of care. OBJECTIVES: To examine the work satisfaction, quality of life and leisure time of residents in the Soroka University Medical Center. METHODS: A validated questionnaire was delivered during the second half of 2004 to 252 residents in the Soroka University Medical Center The data was analyzed using the SPSS 12 for windows program. Descriptive analysis, parametric Students' T Test [where p<0.05 was set to be considered valid) and a-parametric Mann Whitney and x2 tests were conducted. RESULTS: A total of 137 residents responded to the questionnaire (response rate of 54.36%]. The residents' satisfaction level was low, mainly due to dissatisfaction with their quality of life. There was no difference in satisfaction between male and female residents. Residents in the early stage of their internship were more satisfied than residents who had completed the first stage in regard to their income (p=0.005). Surgical residents were less satisfied than non-surgical residents (p=0.003), mainly from the work relations with their superiors (p=0.015). CONCLUSIONS: The residents at the Soroka University Medical Center were satisfied with their work environment but not with their quality of life and leisure time. Further attention must be given to these matters--a step which will eventually improve patient care, and delay, to some extent, the burnout of physicians.

Gender differences in morbidity and health care utilization among adult obstructive sleep apnea patients.

STUDY OBJECTIVE: To explore gender differences in morbidity and total health care utilization 5 years prior to diagnosis of obstructive sleep apnea (OSA). DESIGN: Case-control study; patients were recruited between January 2001 and April 2003. SETTING: Two university-affiliated sleep laboratories. PATIENTS: 289 women (22-81 years) with OSA were matched with 289 men with OSA for age, body mass index (BMI), and apnea-hypopnea index (AHI). All OSA patients were matched 1:1 with healthy controls by age, geographic area, and primary physician. MEASUREMENTS AND RESULTS: Women with OSA compared to men with OSA have lower perceived health status and Functional Outcomes of Sleep Questionnaire score (54.5% vs. 28.4%, P <0.05 and 67.5+/-21.4 vs. 76+/-20.1, P <0.05, respectively). Compared to men with OSA, women with OSA have higher risk of hypothyroidism (OR 4.7; 95% CI, 2.3-10) and arthropathy (OR 1.6, 95% CI, 1.1-2.2) and lower risk for CVD (OR 0.7; 95% CI, 0.5-0.91). Compared to controls, both women and men with OSA had 1.8 times higher 5-year total costs (P <0.0001). Compared to men with OSA, expenditures for women with OSA are 1.3 times higher (P <0.0001). The multiple logistic regression (adjusting for BMI, AHI) revealed that age (OR 1.04; 95% CI, 1.01-1.07), antipsychotic and anxiolytic drugs (OR 2.3; 95% CI, 1.2-4.4), and asthma (OR 2.4; 95% CI, 1.1-5.6) are independent determinants for "most costly" OSA women. CONCLUSION: Compared to men with similar OSA severity, women are heavier users of health care resources. Low FOSQ score and poor perceived health status in addition to overuse of psychoactive drugs are associated with high health care utilization among women with OSA.

Unconscious defensive medicine: The case of erythrocyte sedimentation rate.

BACKGROUND: We investigated physician rationale for and against performing routine erythrocyte sedimentation rate (ESR) tests during hospital admissions. METHODS: A comparative, descriptive, prospective study among 82 physicians in 15 departments of internal medicine from two University Medical Centers - A and B - in Israel was conducted between July and August 2004. Reasons for physicians' use of ESR were examined using a confidential questionnaire. A panel of four experts reviewed the need to perform an ESR test in 100 patients' files from center B. The main outcome measures were the use of ESR in routine hospital admissions and reasons for use. RESULTS: Forty-four vs. zero physicians from medical centers B and A, respectively, routinely perform ESR tests for all admitted patients (p<0.001). According to the experts, in only 10-30% of the 67 new patients could ESR tests have been of some value. Reasons for performing ESR routinely were as follows: to identify severe and "hidden" diseases (21/44, 47.7%); because it is crucial for all patients, both new and returning (10/44, 22.7%); because it is a guideline from department head (6/44, 13.6%); it is recommended in the literature (5/44, 11.4%); don't know why (2/44, 4.5%); defensive medicine (1/44, 2.3%); and other (6/44, 13.6%). CONCLUSION: Routine use of ESR tests on admission can be explained by old habits and by an unconscious concern about liability, i.e., unconscious defensive medicine.

[Medical students' knowledge and attitudes towards costs of tests and treatments].

OBJECTIVES: 1) To examine medical students' knowledge about costs of laboratory tests, imaging procedures, and treatments. 2) To examine medical students' attitudes regarding receiving information about costs, and its effect on their future clinical behavior. DESIGN: This was a cross-sectional study using an anonymous three-part questionnaire that was distributed to all students of the Ben Gurion University Medical School. Responses were received from 269 students (approximately 70%). RESULTS: According to the results, most students did not estimate the costs correctly. It was found that: 69.5% of the students did not receive any information about costs during their studies; 81.4% of the students expressed interest in receiving such information; 66.2% thought that knowing the costs would change their future clinical decision making. CONCLUSIONS AND RECOMMENDATIONS: Medical students lack information regarding the cost of laboratory tests and medical treatments. Providing information to medical students about costs may help reduce future health care expenses. Our recommendations are: 1. To include economic content in the medical curriculum; 2. To perform periodic updates and continuing medical education in this area; 3. To combine this educational program with other intervention methods in order to effectively reduce health care expenses.

Low socioeconomic status is a risk factor for cardiovascular disease among adult obstructive sleep apnea syndrome patients requiring treatment.

STUDY OBJECTIVE: To evaluate the possible role of low socioeconomic status (SES) as a risk factor for cardiovascular disease (CVD) among obstructive sleep apnea syndrome (OSAS) patients requiring treatment. DESIGN: Polysomnographic and demographic characteristics and associated morbidity were measured in 686 prospectively recruited adult OSAS patients from two regions in Israel. SETTING: Two university-affiliated sleep laboratories. MEASUREMENTS AND RESULTS: The multiple logistic regression (after adjusting for gender, body mass index [BMI], and smoking) revealed that the following are independent determinants for CVD in OSAS patients requiring treatment: each decrease in income level category (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1 to 1.7), age > or = 1 year (OR, 1.07; 95% CI, 1.04 to 1.1), hypertension (OR, 2.0; 95% CI, 1.3 to 3.1), and hyperlipidemia (OR, 3.7; 95% CI, 2.4 to 5.8); area under the receiver operating characteristic (ROC) = 81.9%. The multivariate determinants describing the low-SES OSAS patients included: minorities and immigrants combined (OR, 6.0; 95% CI, 2.9 to 12), female gender (OR, 2.4; 95% CI, 1.6 to 3.9), increased BMI (OR, 1.9; 95% CI, 1.3 to 2.9), unmarried status (OR, 1.9; 95% CI, 1.2 to 3.1), and years of education (> or = 1 year) [OR, 0.8; 95% CI, 0.7 to 0.8]; area under the ROC = 78.1%. CONCLUSION: In addition to the already known traditional risk factors, low SES was found to be a novel independent risk factor for CVD among adult OSAS patients requiring treatment.

Defining localities of inadequate treatment for childhood asthma: a GIS approach.

BACKGROUND: The use of Geographic Information Systems (GIS) has great potential for the management of chronic disease and the analysis of clinical and administrative health care data. Asthma is a chronic disease associated with substantial morbidity, mortality, and health care use. Epidemiologic data from all over the world show an increasing prevalence of asthma morbidity and mortality despite the availability of effective treatment. These facts led to the emergence of strategies developed to improve the quality of asthma care. THE OBJECTIVE: To develop an efficient tool for quality assurance and chronic disease management using a Geographic Information System (GIS). GEOGRAPHIC LOCATION: The southern region of Israel. January 1998 - October 2000. DATABASES: Administrative claims data of the largest HMO in Israel: drug dispensing registry, demographic data, Emergency Room visits, and hospitalization data bases. METHODS: We created a list of six markers for inadequate pharmaceutical treatment of childhood asthma from the Israeli clinical guidelines. We used this list to search the drug dispensing registry to identify asthmatic children who received inadequate treatment and to assess their health care utilization and bad outcomes: emergency room visits and hospitalizations. Using GIS we created thematic maps on which we located the clinics with a high percentage of children for whom the treatment provided was not in adherence with the clinical guidelines. RESULTS: 81% of the children were found to have at least one marker for inadequate treatment; 17.5% were found to have more than one marker. Children with markers were found to have statistically significant higher rates of Emergency Room visits, hospitalizations and longer length of stay in hospital compared with children without markers. The maps show in a robust way which clinics provided treatment not in accord with the clinical guidelines. Those clinics have high rates of Emergency Room visits, hospitalizations and length of stay. CONCLUSION: Integration of clinical guidelines, administrative data and GIS can create an efficient interface between administrative and clinical information. This tool can be used for allocating sites for quality assurance interventions.

Outsourcing primary medical care in Israeli defense forces: decision-makers' versus clients' perspectives.

BACKGROUND: Decision-makers in the Israeli defense force (IDF) have determined that the Medical Corp (MC) would outsource the primary care services required by career soldiers to a skilled civilian health care provider, in an attempt to improve efficiency, quality and "image" of the MC care system, while controlling expenses. METHODS: A cross-sectional survey to reveal decision-makers' considerations for outsourcing primary care for career soldiers and to evaluate whether these considerations match career soldiers' satisfaction level parameters was conducted between February 2002 and 2003 in IDF bases and civilian primary care clinics. RESULTS: Medical Corp decision-makers are concerned about loss of professional prestige and dependence on the civilian system. A high level of satisfaction following outsourcing was found among career soldiers due to: medical staff attitude, pleasant facilities, quality of care, availability and accessibility of medical care. Agreement about five factors was found among decision-makers and career soldiers: working environment, medical personnel attitude, quality and availability of medical care, and patient satisfaction level. CONCLUSIONS: Outsourcing of primary care from military to civilian providers gives high client satisfaction level.

Adherence to therapeutic guidelines for acute otitis media in children younger than 2 years.

OBJECTIVES: to analyze adherence to therapeutic guidelines for AOM. METHODS: Descriptive retrospective study of community primary care providers in southern Israel. Study population (n = 590) included all children aged 0-48 months diagnosed with AOM in PED during the year 2000 who had a referral letter from a community physician and an AOM diagnosis confirmed by tympanocentesis. AOM antibiotic treatment was considered appropriate when in accord with CDC and local therapeutic guidelines. RESULTS: Referral letter data allowing characterization of AOM by category were available in 471 (79.8%) children, 320 (68%) with simple AOM and 151(32%) with complicated AOM. AOM diagnosis made by the primary care physician was in accord with PED diagnosis in 365/590 (62%) patients. Three hundred and fifty-five (60.2%) patients did not receive antibiotics in the community. Of 365 (62%) children diagnosed with AOM in the community, 235 (64.4%) were treated with antibiotics prior to arrival to PED. Amoxicillin was prescribed to 109 (46.4%), cefuroxime axetil to 48 (20.4%), amoxicillin/clavulanate to 31 (13.2%) and i.m. ceftriaxone to 20 (8.5%) of the patients. Eighty-three (25.9%) patients with simple AOM were treated with antibiotics in the community and only 46 (55.4%) received amoxicillin according to the therapeutic guidelines. Eighty-one (53.6%) patients with complicated AOM were treated with antibiotics in the community and only 41 (50.6%) of them received antibiotics according to AOM therapeutic guidelines. More antibiotics were prescribed in the community to patients with complicated AOM than to patients with simple AOM (81/151, 53.6% versus 83/320, 25.9%, respectively, p < 0.001). Adherence to therapeutic guidelines was similar between the simple and the complicated AOM groups (46/83, 55.4% versus 41/81, 50.6%, respectively, p = 0.5). CONCLUSION: We found partial adherence to AOM therapeutic guidelines among primary care providers in the community in Southern Israel.

Do we need routine complete blood count following vaginal delivery?

Routine post partum complete blood count examination (CBC) is customary in many medical centers. The rationale behind drawing a routine CBC is to estimate blood loss during delivery and to identify patients who will need blood transfusions. The present study was aimed to determine the necessity of routine post-partum CBC following vaginal delivery. A retrospective cohort study was performed including all patients who received blood transfusions following vaginal delivery between January 2003 and November 2004. Data were collected from birth files. The indications for administration of blood transfusions were noted. Of 20,694 vaginal deliveries, 0.7% (n = 138) received blood transfusions. All patients had at least one obstetric risk factor of postpartum hemorrhage or symptomatic anemia. None received the blood transfusion based upon postpartum CBC hemoglobin level alone. Routine postpartum CBC is not warranted for the purpose of identifying the patient in need of blood transfusions. Postpartum CBC should be performed when indicated according to risk factors for excessive blood loss or patients' complaints.

Adherence to Medical Cannabis Among Licensed Patients in Israel.

Objectives: To evaluate adherence among Israeli patients who are licensed to use medical cannabis and to identify factors associated with adherence to medical cannabis. Methods: Ninety-five novice licensed patients were interviewed for this cross-sectional study. The questionnaire measured demographics, the perceived patient-physician relationship, and the level of patients' active involvement in their healthcare. In addition, patients were queried about adverse effect(s) and about their overall satisfaction from this medical treatment. Results: Eighty percent (n=76) has been identified as adherent to medical cannabis use. Variables found associated with adherence were "country of origin" (immigrant status), "type of illness" (cancer vs. non-cancer), and "experiencing adverse effect(s)." Three predictors of adherence were found significant in a logistic regression model: "type of illness" (odds ratio [OR] 0.101), patient-physician relationship (OR 1.406), and level of patient activation (OR 1.132). 71.5% rated themselves being "completely satisfied" or "satisfied" from medical cannabis use. Conclusions: Our findings show a relatively high adherence rate for medical cannabis, as well as relative safety and high satisfaction among licensed patients. Additionally indicated is the need to develop and implement standardized education about this evolving field-to both patients and physicians.