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.

Acute pulmonary edema in the emergency department: clinical and echocardiographic survey in an aged population.

BACKGROUND: This study is aimed at better defining the prevalence of left ventricular dysfunction, atrial fibrillation, and mitral regurgitation in aged patients with cardiogenic acute pulmonary edema. METHODS: One hundred and twenty-three consecutive patients with acute pulmonary edema (APE) arriving at the emergency department of a peripheral hospital who underwent Doppler echocardiography within 36 hours of admission were reviewed retrospectively. RESULTS: Left ventricular ejection fraction (LVEF) was normal or near normal (ie, LVEF > or = 40%) in 41.4% (n = 51 patients), and depressed in 58.5% (n = 72). Significant valvular dysfunction was present in 37.4%; mitral regurgitation was the most frequent (22.8%; n = 28). We found a significant positive correlation between systolic blood pressure (SBP) and LVEF (P = 0.003). Within the group of patients presenting with lower SBP (< or = 140 mm Hg), as blood pressure diminished, LVEF also diminished significantly (P = 0.008). In a logistic regression analysis, male sex and SBP of less than 120 mm Hg were found to be the strongest predictors for LVEF < or = 40%, conferring a 2.68- and 2.73-fold risk, respectively (95%CI, 1.19 to -6.00; P = 0.016 and 95%CI, 0.956-7.80; P = 0.061, respectively) compared with female sex and higher SBP groups. CONCLUSIONS: This study emphasizes that emergency departments should have clear-cut policies for diagnosing and treating acute coronary syndromes and tachyarrhythmias, as being potential treatable causes of APE. Once stabilized, patients should be examined for treatable valvular causes. A further study, of acute echocardiography done upon arrival to the emergency department in patients with APE is warranted.