Implementation of a program for treatment of acute infections in nursing homes without hospital transfer.

Background: Nursing care residents have high hospitalization rates. To address this, we established a unique virtual geriatric unit that has developed a program aimed at providing support to nursing homes. Aims: We aimed to evaluate effectiveness of in-house intravenous antibiotic treatment in nursing hospitals after the implementation of the specially designed training program. Methods: A cohort study of nursing home residents to evaluate a training program for providers, designed to increase awareness and give practical tools for in-house treatment of acute infections. Data obtained included types of infections, antibiotics used, hospital transfer, and length of treatment. Primary outcomes were in-house recovery, hospitalization and mortality. Univariate analysis and multivariable logistic regression analysis to assess association between different factors and recovery. Results: A total of 890 cases of acute infections were treated with intravenous antibiotics across 10 nursing homes over a total of 4,436 days. Of these cases, 34.8% were aged 90 years or older. Acute pneumonia was the most prevalent infection accounted for 354 cases (40.6%), followed by urinary tract infections (35.7%), and fever of presumed bacterial infection (17.1%). The mean duration of intravenous antibiotic treatment was 5.09 ± 3.86 days. Of the total cases, 800 (91.8%) recovered, 62 (7.1%) required hospitalization and nine (1.0%) resulted in mortality. There was no significant difference observed in recovery rates across different types of infections. Discussion: Appling a simple yet unique intervention program has led to more "in-house" residents receiving treatment, with positive clinical results. Conclusion: Treating in-house nursing home residents with acute infections resulted in high recovery rates. Special education programs and collaboration between healthcare organizations can improve treatment outcomes and decrease the burden on the healthcare system.

Burnout among family medicine residents: a cross-sectional nationwide study.

BACKGROUND: In addition to pressures typical of other medical professions, family physicians face additional challenges such as building long-term relationships with patients, dealing with patients' social problems, and working at a high level of uncertainty. We aimed to assess the rate of burnout and factors associated with it among family medicine residents throughout Israel. METHODS: A cross sectional study based on a self-administered questionnaire. RESULTS: Ninety family medicine residents throughout Israel completed the questionnaire. The rate of clinically significant burnout, assessed by the composite Shirom-Melamed Burnout Questionnaire score, was 14.4%. In univariate analyses several personal and professional characteristics, as well as all tested psychological characteristics, showed significant associations with burnout. However, in the multivariable logistic regression only psychological work-related characteristics (work engagement, psychological flexibility (reverse scoring), and perceived work-related stress) were significantly associated with burnout at OR (95% CI) = 0.23 (0.06-0.60), 1.31 (1.10-1.71), and 1.16 (1.05-3.749), respectively. CONCLUSION: The integration of burnout prevention programs into academic courses during residency could explain the relatively low prevalence of burnout among family medicine residents in this study. Given the strong association of burnout with psychological characteristics, further investment in burnout prevention through targeted structured courses for residents should be encouraged.

The second generation and asthma: Prevalence of asthma among Israeli born children of Ethiopian origin.

BACKGROUND: Immigrant populations moving from undeveloped countries with low asthma prevalence have shown increased asthma prevalence in their new Westernized environment. We compared the prevalence of asthma among Israeli born children of Ethiopian origin to that in non-Ethiopian children. METHODS: Cross sectional study. Data was retrieved for children aged 6-18 years in four clinics with a large proportion of patients of Ethiopian origin. For each Israeli born child from Ethiopian origin we matched an Israeli born child of any other origin of the same age and gender, receiving primary care from the same physician at the same clinic. Asthma was defined as any visit to a primary care physician, emergency room or hospitalization related to asthma symptoms or subsequent purchasing of any asthma medication during 2008. RESULTS: 1217 children of Ethiopian origin and 1217 matched controls were studied. More Ethiopian children came from families with a low socioeconomic status (23.9% vs. 17%, p < 0.001), and with significantly lower parental smoking (5.1% vs. 40.1%, p < 0.001). The prevalence of asthma was 92/1217 (7.5%) among children of Ethiopian origin, compared to 122/1217 (10.0%) among the control group (OR = 0.74, 95% CI: 0.56-0.98, p = 0.032). When adjusted for tobacco exposure, the OR for risk of asthma in the Ethiopian children was 0.80 (95% CI: 0.59-1.09, p = 0.16). CONCLUSION: Asthma prevalence in the second generation of Israeli born children of Ethiopian origin does not seem to differ from other children in their community. This observation supports the theory that environmental exposures, rather than genetic factors, dictated the increase in asthma in this immigrant population.

Patient characteristics correlated with quality indicator outcomes in diabetes care.

BACKGROUND: Quality indicators were adopted to compare quality of care across health systems. AIM: To evaluate whether patient characteristics influence primary care physicians' diabetes quality indicators. DESIGN OF STUDY: Retrospective cohort study. SETTING: Primary care setting. METHOD: The study was conducted in the Central District of Clalit Health Service in Israel. The five measures of diabetes follow-up were: the percentage of patients with diabetes for whom glycosylated haemoglobin (HbA(1c)), microalbumin, low-density lipoprotein (LDL)-cholesterol, and blood pressure were measured at least once, and the percentage of patients who were seen by an ophthalmologist, during 2005. Three outcome measures were chosen: the percentage of patients with diabetes and HbA(1c) <7 mg%, the percentage of patients with diabetes and blood pressure <130/80 mmHg, and the percentage of patients with diabetes and LDL-cholesterol <100 mg/dl in 2005. Sociodemographic information was retrieved about all the physicians' patients with diabetes. RESULTS: One-hundred and seventy primary care physicians took care of 18 316 patients with diabetes. The average number of patients with diabetes per physician was 107 (range 10-203). A lower quality indicator score for HbA(1c) <7 mg% was correlated with a higher percentage of patients of low socioeconomic status (P<0.001) and new immigrants (P = 0.002), and correlated with borderline significance with higher mean patients' body mass index (P = 0.024); lower quality indicator score for blood pressure <130/80 mmHg was related to higher patients' age (P = 0.006). None of the diabetes follow-up measures were related to patients' characteristics. CONCLUSION: Achieving good glycaemic control is dependent on patient characteristics. New immigrants, patients of low socioeconomic status, and older patients need special attention to avoid disparities.

Patient attitudes to being treated by junior residents in the community.

OBJECTIVE: Understanding the attitudes of patients to being treated by residents in the community. METHODS: A questionnaire was administered to patients visiting community family medicine teaching clinics. The study methodology included statements to which they agree or disagree. RESULTS: Three hundred and four questionnaires were completed by patients; 94% had visited a resident in the past year; 78.9% agreed that residents were as skilled as senior doctors, but only 45.4% felt that they were as quick at diagnosis as the senior doctors; 73.0% felt that residents spent more time with them; 40.0% were not pleased by the constant change of the residents attending on them. Analysis by logistic regression showed that men had a more positive attitude to the competence of the residents as well as their professionalism (OR 2.73, 95% CI, 1.45-5.10). Frequent visitors to the clinic had a more negative attitude to the residents' professionalism (OR 0.91 (0.85-0.98)) and were more likely to agree with the statement "I would prefer to see the regular doctor and not a different resident each time" (OR 1.09 (1.01-1.18)). Those who were attended more by residents on their visits showed a positive attitude to the professionalism of residents (OR 1.14 (1.01-1.28)) and were less likely to agree with the statement "I would prefer to see the regular doctor and not a different resident each time" (OR 0.90 (0.84-0.98)). CONCLUSIONS: Patients have a positive attitude to being treated by residents in ambulatory clinics, which is associated with repeat exposure to care by residents. PRACTICAL IMPLICATIONS: Departments with ambulatory training should consider having constant presence of residents in their teaching clinics, and teaching staff in the clinics should develop ways to recommend patients to be seen by residents.

[Attitudes of family physicians to influenza vaccination after a cluster of deaths that were initially attributed to the vaccination].

BACKGROUND: The influenza vaccination rates in high risk populations decreased in 2006, in part, perhaps, as a reaction to a cluster of deaths that were initially attributed to the vaccine. We postulated that this event affected family physicians who usually recommend vaccination, and caused a change in their prescribing behavior. OBJECTIVES: To survey family physicians as to their recommendation of the influenza vaccine in 2006 as opposed to the previous year. METHODS: After the 2006 influenza vaccination season an anonymous questionnaire was distributed in various settings to family physicians. The questions related to prescribing behavior in various target populations and whether they vaccinate themselves and their families. RESULTS: A total of 122 physicians responded; 74.5% thought that there was minimal or no connection between the vaccine and the deaths, 75.8% also denied any change in their recommendation behavior. However, there was a significant decrease in the recommendation strength as seen in the percentage of physicians who reported very strong recommendations to the elderly (57.4% vs. 32.3%, p < 0.05) and chronically ill patients (64.8% vs. 39%, p < 0.05). No difference was seen in their reported personal vaccination behavior. A multivariate regression model did not find any correlations between characteristics of the responding physicians and their attitudes or changes in attitudes to the influenza vaccine. CONCLUSIONS: The family physicians were more hesitant in recommending the influenza vaccine in 2006, and this may have affected vaccination rates. Improved availability of information and guidance to family physicians after the cluster of deaths may have prevented this.

Transition to insulin in Type 2 diabetes: family physicians' misconception of patients' fears contributes to existing barriers.

BACKGROUND: Many patients with Type 2 diabetes require treatment with insulin but do not receive it. AIM: To examine the barriers that hinder the transition to insulin from the point of view of patients and family physicians. PATIENTS: Study group (SG)-92 patients who need insulin (maximum oral medications and HbA(1c)>8.5%). Control group (CG)-101 patients who had begun insulin medication recently. PATIENTS were interviewed about attitudes and beliefs regarding their illness and insulin treatment. Physicians: 157 family physicians completed a questionnaire regarding barriers to insulin treatment and answered an open-ended question about the criteria for starting insulin. RESULTS: In comparing between barriers of SG patients and perspectives of the CG patients, SG patients perceived their illness as not very serious (46.7% vs. 7%, P<.0001), had more fear of addiction to insulin (39% vs. 20.8%, P<.01) and hypoglycemia (12% vs. 4%, P=.05), and perceived the quality of their treatment worse (P<.001). Pain associated with injection and blood tests ranked low. Only 44.3% of physicians specified two criteria or more for treatment with insulin. Physicians' main barriers for commencing insulin medication were as follows: patients' compliance (92.3%), hypoglycemia (79.9%), coping with pain associated with blood tests (53.9%), and pain associated with injections (47.4%). CONCLUSION: Physicians' knowledge was relatively low, and they assign much more importance to the physical fears of patients and are not sufficiently aware of patients' misconceptions regarding the seriousness of their condition and concerns of addiction. This gap apparently contributes to the delay or even the prevention of commencing insulin medication.

The role of periodic mortality case review sessions in a primary care teaching clinic.

BACKGROUND: Maintaining a death register and holding staff discussions about patients who died can aid the physician in audit and research, which will lead to improved care of the terminally ill and the bereaved and to the development of prevention strategies. These issues are important for students and residents as well. OBJECTIVES: To review the value of mortality-case discussions in primary care clinics, particularly teaching clinics. METHODS: The clinic death register, instituted in 1998, includes age, gender, cause of death, place of death, relevant illnesses, and support provided to the patient before the death. In the half-yearly sessions, the data are reviewed, and individual cases that had an emotional impact on the staff, or information that can bring about changes in future care are discussed by the clinic staff and trainees. RESULTS: In our clinic 233 deaths occurred during a 6 year period (1998-2003). The crude all-cause mortality rate was 7.1/1000. The median age was 80 years old. Neoplastic causes were slightly more frequent than cardiovascular causes of death. Only 15% died at home; 20% lived alone and 70% lived with a spouse or family members before the death. Topics discussed in the mortality review meetings include identifying pre-suicidal patients, when to hospitalize the sick elderly, dealing with the anger of bereaved families, and ensuring proper home care for terminal patients. CONCLUSIONS: We recommend keeping a death register and conducting mortality review sessions in order to improve the quality of care, emotional support of the staff, and training students and residents about the complex issues surrounding the death of patients.