The tools of an evidence-based culture: implementing clinical-practice guidelines in an Israeli HMO.

PURPOSE: Although clinical-practice guidelines (CPGs) are implemented on the assumption that they will improve the quality, efficiency, and consistency of health care, they generally have limited effect in changing physicians' behavior. The purpose of this study was to design and implement an effective program for formulating, promulgating, and implementing CPGs to foster the development of an evidence-based culture in an Israeli HMO. METHOD: The authors implemented a four-stage program of stepwise collaborative efforts with academic institutions composed of developing quantitative tools to evaluate prescribing patterns, updating CPGs, collecting MDs' input via focus groups and quantitative surveys, and conducting a randomized controlled trial of a two-stage, multipronged intervention. The test case for this study was the development, dissemination, and implementation of CPG for the treatment of acute uncomplicated cystitis in adult women. Interventions in the form of a lecture at a conference and a letter with personalized feedback were implemented, both individually and combined, to improve physicians' rates of prescribing the first-line drug, nitrofurantoin, and, in the absence of nitrofurantoin, adhering to the recommended duration of three days of treatment with ofloxacin. RESULTS: The tools and data-generating capabilities designed and constructed in Stage I of the project were integral components of all subsequent stages of the program. Personalized feedback alone was sufficient to improve the rate of adherence to the guidelines by 19.4% (95% CI = 16.7, 22.1). CONCLUSIONS: This study provides a template for introducing the component of experimentation essential for cultivating an evidence-based culture. This process, composed of collaborative efforts between academic institutions and a managed care organization, may be beneficial to other health care systems.

Pediatricians' satisfaction with their abilities to care for children with developmental, behavioral and psychosocial problems.

BACKGROUND: Developmental and behavioral pediatrics has emerged as an area of special interest and new responsibility for pediatricians. The aim of this study was to evaluate the impact of training, experience, and other factors on pediatricians' satisfaction with their abilities to care for children with developmental, behavioral and psychosocial problems. METHODS: A questionnaire was sent to 211 pediatricians working in primary care clinics in the community in Israel. Items included personal characteristics and experience, practice and satisfaction with the care of children with developmental, behavioral and psychosocial problems. Overall, pediatrician satisfaction with their personal abilities in this domain was defined as the dependent variable on multivariate analysis. RESULTS: The response rate was 76.3% (n = 161). Pediatricians' satisfaction with their overall professional ability to care for children with developmental, behavioral and psychosocial problems was significantly and positively associated with the following independent variables: (i) satisfaction with training received in the child development field; (ii) satisfaction with psychiatric updates; (iii) general satisfaction with the available child development services; (iv) prescription of methylphenidate to children with attention deficit/hyperactivity disorder; and (v) having completed their medical studies in a country in which the issue is emphasized. CONCLUSIONS: Imparting more knowledge and skills in child development and behavioral pediatrics in pediatric residency and continuing education programs will help improve the attitudes of primary care pediatricians towards developmental and behavioral problems, encourage them to treat these patients and their families, and better the quality of care.

Effect of the characteristics of family physicians on their utilisation of laboratory tests.

BACKGROUND: The use of laboratory tests by family physicians has increased in recent years. AIMS: To evaluate the relationship between family physicians' characteristics and the number and type of laboratory tests requested, taking into account chronic diseases. DESIGN OF STUDY: Retrospective, cross-sectional study. SETTING: One hundred and sixty-two physicians treating 230 123 patients in one district of a health management organisation in Israel. METHOD: Physicians' use of 16 common types of laboratory tests was assessed in relation to physicians' demographic, professional, and clinic characteristics. The utilisation rate over 1 year was divided into quintiles for each laboratory test, and each physician was given a global laboratory score (for each test the physician got a score from 1 (utilisation in the lower quintile) to 5 (higher quintile). The global score was the sum of scores of the individual tests. RESULTS: On logistic regression analysis, four background characteristics were associated with the global score for the utilisation of laboratory tests. The highest hazard ratios were for being a female doctor (3.2, 95% confidence interval [CI] = 1.5 to 6.5), working in an urban clinic (3.2, 95% CI = 1.1 to 9.8), and having a greater workload than doctors in rural clinics (1.4, 95% CI = 1.1 to 1.8). Being a graduate of a Western country or Israel had a negative association with the global score (0.4, 95% CI = 0.1 to 0.99). CONCLUSION: Female sex and working in a urban clinic were major factors in the use of laboratory tests in clinical practice. As more women enter the medical profession, an improved understanding of the sex differences in ordering medical tests is important.

Ethnic variability in warfarin maintenance in the community setting: a population-based study in a managed care environment in Israel.

BACKGROUND: Ethnicity has been associated with variance in warfarin treatment regimens in various settings. OBJECTIVES: To determine whether ethnicity is associated with variance in patient management in Israel. METHODS: Data were extracted from the electronic patient records of Clalit Health Services clinics in the Sharon Shomron region. The study group comprised all patients treated with warfarin who performed international normalized ratio tests for at least 6 months in 2003. The proportion of tests of each patient within the target range was calculated, as was the crude average rates and 95% confidence intervals for Jewish and Arab patients. The data were then stratified by patient's gender and age, specialty of the attending physician, and the country where the physician studied medicine. RESULTS: We identified 2749 Jews and 293 Arabs who met the inclusion criteria of the study. The crude average rate of patients' INR tests within the target range was 62.3% among Jews (95% CI 61.5-63.1) and 52.7% (95% CI 49.9-55.5) among Arabs. When stratified by gender, age, and the treating physician's specialty and country of education, the stratum-specific rates among Jewish patients were consistently higher than among Arabs. CONCLUSIONS: These results suggest that cultural differences regarding adherence to recommendations for drug therapy in addition to genetic factors may be associated with this variance.

Empiric treatment of uncomplicated urinary tract infection with fluoroquinolones in older women in Israel: another lost treatment option?

BACKGROUND: Current guidelines for the treatment of uncomplicated urinary tract infection (UTI) in women recommend empiric therapy with antibiotics for which local resistance rates do not exceed 10-20%. We hypothesized that resistance rates of Escherichia coli to fluoroquinolones may have surpassed this level in older women in the Israeli community setting. OBJECTIVES: To identify age groups of women in which fluoroquinolones may no longer be appropriate for empiric treatment of UTI. METHODS: Resistance rates for ofloxacin were calculated for all cases of uncomplicated UTI diagnosed during the first 5 months of 2005 in a managed care organization (MCO) in Israel, in community-dwelling women aged 41-75 years. The women were without risk factors for fluoroquinolone resistance. Uncomplicated UTI was diagnosed with a urine culture positive for E. coli. The data set was stratified for age, using 5 year intervals, and stratum-specific resistance rates (% and 95% CI) were calculated. These data were analyzed to identify age groups in which resistance rates have surpassed 10%. RESULTS: The data from 1291 urine cultures were included. The crude resistance rate to ofloxacin was 8.7% (95% CI 7.4 to 10.2). Resistance was lowest among the youngest (aged 41-50 y) women (3.2%; 95% CI 1.11 to 5.18), approached 10% in women aged 51-55 years (7.1%; 95% CI 3.4 to 10.9), and reached 19.86% (95% CI 13.2 to 26.5) among the oldest women (aged 56-75 y). CONCLUSIONS: Physicians who opt to treat UTI in postmenopausal women empirically should consider prescribing drugs other than fluoroquinolones. Concomitant longitudinal surveillance of both antibiotic utilization patterns and uropathogen resistance rates should become routine practice in this managed-care organization.

Microbial colonization of nebulizers used by asthmatic children.

BACKGROUND: The aim of the present study was to determine the microbial colonization of nebulizers used at home by asthmatic children, and to investigate their parents' cleaning and maintenance routines. METHODS: The nebulizer equipment used at home by 39 asthmatic children was examined. Swabs taken from the inner surface of the reservoir cups, face masks and filters were cultured. Results were recorded as mean number of colony-forming units per cultured surface. Parents were interviewed regarding their cleaning and disinfection routines. RESULTS: Twenty-six reservoir cups (66.7%), 24 face masks (61.5%), and 18 filters (78.3%) were found to be contaminated. Pseudomonas aeruginosa was isolated from 17 reservoir cups (43.6%) and 12 face masks (30.8%), and Staphylococcus aureus from two face masks (5.1%). None of the parents knew that the nebulizer has a filter and that it requires periodic cleaning or changing; only eight of the parents (20.5%) received maintenance instructions from the medical staff, and only 19 (48.7%) cleaned the nebulizer equipment after use. CONCLUSION: Home nebulizers are frequently colonized with microorganisms. As recommended, nebulizers should be washed after each use and air-blown dry. Nebulizer maintenance should be emphasized in educational programs for managing asthma.

[The increase in requests for laboratory tests in the community--are there any effective intervention programs?].

In recent years there is a steady increase in requests for laboratory tests by primary care physicians. This increase does not necessarily have a diagnostic and therapeutic yield. There is a relationship between background characteristics of the family physicians and their utilization of laboratory tests. Various studies have been conducted in order to understand the physician's motives for ordering laboratory tests in attempts to reduce their number. Interventions to reduce laboratory test utilization yield different and sometimes opposing results. We reviewed the literature dealing with laboratory test utilization and interventions to reduce it.

When gatekeepers meet the sentinel: the impact of a prior authorization requirement for cefuroxime on the prescribing behaviour of community-based physicians.

AIMS: Prior authorization (PA), the requirement of physicians to obtain pre-approval as a prerequisite for coverage, may decrease drug utilization via a 'sentinel effect', a decrease in utilization caused by external review of prescribing. The purpose of this study was to assess the affect a PA restriction had on the utilization patterns of cefuroxime tablets in a managed care organization (MCO) in Israel. METHODS: Physician prescribing patterns were evaluated by conducting a retrospective drug utilization analysis. Data were derived from the electronic patient records of the MCO studied. All prescriptions for solid state antibiotics for patients diagnosed with an infectious disease written during three parallel 3-month segments, before, during and after a PA restriction for cefuroxime was enforced, were included. Frequency and proportion of antibiotic prescriptions for cefuroxime tablets, distribution of infectious diseases treated with cefuroxime, and the request rejection rate when PA was required were calculated. RESULTS: Prescriptions for cefuroxime declined from 5538 prescriptions (8.0% of eligible antibiotic prescriptions, 95% CI 7.8, 8.2) in the initial period to 1036 (1.2%, 95% CI 1.1, 1.3) during the PA period, rising to 3961 (4.3%, 95% CI 4.2, 4.4) in the post-PA period. Changes in the distribution of diseases treated with cefuroxime during the PA stage tended to regress after revocation to those observed in the pre-PA period. The rejection rate was found to be 8.5% (95% CI=6.9, 10.1). CONCLUSIONS: The implementation of a prior authorization requirement for cefuroxime tablets markedly reduced the use of this drug, probably due to a 'sentinel effect'.

Survey of parents, nurses, and school principals on their perceptions of the controversial role of schools in health promotion.

BACKGROUND: The aim of this paper was to study the perceptions of parents, nurses, and school principals of the role of the health services in elementary schools. METHODS: A questionnaire was distributed to the heads of parents' committees, school nurses, and school principals of 35 randomly selected elementary public schools in Israel. Respondents were asked to qualify the degree of importance of the traditional and contemporary roles of the school health-care team. RESULTS: Response rates were 80.0% for parents, 100% for nurses, and 97.1% for principals. All respondents agreed that both the traditional and new roles are very important. Nurses rated three interconnected roles significantly lower than parents and school principals: 'Evaluation of students with behavioral problems', 'Evaluation of students with low academic performance', and 'Follow up and care of students with behavioral problems and low performance'. CONCLUSIONS: Nurses, parents and school principals in Israel agree that the traditional roles of health teams in elementary schools, that is, providing first aid and ensuring school hygiene, are very important. Most are ready to accept a move from an illness-based to a social-based model, with less time spent on screening and surveillance and more on identifying and managing special needs of children and staff.

Pediatrician attitudes to exclusion of ill children from child-care centers in Israel: pressure on ambulatory practices.

BACKGROUND: The exclusion of ill children from child-care centers may be associated with high social, economic and medical costs. OBJECTIVE: To assess the opinions of pediatricians working in an outpatient setting in Israel on the exclusion/return of children in child-care centers. METHODS: A questionnaire on practices of exclusion/return of children in child-care centers, in general and according to specific signs and symptoms, was administered to a random computer-selected cross-sectional sample of 192 primary care community pediatricians in Israel. RESULTS: One hundred and seventy-three pediatricians completed the questionnaires, for a response rate of 90%; 147 were board-certified and 26 were not. About half the pediatricians felt pressured by parents requesting antibiotic therapy to accelerate the return of their sick child to the child-care center. The majority also believed their practice was overloaded by often unnecessary demands for medical notes by the child-care centers before children could return. More than half based their decision to exclude children on "common sense" and the remainder, on accepted guidelines. Except for scabies and lice, there were no significant correlations between the physicians' stipulation for a note on return of the child and the specific illness guidelines. CONCLUSIONS: This study shows that a high proportion of pediatricians based their exclusion practices on "common sense" and personal understanding instead of established guidelines, and that the guidelines did not affect their opinion on the duration of illness that warrant a note. Furthermore, half were subjected to parental pressure to employ inappropriate practices. These findings, combined with our earlier survey of child-care centers staff, indicate that better education of parents and day-care staff about ill child-care-center-exclusion policy in Israel would increase their common understanding with pediatricians.

Teaching evidence-based medicine in a managed care setting: from didactic exercise to pharmacopolicy development tool.

OBJECTIVES: To implement a residency-based program for the teaching of evidence-based medicine in an Israeli HMO and to incorporate this effort into the HMO's routine drug policy formulation process. METHODS: Residents and preceptors participating in the family practice residency program in The Leumit Health Fund, 1 of the 4 HMOs operating in Israel, were invited to participate in a workshop for the formulation of guidelines for antibiotic treatment of the common infectious diseases encountered in primary care. The participants were allocated to teams consisting of a preceptor (an attending physician) and a resident physician, with each team choosing a different disease to analyze. Upon completion of the program, a questionnaire was sent to all residents and preceptors who participated in the workshop to evaluate attitudes concerning the outcomes of the program. RESULTS: Guidelines for the treatment of 14 infectious diseases commonly seen in the primary care setting were formulated. The program was accepted by the participants, who ultimately cooperated with the relevant HMO stakeholders in the formulation of official HMO policies for drug prescribing. CONCLUSION: The utilization of family practice residents is a feasible method of formulating in-house clinical practice guidelines for a managed care setting. The program was mutually beneficial for both the residents and for the stakeholders in the HMO.

Bacterial contamination of spacer devices used by asthmatic children.

OBJECTIVES: To investigate bacterial contamination in spacer devices used by asthmatic children and the device maintenance procedures practiced by parents. METHODS: Spacer devices used by 62 asthmatic children were examined. Swabs taken from the inner surface of the reservoirs and face masks were cultured. Parents were interviewed regarding their spacer cleaning and disinfection routines. RESULTS: Bacterial contamination was noted in 22 reservoirs (35.5%) and 16 masks (25.8%). Pseudomonas aeruginosa was isolated from 21.0% of the reservoirs and 14.5% of the face masks, Klebsiella pneumoniae from 6.5% and 4.8%, and Staphylococcus aureus from 9.7% and 8.1%, respectively. Only 34 parents (54.8%) reported that they received cleaning and maintenance instructions from the medical staff at initiation of spacer use by their child, and only 38 (61.8%) cleaned the device after each use. CONCLUSION: Bacterial contamination is common in spacer devices. This study demonstrates that contamination rates are significantly lower when parents clean and actually dry (preferably with an air blower) spacer devices after each use. Spacer device maintenance should be emphasized in education programs for managing asthma.

Exclusion of ill children from child-care centers in Israel.

The aim of the study was to examine criteria for ill children in child-care centers. A questionnaire on practices of exclusion/return of children according to specific signs and symptoms was mailed to the directors of care centers in central Israel. Thirty-six of the 60 questionnaires (60%) were returned by mail and the reminded were completed in personal visits to the CCCs achieving a response rate of 100%. About half (51.7%) used "common sense" and "personal feelings" to exclude children and to allow their return, and 29 (48.3%) used the guidelines of the Ministries of Education and Health or other authorities. The percentage of centers excluding children by signs/symptoms was as follows: high fever (>38 degrees C), 100%; low-grade fever, 76.7%; asthma exacerbation, 80.0%; heavy cough, 75.0%; eye discharge or conjunctivitis, 83.3%; diarrhea and vomiting more than twice per day, 100%; rash, 72.3%; otalgia, 46.7%; and infected skin lesion, 66.7%. Only four centers excluded children with head lice. Most centers required a physician's note on return of a child after high fever (76.7%), eye discharge or conjunctivitis (48.3%), and from 75 to 80%, respectively, for frequent vomiting and bloody or mucinous diarrhea. The results show that exclusion practices among child-care centers (CCCs) vary widely, suggesting the need for the establishment of a uniform exclusion and return policy in Israel, with distribution of clear, up-to-date guidelines on the prevention and control of communicable diseases to all day-care centers. In a simple way, this study identified attitudes concerning the exclusion/return of sick children in CCCs and was useful for the discussion of the related policy with CCCs responsible and national health and educational authorities.

Efficacy of postexposure immunization with live attenuated varicella vaccine in the household setting--a pilot study.

The aim of the present study was to examine the efficacy of postexposure vaccination with Varilrix in the household setting. A randomized, double-blind, placebo-controlled design was used. Twenty-two children received the varicella vaccine and 20, a placebo. The relative risk of developing varicella with a placebo compared with the vaccine was 1.1 (95% confidence interval 0.55-2.21). The risk of developing moderate to severe disease was eight times greater in the placebo group (RR=8), indicating an 80% protective effect against moderate/severe disease. The varicella vaccine Varilrix may not be effective in preventing varicella when administered after household exposure, although it is highly effective in ameliorating the disease in those who acquire it under these circumstances.

Economic evaluation of an updated guideline for the empiric treatment of uncomplicated urinary tract infection in women.

BACKGROUND: Until recently trimethoprim-sulfamethoxazole was the drug recommended in the Leumit Health Fund for the empiric treatment of uncomplicated urinary tract infection in women. However, due to increased uropathogen resistance to this drug, the fund has designated nitrofurantoin as its new drug of choice. OBJECTIVES: To evaluate the potential economic impact of implementing this new pharmaco-policy. METHODS: Using data derived from the electronic patient records of the Leumit Health Fund, we identified all non-recurrent cases of women aged 18-49 with a diagnosis of acute cystitis or UTI without risk factors for complicated UTI and empirically treated with antibiotics throughout 2003. The final sample comprised 5,489 physician-patient encounters. The proportion of cases treated with each individual drug was calculated, and the excess expenditure due to non-adherence to the new guideline from the perspective of the health fund was evaluated using 5 days of therapy with nitrofurantoin as the reference treatment. RESULTS: Ofloxacin was the most frequently prescribed drug (30.24%), followed by TMP-SMX (22.43%), cephalexin (15.08%), and nitrofurantoin (12.59%). The observed net aggregate drug expenditure was 2.3 times greater than expected had all cases been treated with nitrofurantoin according to the guideline duration of 5 days. The cost of treatment in 53% of the cases exceeded the expected cost of the guideline therapy. CONCLUSIONS: Successful implementation of the new drug will likely improve quality of care and reduce costs to the health fund.

Physician adherence to recommendations for duration of empiric antibiotic treatment for uncomplicated urinary tract infection in women: a national drug utilization analysis.

BACKGROUND: Current guidelines for the empiric treatment of uncomplicated urinary tract infection in women recommend that first-line trimethoprim-sulfamethoxazole (TMP-SMX) or ofloxacin be given for 3 days and nitrofurantoin for 5 days. Increasing the duration of treatment raises costs, and perhaps, the incidence of adverse effects, without contributing to effectiveness. The aim of this study was to investigate physician adherence to these recommendations. METHODS: The electronic patients record system of a nationwide health management organization in Israel was reviewed for all primary care visits by adult women treated empirically for cystitis or urinary tract infection from January 2001 to June 2002 (n = 7738 patient-physician encounters). The proportion of cases treated according to the guidelines, with regard to duration, was calculated for each drug used. RESULTS: Rate of adherence was 3.36% for cases of TMP-SMX treatment (95%CI: 2.56%, 4.15%), 22.23% for nitrofurantoin (95%CI: 19.81%, 24.65%) and 4.08% for ofloxacin (95%CI: 2.88%, 5.28%). The crude rate of adherence for all cases of treatment with these drugs was 8.67% (95%CI: 7.82%, 9.52%). CONCLUSIONS: The high rate of nonadherence observed (91.33%) indicate a need for a remedial education program for physicians to improve empiric treatment of urinary tract infection in women. Since this issue is of global importance, we believe our evaluation can serve as model for other settings and countries.

Adverse reactions to accidental forearm injection of Bacille Calmette-Guerin vaccine in schoolchildren: 12-month cohort follow-up.

This study examined the natural history of reaction after accidental intradermal administration of bacille Calmette-Guerin (BCG) vaccine instead of purified protein derivative (PPD) in 226 schoolchildren. At 18 days after vaccination, a local reaction with a diameter of 4.5-14 mm was found in 62% of the students, and ulceration with discharge was found in 26.6%; corresponding rates at 120 days were 72.3% and 38% and at 281 days were 73% and 6%. At 345 days, 85% of the students had a dry scar measuring 5-14 mm in diameter, and none had ulceration or discharge.

Are people who use "natural drugs" aware of their potentially harmful side effects and reporting to family physician?

We studied the extent of patients' utilization of complementary medicine (CM), and their knowledge and attitude regarding it in 740 patients visiting 25 randomly family medicine practices. One-third reported using some kind of CM, usually a natural drug (67.6%), often together with conventional drugs. Among the users of natural drugs, 56.2% believed they caused no side effects, 44.7% never reported natural drug usage to their physician, and 11% did so only rarely. There was a significant correlation (P = 0.03) between the belief that natural drugs can cause adverse effects and the tendency to report their usage to the family physician. Compared to nonusers, the typical user of any kind of CM was older (with a 1.05-fold increase for every year of age), defined his/her health status as bad (8.6-fold higher incidence), visited the family doctor more often, and was of Eastern European origin. In conclusion, although the use of natural drugs is extensive, patients' knowledge of their potential adverse effects is poor. A public educational campaign, with inclusion of the need to report such usage to the family physician, should be implemented, and questions on the use of complementary medicine/natural drugs should be incorporated as an integral part of the history taking by primary care physicians.

Assessment of participation in physical activities and relationship to socioeconomic and health factors. The controversial value of self-perception.

Physician counseling on physical activities for sedentary people is usually based on anamneses. The aim of the present study was to investigate the accuracy of self-perception of participation in physical activities, and the correlation of physical activity with background factors. A random sample of 276 individuals aged 20-65 years completed a detailed questionnaire on type and intensity of physical activity and associated socioeconomic and health factors. Physical activities were divided into work, leisure-time, and sports and rated according to Baecke's four-item index. In addition, subjects answered a yes/no item that resembled the general question regarding physical activity usually asked by physicians in a typical anamnesis. About half of the population was found to lead a sedentary life-style. The lower the level of education, the greater the physical activity at work. Males had a higher sports index than females. Interestingly, 1.3% of those with a high questionnaire score reported on the anamnesis question that they did not engage in regular physical activity, whereas 17.5% with a low questionnaire score answered "yes" to the last item. In conclusion, self-reports on physical activity may be inaccurate and to ensure proper counseling, primary care physicians must place greater weight on the patient history.

Effectiveness of an herbal preparation containing echinacea, propolis, and vitamin C in preventing respiratory tract infections in children: a randomized, double-blind, placebo-controlled, multicenter study.

OBJECTIVE: To evaluate the effectiveness and safety of a preparation containing echinacea, propolis, and vitamin C in the prevention of respiratory tract infections in children during a 12-week winter period. DESIGN: Randomized, double-blind, placebo-controlled study. SUBJECTS: Four hundred thirty children, aged 1 to 5 years, were randomized to an herbal extract preparation (n = 215) or a placebo elixir (n = 215). INTERVENTION: Administration of an herbal preparation (Chizukit) containing 50 mg/mL of echinacea, 50 mg/mL of propolis, and 10 mg/mL of vitamin C, or placebo (5.0 mL and 7.5 mL twice daily for ages 1 to 3 years and 4 to 5 years, respectively) for 12 weeks. RESULTS: Significant mean +/- SD reductions of illnesses were seen in the Chizukit group in the number of illness episodes, 138 vs 308 (55% reduction); number of episodes per child, 0.9 +/- 1.1 vs 1.8 +/- 1.3 (50% reduction, P<.001); and number of days with fever per child, 2.1 +/- 2.9 vs 5.4 +/- 4.4) (62% reduction, P<.001). The total number of illness days and duration of individual episodes were also significantly lower in the Chizukit group. Adverse drug reactions were rare, mild, and transient. CONCLUSION: A preventive effect of a product containing echinacea, propolis, and vitamin C on the incidence of respiratory tract infections was observed.