The Impact of Change in Hospital Admissions When Primary Care Is Provided by a Single Primary Care Physician: A Cohort Study Among HMO Patients in Israel.

OBJECTIVES: An Israeli health maintenance organization (HMO) changed its policy from freedom of choice in choosing any primary care physician (PCP) to provide health care to one provider allocated to the patients. We examined outcome measures before and after the intervention in the study population. DESIGN: During a 2.5-year period (from June 2013 to December 2015), continuity of care by PCPs was achieved by a single provider. The change was computed for each participant according to the most visited PCP in the last year. PARTICIPANTS: A total of 208,286 patients aged 20 and older fulfilled the inclusion criteria. MAIN OUTCOME MEASURES: Future likelihood of hospitalization, number of PCP visits, and medication use before and after the intervention. RESULTS: After controlling for demographics, high continuity of care before and after intervention was associated with a lower likelihood of hospitalization for any condition (adjusted odds ratio [OR] = 0.90; 95% confidence interval [CI], 0.85-0.95; p = 0.003). No significant change was recorded for number of ambulatory visits or medication use. CONCLUSIONS: Changing Leumit HMO policy to continuity of care with a single provider is associated with a decreased future likelihood of hospitalization. This suggests that policies that encourage patients to concentrate their care with a single provider may lead to lower hospitalization rates and possibly lower healthcare costs.

Incidence and prevalence of psoriasis in Israel between 2011 and 2017.

BACKGROUND: Psoriasis is a common chronic inflammatory skin disease associated with a heavy burden of morbidity, disability and cost. The occurrence of the disease in Israel has not been previously investigated. OBJECTIVES: To provide standardized estimates of trends in psoriasis incidence, prevalence and mortality among patients in Israel between 2011 and 2017. METHODS: Using electronic health records from Clalit Health Services, the largest nationwide public health provider in Israel, we conducted a population-based study investigating trends in the annual incidence and prevalence of psoriasis between the years 2011 and 2017. We report age- and sex-adjusted rates, using the standard European population as a reference. RESULTS: We identified 71 094 incident psoriasis cases. The mean (SD) age of onset was 42.4 (21.0) years with a bimodal distribution, peaking in the early '30s and early '60s. Late-onset psoriasis, occurring after 40 years of age, accounted for 51.1% of incident cases. The annual psoriasis incidence rate was constant throughout the study period (280/100 000 person-years). Psoriasis prevalence rose from 2.5% in 2011 to 3.8% in 2017. CONCLUSIONS: Psoriasis prevalence is increasing in Israel, although its incidence is stable. Clinicians and policymakers should plan to address the growing demands in the clinical, economic and societal burden of psoriasis.

Psychiatric comorbidities in 3207 patients with hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic recurrent inflammatory disease affecting skin that bears apocrine glands. Only anecdotal reports and a few small studies have demonstrated a possible association between HS and depression, but these studies were uncontrolled or were based on small sample sizes. To the best of our knowledge, the association between HS and other psychiatric disorders has never been investigated. OBJECTIVES: To investigate the association between HS and psychiatric disorders: depression, anxiety, psychoses, schizophrenia and bipolar disorder. METHODS: A cross-sectional study was conducted utilizing the database of Clalit Health Services (over 4,100,000 patients). Case patients were defined as having HS when diagnosed by a dermatologist. Control patients without HS were age and gender matched in a 2 : 1 manner. The proportions of patients with psychiatric diseases were compared between patients with and without HS. The association between HS and psychiatric diseases was assessed in multivariate models using logistic regression analyses. RESULTS: The study included 3207 patients with HS and 6412 age- and gender-matched controls. Depression was diagnosed in 5.9% of patients with HS vs. 3.5% of patients without HS (P < 0.001). Anxiety was diagnosed in 3.9% of patients with HS vs. 2.4% of patients without HS (P < 0.001). These associations were significant after controlling for the confounders age and gender (Depression: OR = 1.7, 95% CI: 1.4-2.1; Anxiety: OR = 1.7, 95% CI: 1.3-2.1). CONCLUSIONS: Hidradenitis suppurativa was associated with depression and anxiety. Dermatologists treating patients with HS should be aware of this important association.

Opportunities and challenges in delivering remote primary care during the Coronavirus outbreak.

BACKGROUND: Social distancing and lockdowns were implemented during the first period of the COVID-19 pandemic. Primary care physicians needed to adapt quickly to deliver remote care/telemedicine. METHODS: A cross-sectional, 47-item online Google Survey was distributed through the Israel Association of Family Physicians (IAFP) mailing list between March 31-May 5, 2020. The questionnaire included demographics, physician characteristics, and information on usage and perceived telemedicine quality. Sampling weights by sex and age groups were applied. RESULTS: One hundred fifty-nine primary care physicians (10.6% of registered IAFP members; 63.5% women; mean age 53.4 ± 10.4 years and median professional experience 21.3 years) replied to the survey. The majority (59.7%) of the participants performed a mixture of in-person along with phone counseling. About 40% had no former telemedicine experience. The majority indicated that telephone and video formats were inferior to in-person consultation (68%, 57.1% online and phone, respectively). The overall counseling quality grade (on a 1-10 scale,)median (IQR)) was 6.2 (3) for telephone and 7(2) for video. While 66.9% reported experiencing no challenges, 10% had technical problems, 10% interpersonal problems, 5.6% scheduling difficulties, and 7.5% other difficulties. Majority of 56.6% physicians indicated they prescribed more antibiotics,16.4% sent more blood tests, 24.5% referred more to experts, and 49.7% referred more to imaging in comparison to usual counseling. Higher phone quality score was significantly associated with physicians who indicated not prescribing more antibiotics during the pandemic (OR = 0.30, 95%CI 0.134-0.688, p = 0.004). Higher online quality score was associated with physicians who indicated not sending more blood tests during the pandemic (OR = 0.06 95%CI 0.008-0.378, P = 0.003). CONCLUSIONS: Our findings suggest telehealth holds considerable promise for counseling in the primary care setting. However, interpersonal challenges raised by physicians should be understood in-depth to develop tailored training and further examine it in randomized trials while integrating patient-reported outcomes. Finally, further research on utility, cost, and cost-efficiency during remote counseling with follow-ups, medical prescribing, and additional referrals is needed.

Does a policy that requires adherence to a regular primary care physician improve the actual adherence of patients?

BACKGROUND: Continuity of care by the same personal physician is a key factor in an effective and efficient health care system. Studies that support the association between high adherence and better outcomes were done in settings where allocation to the same physician was a long-term policy. OBJECTIVES: To evaluate the influence that changing organizational policy from the free choice of a primary care physician to a mandatory continuity of care by the same physician has on adherence to a personal physician. METHODS: A cross-sectional study based on electronic databases; comparison of adherence and demographic characteristics (sex, age, and socio-economic status) of 208,286 Leumit enrollees who met the inclusion criteria, according to change in the adherence to a personal physician. To evaluate adherence, we used the Usual Provider of Care (UPC) index, which measures the number of visits made to the personal doctor out of the total primary care physician visits over the same period. The patients were divided into groups according to their UPC level. RESULTS: The data shows that 54.5% of the patients were high adherers even before the organizational change; these rates are similar to those published by various organizations worldwide, years after mandating continuity of care by the same physician. In the year following the intervention, only 34.5% of the patients changed the level of their adherence group. Of these, 64% made a shift to a higher adherence group. Before the intervention, the high adherers were older (mean age 57.8 vs. 49.3 years in the low adherers group) and from a higher SES (mean SES status 9.32 vs. 8.71). After the intervention, a higher proportion of older patients and patients from a higher SES changed their adherence to a higher group. Sex distribution was similar over all the adherence level groups and did not change after the intervention. CONCLUSIONS AND POLICY IMPLICATIONS: A policy change that encouraged adherence to an allocated primary care physician managed to improve adherence only in specific groups. Health organizations need to examine the potential for change and the groups they want to influence and direct their investment wisely. TRIAL REGISTRATION: retrospectively registered.

A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus: a 1-year prospective randomized intervention study.

BACKGROUND: The appropriate dietary intervention for overweight persons with type 2 diabetes mellitus (DM2) is unclear. Trials comparing the effectiveness of diets are frequently limited by short follow-up times and high dropout rates. AIM: The effects of a low carbohydrate Mediterranean (LCM), a traditional Mediterranean (TM), and the 2003 American Diabetic Association (ADA) diet were compared, on health parameters during a 12-month period. METHODS: In this 12-month trial, 259 overweight diabetic patients (mean age 55 years, mean body mass index 31.4 kg/m(2)) were randomly assigned to one of the three diets. The primary end-points were reduction of fasting plasma glucose, HbA1c and triglyceride (TG) levels. RESULTS: 194 patients out of 259 (74.9%) completed follow-up. After 12 months, the mean weight loss for all patients was 8.3 kg: 7.7 kg for ADA, 7.4 kg for TM and 10.1 kg for LCM diets. The reduction in HbA1c was significantly greater in the LCM diet than in the ADA diet (-2.0 and -1.6%, respectively, p < 0.022). HDL cholesterol increased (0.1 mmol/l +/- 0.02) only on the LCM (p < 0.002). The reduction in serum TG was greater in the LCM (-1.3 mmol/l) and TM (-1.5 mmol/l) than in the ADA (-0.7 mmol/l), p = 0.001. CONCLUSIONS: An intensive 12-month dietary intervention in a community-based setting was effective in improving most modifiable cardiovascular risk factors in all the dietary groups. Only the LCM improved HDL levels and was superior to both the ADA and TM in improving glycaemic control.

Pseudotumor cerebri in systemic lupus erythematosus.

OBJECTIVE: To assess the association between pseudotumor cerebri (PC) and systemic lupus erythematosus (SLE), and to seek a pathogenic mechanism that may elucidate the appearance of PC in patients with SLE. DATA SOURCE: Original English articles having the terms SLE, PC, or benign intracranial hypertension in their titles were identified by Medline search. In addition we report three new patients with this association. STUDY SYNTHESIS: Thirteen articles were found and 21 patients were analyzed. DATA EXTRACTION: Of the reported 21 patients, 18 were previously reported and 3 new patients with coexisting PC and SLE are described. The clinical characteristics of the patients is presented. Patients with PC and SLE generally had a more severe course of SLE; renal involvement occurred in 79%, massive proteinuria in 47%, and hematologic abnormalities were detected in a third. A hypercoagulable state manifest by either recurrent thromboembolic events or a high anti-cardiolipin antibody titer was detected in 58% of the patients described. CONCLUSIONS: The association of PC and SLE is probably not coincidental. The high prevalence of serologic or clinical evidence of a hypercoagulable state suggests that microscopical thromboembolic events play a role in the genesis of PC.

Baseline tests or screening: what tests do family physicians order routinely on their healthy patients?

OBJECTIVE: The purpose of this study was to survey the attitudes of family doctors to the performance of baseline tests and to determine which doctors perform these tests. SETTING: Family physicians in a continuing medical education programme in Tel Aviv, Israel. METHOD: An anonymous questionnaire was distributed focusing on performance of tests by doctors in healthy patients and not as part of a screening programme. RESULTS: Questionnaires were returned by 147 of 165 physicians surveyed (89% response rate). Baseline tests were performed by 98% of respondents: not routinely by 54%, 7% at the patient's request, and 2% did not perform tests. The decision to perform baseline tests was influenced by the presence of other risk factors of disease (86%), patient age (61%), family history (59%), patient request for tests (24%), and patient sex (20%). The tests performed were blood counts, glucose, renal function tests, urinalysis, liver function tests, and electrocardiograms. Baseline tests were useful in case finding of new illnesses for 49% of physicians and 40% said the tests had proved useful during a subsequent illness. The remainder of the physicians found no use for baseline tests. Physicians from the former Soviet Union were more likely to favour baseline tests. CONCLUSION: Almost all of the physicians in this study reported that they perform baseline tests on most of their patients. Evidence based guidelines for these tests and education of physicians are needed.

Recurrent salmonella sepsis with different species in a systemic lupus erythematosus patient.

Infections are a common cause of morbidity and mortality in systemic lupus erythematosus (SLE) patients. The primary disease process and complications of drug management may contribute to this increased susceptibility. A high incidence of salmonella infections have been reported in SLE patients. We report an unusual case of a SLE patient who developed recurrent salmonella sepsis. The first episode with salmonella typhimurium was followed a few months later by an episode of salmonella enteritides sepsis.

Palmar fasciitis and polyarthritis associated with ovarian carcinoma in a young patient. A case report and review of the literature.

Palmar fasciitis and polyarthritis (PFPA) is an uncommon syndrome characterized by progressive and extensive rheumatic disease. It has usually been associated with neoplasms, most commonly in elderly patients, preceding or accompanying the diagnosis of malignancy. We report a case of a 25-year-old patient with severe deforming PFPA preceding the diagnosis of carcinoma of the ovary. The histopathological findings of diffuse fibrosis, connective tissue proliferation and vasculitis with C3 and IgM deposits in subcutaneous tissue and synovia may further clarify the possible pathogenesis of this unique syndrome.

Conservative treatment of adenocarcinoma of the endometrium in young patients. Is it appropriate?

Few reports have suggested that nulliparous young patients with endometrial cancer may be treated conservatively to preserve fertility. We present a young nulliparous woman with a well differentiated adenocarcinoma of the endometrium treated with progestins. Since she did not respond, a definite operation was performed revealing involvement of the uterine isthmus, thus necessitating adjuvant radiotherapy.

A quality management project in Israeli navy primary care clinics.

The objective of this project was to establish a measurable process of continuous quality improvement of health care services in the Israeli naval primary care clinics. All navy clinics were surveyed at 6-month intervals. The quality of medical recording was evaluated, and instructive workshops were given on the matter. Real-time physician-patient interactions were evaluated, and immediate feedback was given to the examining physician. Complementary medical services were evaluated and steps toward improvement were taken. A total of 1043 medical records were examined. A general improvement in medical-record documentation (from a score of 6.0 +/- 2.5 to a score of 7.4 +/- 1.9, P < .001) was demonstrated during the first 3 years of the project. No significant change was noticed in the physician-patient interaction score. Complementary medical services improved from a score of 4.9 +/- 1.5 in 1994 to a score of 7.4 +/- 0.9 3 years later (P < .02). This project achieved a significant improvement in the quality of medical recording and of complementary medical services.

Israel under threat of biological warfare--the reactions of our patients during the 1998 Persian Gulf crisis.

BACKGROUND AND OBJECTIVES: During February 1998, there was heightened tension in the Persian Gulf area. Iraq's ruler, Saddam Hussein, threatened Israeli citizens with the use of biological weapons. This study observed the use of health care services by patients visiting our clinics during this period. METHODS: During the period of February 17, 1998, through March 1, 1998, 12 family physicians classified all clinic visits as "related" or "unrelated" to the crisis. The participating clinics were situated in (A) high-risk and (B) low-risk areas, according to their location as related to missile hits during the 1991 Gulf War. RESULTS: A total of 1,841 visits were recorded during the crisis period (February 17-23). There were 934 visits in Area A and 907 in Area B. Overall, 194 visits related to the crisis were recorded, of which 155 were in Area A. The rate of crisis-related visits was higher in Area A (16.6% versus 3.4%). There were more visits for authorizations for special masks (8.2% versus .8%), requests for information (3.9% versus 1.3%), and tranquilizers (2.1% versus .5%). In the period subsequent to the agreement reached on February 24, crisis-related visits declined sharply in both areas. CONCLUSIONS: During the crisis, there was an increase in visits related to the threat of biological warfare. The phenomenon was more pronounced in areas that had sustained missile hits during the 1991 Gulf War.

An unusually high prevalence of asthma in Ethiopian immigrants to Israel.

BACKGROUND AND OBJECTIVES: The past 20 years have seen a large immigration of Ethiopian Jews to Israel, primarily in 2 airlifts, one in 1984-1985 and one in 1991. Infectious and parasitic diseases were the dominant health problems in the early years. Recently, we noticed changing health patterns in this population, particularly an increase in clinic visits for asthma, which contrasted with asthma rates of 2.5% reported among Ethiopian Jews at the time of immigration to Israel. This study evaluated the prevalence and characteristics of asthma in a population of Jews of Ethiopian origin who had been in Israel for 8-17 years. METHODS: We audited 302 files of adult patients of Ethiopian origin and 604 files of age- and gender-matched patients of non-Ethiopian origin. Each file was reviewed by 2 physicians. Asthma was defined by published clinical criteria as found in the patient file. Data on allergies and eosinophilia were collected as well. RESULTS: The average age of the 2 groups of asthmatics was 44.1 +/- 16.2 and 42.4 +/- 20.7 years, respectively. The prevalence of asthma in the patients of Ethiopian origin was 51/302 (17%), compared with 35/604 (5.8%) in the control group. Thirty-three percent of the Ethiopian asthmatics and 37% of the control group suffered from various allergic diseases. Among the patients of Ethiopian origin, the prevalence of eosinophilia was 44%, with no significant difference between asthmatics and non-asthmatic patients (49% versus 43%). Eosinophilia was found in 8.4% of the control group. Asthma was more prevalent among patients with eosinophilia (22%) than without eosinophilia (6.4%). CONCLUSIONS: Asthma is 3 times as prevalent in adults of Ethiopian origin, compared with the general population in our clinics, and markedly increased above the rate reported for newly immigrated Ethiopian Jews. We conclude that the move from the rural hills of Ethiopia to the more urban and industrialized setting of Israel has resulted in an increased prevalence of asthma in this population, but the specific cause is uncertain.

Home visits to the housebound patient in family practice: a multicenter study. Israeli General Practice Research Network.

BACKGROUND: Most countries today are experiencing an accelerated pace of population aging. The management of the elderly housebound patient presents a special challenge to the family physician. OBJECTIVES: To investigate a series of home visits to housebound patients, the therapeutic procedures used, the equipment needed, and the diagnostic conclusions reached. METHODS: The details of 379 consecutive home visits to housebound patients were recorded by 91 family doctors serving 125,000 patients in Israel. RESULTS: The average age of the patients was 76.1 years. The vast majority of the visits were during office hours (94%). In 24.1% it was the doctor who decided to make the home visit on his/her own initiative. The most common initial reason for a home visit was undefined general symptoms, but the doctor was usually able to arrive at a more specific diagnosis after the visit. Medications were prescribed in 59.1% of the visits, and in 23.5% the medication was administered directly by the physician. The commonest drugs used were analgesics and antibiotics. In 19.3% of visits no action at all, other than examination and counseling, was undertaken. The equipment needed included prescription pads (73%), a stethoscope (81%), sphygmomanometer (74.9%), and otoscope/torch (30.6%). Only 15% of visits resulted in referral to hospital. CONCLUSIONS: Home visits to housebound patients serve as a support to caregivers, provide diagnostic information, and help the family with the decision as to when hospitalization is appropriate. The specific medical cause for the patient being housebound had little effect on the process of home visiting.

Patients' attitudes towards the presence of medical students in family practice consultations.

BACKGROUND: Patients' consent to being part of medical education is often taken for granted, both in primary and secondary care. Formal consent procedures are not used routinely during teaching and patients are not always aware of teaching activities. OBJECTIVE: To investigate patients' attitudes and expectations on issues of consent regarding participation in teaching in general practice, and the influence of a student's presence on the consultation. METHODS: The study took place in 46 teaching practices during the sixth year clinical internship in family medicine. Patients completed questionnaires at the end of 10 consecutive eligible consultations. The questionnaire contained data on the willingness to participate in teaching, the preferred consent procedure and the effects of the student's presence. The doctors were asked to estimate the sociodemographic level in their clinic area. RESULTS: A total of 375 questionnaires were returned; the response rate was not affected by the clinic's sociodemographic level. Overall, 67% of the patients had come into contact with students in the past; 3.2% of the participants objected to the presence of a student during the consultation; 15% would insist on advance notification of the presence of a student, and another 13.9% would request it; 4% stated that the presence of students had a detrimental influence on the physical examination and history; and 33.6% would refuse to be examined by a student without the doctor's presence. CONCLUSION: Most patients agreed to have a student present during the consultation; some would like prior notification; a minority refused the student's presence. A large minority would refuse to be examined without the tutor's presence. Our findings need to be taken into account when planning clinical clerkships.

Folk, traditional and conventional medicine among elderly Yemenite immigrants in Israel.

BACKGROUND: Migration leads to changes in almost all areas of life including health. But how far are health beliefs also preserved, and how far are they affected by the process of acculturation to the host society? OBJECTIVES: To examine the difference between behavior and attitudes towards conventional and traditional medicine among elderly Yemenite immigrants. METHODS: A community-based study was conducted in the Yemenite neighborhoods in the city of Rehovot. All inhabitants of Yemenite origin over the age of 70 were identified from the population register, excluding those who were institutionalized or demented. Social work students interviewed them at home. The questionnaire inquired after health problems in the preceding month. For each of these problems, the respondent was asked whether any mode of treatment had been employed--Yemenite folk remedies, conventional medical care, or other. Their attitudes towards Yemenite folk medicine and conventional medicine were recorded. Socioeconomic data included their current age, age at immigration, year of immigration, marital status, gender, religiosity, and education. RESULTS: A total of 326 elderly people were identified who fulfilled the selection criteria, of whom 304 (93%) agreed to be interviewed. Of these, 276 (91%) reported at least one health problem in the preceding month, providing 515 problems of which 349 (68%) were reported to a conventional medical doctor while 144 (28%) were treated by popular folk remedies. Fifty-nine problems (11.5%) were treated by specifically Yemenite traditional remedies, mostly by the respondents themselves (38/59) rather than by a traditional healer. Immigrants who arrived in Israel over the age of 30 years, as compared to respondents who immigrated at an earlier age and grew up in Israel, were more likely to use traditional Yemenite remedies (24.4% vs. 8.2%, P < 0.005). CONCLUSION: Aged Yemenite Jews in Israel prefer modern medicine. The earlier the immigrant arrived in Israel, the more positive the attitude towards modern medicine and the less use made of traditional Yemenite healing.