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.

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.

[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.

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.

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.

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.

Usefulness of electronic databases for the detection of unrecognized diabetic patients.

BACKGROUND: Even mild hyperglycemia is associated with future acute and chronic complications. Nevertheless, many cases of diabetes in the community go unrecognized. The aim of the study was to determine if national electronic patient records could be used to identify patients with diabetes in a health management organization. METHODS: The central district databases of Israel's largest health management organization were reviewed for all patients over 20 years old with a documented diagnosis of diabetes mellitus (DM) in the chronic disease register or patient file (identified diabetic patients) or a fasting serum glucose level of >126 mg/100 ml according to the central laboratory records (suspected diabetic patients). The family physicians of the patients with suspected diabetes were asked for a report on their current diabetic status. RESULTS: The searches yielded 1,694 suspected diabetic patients; replies from the family physicians were received for 1,486. Of these, 575 (38.7%) were confirmed to have diabetes mellitus. Their addition to the identified patient group raised the relative rate of diabetic patients in the district by 3.2%. CONCLUSION: Cross-referencing existing databases is an efficient, low-cost method for identifying hyperglycemic patients with unrecognized diabetes who require preventive treatment and follow-up. This model can be used to advantage in other clinical sites in Israel and elsewhere with fully computerized databases.

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.

Prevalence of and change in the prescription of methylphenidate in Israel over a 2-year period.

INTRODUCTION: The use of methylphenidate for the treatment of attention deficit-hyperactivity disorder (ADHD) has increased dramatically in the past decade in some countries in Europe and North America. In response to a public debate in Israel, several Knesset members introduced a legislative initiative that aims to limit the prescription of methylphenidate by physicians. The objective of this study was to examine the rate methylphenidate prescriptions dispensed for the treatment of ADHD in children in northern and central Israel in 1999 and 2001. PATIENTS AND STUDY DESIGN: The population included all children aged 0-18 years living in central or northern Israel and insured by the largest national health management organisation who were prescribed methylphenidate at least once in 1999 or 2001. This was a population-based prevalence study comparing the two timepoints using data from the health management organisation and descriptive statistics. RESULTS: The overall 1-year prevalence of methylphenidate prescriptions dispensed to children was 1.01% in 1999 and 1.22% in 2001 (relative risk [RR] 1.21, 95% CI 1.15-1.26), an increase of 21%. Seventy-seven percent of those prescribed methylphenidate were boys. The prescription rate ranged from 0.2% (RR 1.24, 95% CI 0.76-2.05) in Arabic cities to 5.99% (RR 1.19, 95% CI 1.09-1.30) in kibbutzim; this wide variation by type of residence apparently involved cultural, racial and economic factors. CONCLUSION: Israel shows no unusual or unexpected patterns in methylphenidate prescriptions dispensed to children and a lesser increase over time than other developed countries. This suggests that limiting physician freedom to prescribe methylphenidate to children may not be justified.

Impact of a single-session education program on parental knowledge of and approach to childhood fever.

We evaluated knowledge of and approach to childhood fever in parents before and after attending a single reinforced educational session on the subject given by the pediatrician during a visit with their sick child. The study group consisted of 155 consecutive parents of children who visited the pediatrician for treatment of low-grade fever (<38.5 degrees C) once during the period of July 1999-2000, and again, within 6 months later. The parents received the standard short explanation for fever at the first visit and a reinforced educational session which included discussion supported by written and pictorial material at the second. At the follow-up examination, performed 3-7 days after each visit, the parents completed a questionnaire on their approach to the management of childhood fever, and the responses to the two questionnaires were compared. High-grade fever was correctly defined by 75% of the parents after the reinforced education session compared to 46% before, and over 95% of the parents correctly treated fever after the reinforced session compared to only 50% before. Knowledge of the correct utilization of health services was also improved after the intervention. All these differences were statistically significant. This study suggests that parental knowledge of fever management in children can be significantly improved by a reinforced educational session.

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.

Physicians', nurses', and parents' attitudes to and knowledge about fever in early childhood.

This study investigated physicians', nurses' and parents' approach to fever in early childhood. A total of 2059 questionnaires was completed by the three groups. Though most of the responders (59.8%) believed that fever is a helpful bodily mechanism of the body, there was a significant difference between physicians (85.8%) and nurses and parents (63.9 and 43.1%, respectively) (P<0.001). The majority of parents (62.7%) believed it necessary to treat children with low-grade fever (<38 degrees C) without any other sign of illness, whereas the physicians and nurses did not (10.8 and 30.2%, respectively). Regarding antipyretic medication, 92.3% of the physicians and 84% of the nurses would start treatment for a fever 38-40 degrees C, whereas 38.8% of parents would do so for a fever of 37-38 degrees C. Febrile seizure served as a reason for antipyretic treatment for 34.3% of the nurses and 20% of the parents, compared to 8.7% of the physicians. Finally, fear of brain damage due to fever was noted in almost twice as many nurses as physicians (11.8% versus 7.2%) and in three times as many parents (24.0%) as physicians. Parents and some nurses consider fever a risk factor for serious morbidity, mostly febrile convulsions and brain damage, even though these associations have long since been disproven.

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.

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.

Compliance of primary care doctors with asthma guidelines and related education programs: the employment factor.

BACKGROUND: Primary care physicians' adherence to accepted asthma guidelines is necessary for the proper care of asthma patients. OBJECTIVES: To investigate the compliance of primary care physicians with clinical guidelines for asthma treatment and their participation in related educational programs, and to evaluate the influence of their employment status. METHODS: A questionnaire was administered to a random sample of 1,000 primary care practitioners (pediatricians and family physicians) in Israel. RESULTS: The response rate was 64%. Of the physicians who participated, 473 (75%) had read and consulted the guidelines but only 192 (29%) had participated in an educational program on asthma management in the last 12 months. The younger the responding physician (fewer years in practice), the more likely his/her attendance in such a program (p < 0.0001). After consulting the guidelines 189 physicians (40%) had modified their treatment strategies. Significantly more self-employed than salaried physicians had read the guidelines and participated in educational programs; physicians who were both self-employed and salaried fell somewhere between these groups. This trend was not influenced by the number of years in practice. CONCLUSIONS: All primary care physicians should update their knowledge more often. The publication of guidelines on asthma must be followed by their proper dissemination and utilization. Our study suggests that major efforts should be directed at the population of employed physicians.

The Middle East and IPPNW: recent resolutions and declarations.

The Israeli-Palestinian conflict is characterized by a cycle of violence from both parties. Their policies will continue to fail until realistic and sincere negotiations begin. This essay describes the activities of affiliates of IPPNW and reports a programme to achieve this.

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.