Clinical decision support system recommendations: how often do radiologists and clinicians accept them?

OBJECTIVE: To assess the acceptance and reliability of clinical decision support system (CDSS) imaging referral scores (ESR iGuide). METHODS: A pilot study was conducted in a tertiary hospital. Four different experts were invited to rate 40 simulated clinical cases on a 5-level scale, for the level of agreement with the ESR iGuide's recommended procedures. In cases of disagreement, physicians were asked to indicate the reason. Descriptive measures were calculated for the level of agreement. We also explored the degree of agreement between four different specialists, and examined the cases in which clinicians disagreed with ESR iGuide best practice recommendations. RESULTS: The mean rating of the four experts for the 40 clinical simulated cases was 4.17 ± 0.65, median 4.25 (on a scale of 1-5). All four raters totally agreed with the system recommendation in 75% of cases. No significant relationship was found between the degree of agreement and the number of indications and the patient's age or gender. In an optimistic scenario, using a binary agree/disagree variable, the Overall Percentage Agreement for the rating of the 40 simulated cases between the four experts was 77.28%. There were a total of 20 disagreements out of 160 cases with the ESR iGuide, of which 7 were among the two radiologists. CONCLUSIONS: CDSS can be an effective tool for guiding the selection of appropriate imaging examinations, thus cutting costs due to unnecessary imaging scans. Since this is a pilot study, further research on a larger scale, preferably at national level, is required. KEY POINTS: • The average of the mean rating of the four experts was 4.17 ± 0.65, median 4.25, on a scale of 1-5 where 5 represents total agreement with the CDSS tool. • In an optimistic scenario, using a binary agree/disagree variable, the Overall Percentage Agreement between the four experts was 77.28%. • Radiologists had fewer disagreements with the recommendations of the CDSS tool than other physicians, indicating a better fit of the support system to radiology experts' perspective.

"Some things are even worse than telling a child he is going to die": Pediatric oncology healthcare professionals perspectives on communicating with children about cancer and end of life.

INTRODUCTION: This study explored pediatric oncology healthcare professionals' (HCPs) perspectives on direct communication with children with advanced disease about their disease, palliative care, and end-of-life (EOL) communication. METHODS: Forty-six pediatric oncologists, nurses, psychosocial team members, and other HCPs from six hospital centers in Israel participated in semi-structured interviews. The Grounded Theory method was used. Data were analyzed line-by-line with codes and categories developed inductively from participants' narratives. RESULTS: HCPs viewed communication about disease progression and EOL as vital because children were often aware of their prognosis, because lack of communication could lead to emotional distress, and because communication is a prerequisite for shared decision-making. HCPs identified several barriers for communication including HCP barriers (such as emotional strains, lack of training), parental barriers, guardianship law, and language and culture. HCPs also described strategies to promote EOL communication. Direct strategies include tailoring communication, allowing for silence, echoing children's questions, giving information gradually, and answering direct questions honestly. Indirect strategies included encouraging parents to talk to their children and teamwork with colleagues. CONCLUSIONS: Open communication with children who have cancer is essential. Nevertheless, multiple barriers persist. The rising accessibility of online information calls for urgent training of HCPs in communication so that children will not turn to unmediated and potentially misleading information online in the absence of HCP communication. Evidence-based effective communication training modules and emotional support should be offered to HCPs. Knowledge about children's development, age-appropriate communication, and cultural sensitivity should be included in this training.

Perceptions about the accessibility of healthcare services among ethnic minority women: a qualitative study among Arab Bedouins in Israel.

BACKGROUND: Access to healthcare services has major implications for vulnerable populations' health. Socio-cultural and gender characteristics shape the utilization and access of healthcare services among ethnic minorities worldwide. One such vulnerable ethnic minority is the Arab Bedouin women in Israel. As women, they are marginalized in their community, where women do not have full equity and they experience multiple barriers to healthcare services The main objective of this study is to provide a nuanced, experiential, emic description of healthcare accessibility issues among Bedouin women in Israel. Identifying the barriers, they face in accessing healthcare may help healthcare policymakers make changes based on and tailored to Bedouin women's needs. METHODS: A qualitative study included in-depth semi-structured interviews with 21 Arab Bedouin village residents, consisting of 14 women and 7 men. Eligible participants were Arab Bedouins over 18 years of age and who used healthcare services at least once in the last 5 years. The interviews were carried out in Arabic-Bedouin dialect and included demographic questions, open-ended questions that asked about participants' perceptions regarding their experiences with healthcare services, including the factors that helped and hindered them in accessing these services and questions regarding suggestions for improving the accessibility of healthcare services based on the identified needs. Data collected were analyzed using thematic analysis. Study trustworthiness was ensured using audit, reflexivity, and peer debriefing. RESULTS: Arab Bedouin women experienced varied barriers while accessing healthcare services. This study uncovered how language, cultural and gender barriers intersect with other disadvantages ingrained in social norms, values and beliefs and affect the access of a minority women subgroup to healthcare services. The participants identified subgroups of Bedouin women (e.g. elderly Bedouin women) affected differently by these barriers. CONCLUSION: Taking into consideration the identified needs and the Arab Bedouin women's unique characteristics, along with adopting the intersectional approach should help improve access to healthcare services among such a vulnerable subgroup and other subgroups within minorities worldwide.

Oncologist conceptualizations of pediatric palliative care: challenges and definitions.

PURPOSE: Pediatric palliative care (PC) is an evolving field and involves a comprehensive approach to care of children with cancer. The goal of this paper was to explore how pediatric oncologists define, interpret, and practice pediatric palliative care in their clinical settings. METHODS: The study used the grounded theory approach to data collection and analysis. Twenty-one pediatric oncologists from six pediatric cancer centers across Israel were interviewed. Data was analyzed using line-by-line coding. RESULTS: The analysis resulted in a four-tiered conceptual model. This model included the following categories: (1) ill-defined concept; (2) philosophies of palliative care; (3) trajectory of palliative care; and (4) palliative care treatment goals. CONCLUSION: The findings illustrate the current conceptualizations of pediatric palliative care among the pediatric oncology community in Israel. The conceptual model documents their understanding of pediatric palliative care as a philosophical approach and the challenges they face in differentiating between palliative care and standard pediatric oncology care. Pediatric palliative care is a highly needed and valued sub-specialty. The findings from this study highlight the importance for its continued development in Israel, as it can reduce the suffering of children and their families. Concurrently, pediatric oncologists need to have more resources and access to explicit knowledge of the conceptual and practical aspects of both primary and specialized pediatric palliative care.

Organizational and individual barriers and facilitators to the integration of pediatric palliative care for children: A grounded theory study.

BACKGROUND: Pediatric palliative care has established benefits for children with cancer and their families. Overcoming organizational and healthcare provider barriers have been demonstrated as central for the provision of palliative care in pediatric oncology. A deeper understanding is needed of the influence of these barriers and the interactions between them, specifically in primary palliative care in hospital settings. AIM: To identify the organizational and healthcare provider barriers to the provision of primary pediatric palliative care. DESIGN: This study utilized the grounded theory method. Semi-structured interviews were conducted and analyzed line by line, using NVivo software. SETTING/PARTICIPANTS: Forty-six pediatric oncologists, nurses, psychosocial team members, and other healthcare providers from six academic hospital centers participated in the research. RESULTS: Organizational and healthcare provider factors were identified, each of which acted as both a barrier and facilitator to the provision of pediatric palliative care. Organizational barriers included lack of resources and management. Facilitators included external resources, resource management, and a palliative care center within the hospital. Individual barriers included attitudes toward palliative care among pediatric oncologists, pediatric oncologists' personalities, and the emotional burden of providing palliative care. Facilitators include dedication and commitment, initiative, and sense of meaning. Provider facilitators for palliative care had a buffering effect on organizational barriers. CONCLUSION: Organizational and healthcare provider factors influence the quality and quantity of palliative care given to children and their families. This finding has implications on interventions structured to promote primary palliative care for children, especially in healthcare systems and situations where resources are limited.

Public health nurses' activities at a time of specialization in nursing-A national study.

OBJECTIVES: To provide a detailed, up-to-date account of the job description and practice areas of current public health nurses. DESIGN AND SAMPLE: A cross-sectional study. A sample of 824 public health nurses, 80% of public health nurses in Israel, participated in a national structured survey. MEASURES: A structured questionnaire eliciting self-reported public health nursing activities, priorities, perceived deficiencies, and job satisfaction was compiled. RESULTS: Nearly 70% of surveyed public health nurses provided individual-level interventions and less population-health-focused activities such as community needs assessments and development and implementation of community-based projects. CONCLUSIONS: Advanced training should be required in several areas of practice and the scope of public health nurses' practice should be expanded, with greater emphasis on population health.

Lessons learned from the 2009-2010 H1N1 outbreak for the management of the 2013 silent polio outbreak.

BACKGROUND: The Israeli Ministry of Health (MoH) encountered two substantial outbreaks during the past decade: the H1N1 swine flu outbreak during 2009-2010 and the silent polio outbreak during 2013. Although both outbreaks share several similar characteristics, the functioning of the Israeli MoH was different for each case. The aim of this study was to identify factors that contributed to the change in the MoH response to the polio outbreak in light of the previous 2009-2010 H1N1 outbreak. METHODS: We conducted a qualitative research using semi-structured interviews with 18 Israeli policymakers from the MoH, relevant specialists and politicians. Each interview was transcribed and a thematic analysis was conducted independently by two researchers. RESULTS: Three main themes were found in the interview analysis, which reflect major differences in the MoH management policy during the polio outbreak. 1) clinical and epidemiological differences between the two disease courses, 2) differences in the functioning of the MoH during the outbreaks, 3) differences in the risk communication strategies used to reach out to the local health community and the general public. Most interviewees felt that the experience of the 2009-2010 H1N1 outbreak which was perceived as unsuccessful, fueled the MoH engagement and proactiveness in the later polio outbreak. CONCLUSION: These findings highlight the importance of learning processes within health care organizations during outbreaks and may contribute to better performance and higher immunization rates.

Laypersons' views of material incentives for enhancing colorectal cancer screening.

BACKGROUND: Colorectal cancer (CRC) early detection improves health outcomes; screening programmes invest efforts in initiating invitations to target populations to be tested. Enhanced adherence is essential for reduction of morbidity and mortality. Participation rates in Israel are still relatively low. OBJECTIVE: To explore lay views regarding the concept of receiving material incentives in exchange for enhanced adherence to CRC screening. RESEARCH DESIGN: Qualitative study. Between November 2009 and February 2010 six focus group discussions were carried out in two urban, middle and low socio-economic status primary care clinics in a Northern city in Israel. Participants were eligible individuals for CRC screening, aged 50-68 (N = 24). Data analysis followed the principles of grounded theory, supported by qualitative software. RESULTS: Participants found administering incentives in exchange for CRC screening inappropriate on rational and moral grounds. They valued their relations with the medical team and the health system more than the potential gain expected. Individuals eligible for CRC screening perceived themselves as responsible for their health, admitting difficulties in realizing this responsibility. Incentives were reported unsuitable for solving reported screening difficulties and a potential harm to the doctor-patient relationship. CONCLUSIONS: Focus group participants expressed an unconventional voice towards the use of material incentives. They pointed to the need for focused support of health behaviour change and valued their autonomy. While a proportion of the invitees in the target population see the importance of screening and appreciate the HMO's initiative to invite them for testing, they also expressed their need for support from the HMO in realizing the recommended health behaviour.

Religious leaders' opinions and guidance towards oral health maintenance and promotion: a qualitative study.

Religions emphasize the supreme value of life. However, potential or concrete conflicts of perception between dictates of faith and science often present an inescapable dilemma. The aim of this qualitative research was to examine the views of spiritual and religious leaders towards general and oral health issues. A total of 11 eminent Jewish spiritual and religious community leaders were purposively chosen. They were interviewed using a semi-structured questionnaire. The verbatim transcriptions of the interviews were analysed in the spirit of grounded theory, using qualitative data analysis software. Open, axial, and thematic coding served to build categories and themes. Analysis of participants' perspectives reflected that they, based upon Jewish theology, attributed high importance to primary prevention at both personal and community levels. Religious and orthodox people were depicted as being motivated towards maintaining oral health behaviours due to a sense of obligation to follow religious edicts, strong social support, and elevated perceived spiritual levels. We offer a theoretical model that can explain the potential high motivation among these communities towards implementing positive general and oral health behaviours. Religiosity may be regarded as an example of a psycho-social health determinant, encompassing spiritual belief ("psycho") and social support ("social") components.

[How deaf people cope in routine and emergency situations - suggested paths for thought and action].

Deaf people have unique characteristics and needs. There is a limited amount of research regarding the needs of deaf people, and no studies were found concerning deaf people in emergency situations. The absence of the sense of hearing in deaf people is only one component of the complexity of their world. Many factors contribute to this complexity, but the most striking is the means of communication between the deaf and the hearing person and vice versa. Changes during emergency situations present a challenge for hearing individuals, and even more so, for deaf people. Deaf individuals experience difficulty in obtaining and transmitting information, accessing care and more. These difficulties often result in the dependency of the deaf person on others. The State of Israel enacted laws targeted to facilitate the access of individuals with disabilities in general, and deaf people in particular, to public services. In emergencies, the Home Front Command and the Ministry of Social Welfare distribute pagers to the deaf population, as a device to communicate warning alerts. However, these devices do not fulfil the need for accessible care, bi-directional flow of information, and additional needs that arise during times of emergency. The deaf population is a cultural minority, whose needs in emergency situations are unknown. Familiarity with the deaf population is the first step towards improving treatment and communication that are apt for this population. This paper reviews what is known in the literature about this topic and presents an attempt to bridge the gap of knowledge and barriers to communication between the deaf population and

[How deaf people cope in routine and emergency situations - suggested paths for thought and action].

Oeaf people have unique characteristics and needs. There is a limited amount of research regarding the needs of deaf people, and no studies were found concerning deaf people in emergency situations. The absence of the sense of hearing in deaf people is only one component of the complexity of their world. Many factors contribute to this complexity, but the most striking is the means of communication between the deaf and the hearing person and vice versa. Changes during emergency situations present a challenge for hearing individuals, and even more so, for deaf people. Deaf individuals experience difficulty in obtaining and transmitting information, accessing care and more. These difficulties often result in the dependency of the deaf person on others. The State of Israel enacted laws targeted to facilitate the access of individuals with disabilities in general, and deaf people in particular, to public services. In emergencies, the Home Front Command and the Ministry of Social Welfare distribute pagers to the deaf population, as a device to communicate warning alerts. However, these devices do not fulfil the need for accessible care, bi-directional flow of information, and additional needs that arise during times of emergency. The deaf population is a cultural minority, whose needs in emergency situations are unknown. Familiarity with the deaf population is the first step towards improving treatment and communication that are apt for this population. This paper reviews what is known in the literature about this topic and presents an attempt to bridge the gap of knowledge and barriers to communication between the deaf population and

"When everyone is responsible, no one takes responsibility": exploring pediatric physiotherapy services in Israel.

BACKGROUND: According to Israel's National Health Insurance Law (1994), the Ministry of Health is responsible for the provision of health services in the country including physiotherapy services; moreover, the Special Education Law (1988), stipulates that physiotherapy services for children with motor disabilities, as well as other allied health services, are provided by the Ministry of Education in educational settings. Thus, children with motor disabilities are entitled PT services under two different laws by two different ministries. METHOD: To describe the physiotherapy services for children with motor disabilities and examine how policymakers view these services, we conducted a qualitative study including in-depth semi-structured interviews with 10 policymakers from the Ministry of Health and the Ministry of Education, and the national directors of physiotherapy services from three of the four health maintenance organizations in Israel. RESULTS: Study results indicate that there is an array of physiotherapy services and providers. Despite the regulation of these services for children with motor disabilities, uncertainty and lack of knowledge were found about various issues. Therefore, the thematic analysis was structured around four descriptive questions: Where do the children receive physiotherapy? Who is eligible for physiotherapy treatment and who receives treatment? What interventions do children with motor disabilities receive? Who provides therapy for children with motor disabilities? CONCLUSIONS: Policymakers are dubious regarding the provision of these services, questioning whether children with motor disabilities receive physiotherapy services according to their needs. In addition, the abundance of suppliers does not necessarily improve the quality of services provided to children with motor disabilities, which may ultimately harm their developmental potential.

"I feel like this is an area where one can feel a lot of satisfaction": Physiotherapy students' preferences for their prospective area of practice.

OBJECTIVES: To identify physiotherapy students' preferences about their prospective area of practice and the reasons for their choices. METHODS: Tel-Aviv University physiotherapy students participated in a cross-sectional survey and three open-ended questions that comprise the qualitative component of the study. At the very beginning of their studies, and at the end of the first to fourth years, participants were asked about their area of preference, the factors that shaped their choice, and the reasons for prospective changes in their preference. RESULTS: In total, 289 students filled out the survey. Response rate was 68%. Interest in some areas of practice such as pediatrics remained stable throughout years of physiotherapy studies. In contrast, interest in other areas such as sports declined and interest in others such as rehabilitation increased. The open-ended questions yielded 1,616 codes sorted into five categories that shaped the students' preferences: "I/Me /My" the largest category, followed by "the physiotherapy studies program" and then the relational focused "physiotherapy practice." The number of codes for "working conditions" and "work-life balance" increased steeply with the progression of the studies and the age of the students. CONCLUSIONS: The choice for areas of practice of physiotherapy students vary during their professional formation. During their professional development, their preferences are shaped by their personal feelings, interest in and past experience with the specific areas of practice, as well as their practical exposure, experiences in practicums, and theoretical studies. Millennial physiotherapists prefer areas of practice in which personal as well as relational considerations are core.

Residents' choice of a placement in periphery hospitals in Israel: The significance of personal/family and professional considerations.

Physician maldistribution affects remote and rural population health indicators and as such constitutes a major concern for health systems. Various countries, including Israel, have sought to remedy this problem, often by implementing more than one intervention simultaneously. In this paper, we explored the considerations that motivated Israeli residents to opt for a position in the periphery, as well as potential factors that could facilitate their retention in these underserved areas. We found that the motivation driving young physicians to specialize in a specific hospital includes personal- and family-oriented considerations (proximity to the nuclear family, perceived quality of life and lifestyle) as well as professional considerations (prior acquaintance with a hospital and a specific hospital department, department characteristics, availability of a residence position in a preferred specialty, prospective professional advancement). We therefore argue that the key to recruitment and retention of young physicians in remote areas lies in tailored interventions that take personal, professional and regional issues into account, preferably in consultation with the physicians themselves. The prominence of personal issues in the interviews with young physicians suggests that effective interventions should support a work-life balance. Hence success in attracting residents as a first step towards correcting physician maldistribution hinges upon coordinating policies in the medical field with policies in non-medical arenas - education, welfare, local authorities.

Financial risk-sharing in updating the National List of Health Services in Israel: stakeholders' perceived interests.

OBJECTIVES: Risk-sharing is being considered by many health care systems to address the financial risk associated with the adoption of new technologies. We explored major stakeholders' views toward the potential implementation of a financial risk-sharing mechanism regarding budget-impact estimates for adding new technologies to the Israeli National List of Health Services. According to our proposed scheme, health plans will be partially compensated by technology sponsors if the actual use of a technology is substantially higher than what was projected and health plans will refund the government for budgets that were not fully utilized. METHODS: By using a semi-structured protocol, we interviewed major stakeholders involved in the process of updating the National List of Health Services (N = 31). We inquired into participants' views toward our proposed risk-sharing mechanism, whether the proposed scheme would achieve its purpose, its feasibility of implementation, and their opinion on the other stakeholders' incentives. RESULTS: Participants' considerations were classified into four main areas: financial, administrative/managerial, impact on patients' health, and influence on public image. Most participants agreed that the conceptual risk-sharing scheme will improve the accuracy of early budget estimates and were in favor of the proposed scheme, although Ministry of Finance officials tended to object to it. CONCLUSIONS: The successful implementation of risk-sharing schemes depends mainly on their perception as a win-win situation by all stakeholders. The perception exposed by our participants that risk-sharing can be a tool for improving the accuracy of early budget-impact estimates and the challenges pointed by them are relevant to other health care systems also and should be considered when implementing similar schemes.

Pro-vaccination Groups Expressing Hesitant Attitudes: A Cross-Sectional Study About the Difference Between Attitudes and Actual Behavior in Israel.

Background: Vaccines have contributed to the decline in mortality, morbidity, and even the eradication of various infectious diseases. Over time, the availability of information to the public and the request for public involvement in the health decision-making process have risen, and the confidence in vaccines has dropped. An increasing number of parents and individuals are choosing to delay or refuse vaccines. Objectives: (1) Identifying hesitant attitudes among pro-vaccination parents; (2) testing the difference between the rate of hesitant attitudes and the rate of hesitancy in practice among pro-vaccination parents; and (3) examining the association of sociodemographic characteristics (gender, age, marital status education and religious affiliation) with the difference between hesitant attitudes and hesitancy in practice among pro-vaccination parents. Methods: Descriptive cross-sectional survey using an online survey that measured vaccine hesitancy among pro-vaccination parents (n = 558) whose children were in kindergarten (3-5 years), according to a variety of sociodemographic characteristics. Results: A significant difference was found between the rate of hesitant attitudes and the rate of hesitation in actual vaccination among pro-vaccination and hesitant parents, where despite that 26% of the parents had hesitant attitudes, only 19% hesitated in practice [P = 0.0003]. There was also a significant difference between the rate of hesitant attitudes and the rate of hesitancy in practice among women [P = 0.0056] and men [P = 0.0158], parents between 30 and 39 years of age [P = 0.0008], traditional parents [P = 0.0093], Non-academic parents [P = 0.0007] and parents with BA degree [P = 0.0474]. Conclusion: Pro-vaccination individuals may have hesitant attitudes regarding vaccines. Therefore, it is very important for health authorities to address the public's fears and concerns, including those who are classified as pro-vaccination.

Hesitant and anti-vaccination groups: A qualitative study on their perceptions and attitudes regarding vaccinations and their reluctance to participate in academic research- an example during a measles outbreak among a group of Jewish parents in Israel.

Background: Vaccination is widespread in Western countries and, overall, there is a high vaccination rate. However, immunization is still an enduring challenge. In recent years, the number of parents who choose to delay or refuse vaccines has risen. Objectives: (1) to identify the perceptions and attitudes of hesitant and anti-vaccination parents regarding vaccination in general, and vaccinating their children in particular and; (2) to describe the responses of potential participants to the request to participate in academic research regarding their perceptions and attitudes on the subject of vaccines. Methods: The research employs the qualitative hermeneutic phenomenological method using two research tools: (1) in-depth interviews with 7 hesitant and 11 anti-vaccination Jewish parents in Israel; and (2) the researchers' field notes from this study process, which describe the responses of 32 potential participants to the request to participate in this academic research. Results: The main findings indicate that while most of the interviewees admit to the efficacy of vaccines in preventing diseases, they oppose the way in which vaccines are promoted-based on providing partial information and disregarding parents' concerns and questions. Therefore, they demand transparency about the efficacy and safety of vaccines. The findings also point to a paradoxical finding. On the one hand, these groups claim that health organizations do not understand their position, referring to them as "science-deniers", even though they are not. On the other hand, these parents choose to refrain from participating in scientific studies and voicing their opinions, thereby perpetuating the situation of being misunderstood. Conclusion: Hesitant and anti-vaccination groups express mistrust in academic institutions and health organizations. Therefore, an effective dialogue that would include hesitant and anti-vaccination groups, the academy, and health organizations may contribute to a better understanding of the barriers that prevent these groups from getting vaccinated or vaccinating their children and promote public health.

Factors Involved in the Food Choices of Diners in a Kibbutz Communal Dining Room Buffet: A Qualitative Study.

Improving nutrition improves health outcomes. Eating in a catering system may provide an environment for promoting healthy dietary choices. To map the factors that shape the food choices of diners who routinely eat in catering systems, we collected and analyzed qualitative data about diners' perceptions of their food choices in communal dining rooms in three kibbutzim in Israel. From May to July 2014, we conducted in-depth, semi-structured, face-to-face interviews with 13 diners who ate at least three lunches per week in the kibbutz's dining room. Data analysis followed thematic analysis principles. Two categories of themes emerged from the interviews. In the personal context category, the themes identified were eating as a task and attempts to control one's eating. In the contextual aspects of eating in the catering system category, themes identified were eating in the dining room as a default, the characteristics of the food served, routine, and personal versus public aspects. The sub-theme of the diners' freedom of choice emerged in the two categories of themes. Diners' wishes of maintaining their freedom of choice may be an important contribution to the debate of whether catering systems should provide only healthy foods, which may jeopardize diners' freedom of choice.