Israel Medical Association Journal

Background: In the past decade, numerous new imaging and laboratory tests have been implemented that significantly contribute to improved medical diagnostic capabilities. However, inappropriate utilization, which occurs on a large scale, has significant ramifications for both patient care and health systems.

Objectives: To assess the impact of a novel clinical decision support system (CDSS) applied to our electronic medical records on abdominal ultrasonography utilization pattern.

Methods: We conducted a retrospective cohort study comparing patterns of abdominal ultrasound utilization in cases of liver enzyme elevation, with and without CDSS, between February and May in 2017 (before CDSS implementation) and during the same months in 2018 (after CDSS implementation). The following parameters were collected: number of tests ordered according to the guidelines, tests with a diagnostic value, and order forms completed with any data or a diagnostic question. The comparison was conducted using chi-square test.

Results: Of 152 abdominal ultrasound tests, 72 were ordered in the pre-implementation period and 80 in the post-implementation period. The system failed to reach statistical significance regarding the rates of ordered tests according to the guidelines and/or tests with a diagnostic value. However, the use of the CDSS had a statistically significant impact regarding completing the order form with data, including a specific diagnostic question.

Conclusions: The effect of the system on the efficiency of test utilization was partial. However, our findings strongly suggested that CDSS has the potential to promote proper usage of complementary technologies.

Background: Survivors of acute myocardial infarction (AMI) are at increased risk for recurrent cardiac events and tend to use excessive healthcare services, thus resulting in increased costs.

Objectives: To evaluate the disparities in healthcare resource utilization and costs throughout a decade following a non-fatal AMI according to sex and ethnicity groups in Israel.

Methods: A retrospective study included AMI patients hospitalized at Soroka University Medical Center during 2002–2012. Data were obtained from electronic medical records. Post-AMI annual length of hospital stay (LOS); number of visits to the emergency department (ED), primary care facilities, and outpatient consulting clinics; and costs were evaluated and compared according sex and ethnicity groups.

Results: A total of 7685 patients (mean age 65.3 ± 13.6 years) were analyzed: 56.8% Jewish males (JM), 26.6% Jewish females (JF), 12.4% Bedouin males (BM), and 4.2% Bedouin females (BF). During the up-to 10-years follow-up (median 5.8 years), adjusted odds ratios [AdjOR] for utilizations of hospital-associated services were highest among BF (1.628 for LOS; 1.629 for ED visits), whereas AdjOR for utilization of community services was lowest in BF (0.722 for primary clinic, 0.782 for ambulatory, and 0.827 for consultant visits), compared with JM. The total cost of BF was highest among the study groups (AdjOR = 1.589, P < 0.01).

Conclusions: Long-term use of hospital-associated healthcare services and total costs were higher among Bedouins (especially BF), whereas utilization of ambulatory services was lower in these groups. Culturally and economically sensitive programs optimizing healthcare resources utilization and costs is warranted.

Background: Surgery is a core activity in hospitals. Operating rooms have some of the most important and vital functions in medical centers. The operating rooms and their staff are a valuable infrastructure resource and their availability and preparedness affect human life and quality of care.

Objectives: To prepare operational suggestions for improving operating room utilization by mapping current working processes in the operating rooms of a large private medical center.

Methods: Data on 23,585 surgeries performed at our medical center between August 2016 and March 2017 were analyzed by various parameters including utilization, capacity, working hours, and surgery delays.

Results: Average operating room utilization was 79%, while 21% was considered lost operating room time. The two major factors that influenced the lost operating room time were the time intervals between planned usage blocks and the partial utilization of operating room time. We calculated that each percent of utilized operating room time translates into 440 surgeries annually, resulting in a potential annual increase in income.

Conclusions: Increasing operating room utilization would result in an improvement of operating room availability and an increased number of procedures. Our analysis shows that operating room utilization in the private healthcare system is efficient compared to the public healthcare system in Israel. Therefore the private healthcare system should be treated as a contributing factor to help lower surgery waiting times and release bottlenecks, rather than being perceived as contributing to inequality.

Background: Frailty is a dynamic process with transitions over time.

Objectives: To examine frailty transitions and their relationship to utilization of health services. 

Methods: Frailty status using the Vulnerable Elders Survey (VES-13) was determined for 608 community-dwelling older people interviewed in a 2008 national survey and for 281 re-interviewed in 2014. The effect of frailty on death 6 years later was assessed using Cox proportional hazards analysis. Participants were divided into four groups based on their frailty transition. Demographic, functional and health characteristics were compared between the four groups using the Kruskal-Wallis and paired t-test. The independent association between the four frailty groups and health services utilization was assessed using logistic regression. 

Results: Between 2008 and 2014, 24% of 608 participants were lost to follow-up, 9% were non- frail, 37% were frail, and 30% died. The Cox ratio showed that 86% of the non-frail in 2008 were alive 6 years later vs. 52% of the frail (hazard ratio 3.5, confidence interval 2.2–5.4). Frailty transitions in the 281 participants interviewed at both time points revealed that 19% stayed non-frail, 22% became frail, 22% stayed frail and 37% became more frail. Becoming frail, staying frail or becoming more frail compared to staying non-frail was independently associated with a greater risk for requiring help on a regular basis, having a formal caregiver, and requiring home care. 

Conclusions: Any transition away from the non-frail state increased the use of health care services. Interventions to target early transition to frailty should be encouraged.

 

Background: The number of patients awaiting organ transplantation continues to exceed the number of available organs. 

Objectives: To document changes in the demographic characteristics of brain-dead, heart-beating organ donors over the past 10 years which may impact on organ utilization. 

Methods: Data were extracted from the Israel Transplant Registry and the Donor Action database for the 10 year period 2004–2013, inclusive. 

Results: The median age of the donors increased from 44 (range 3–73 years) to 53.5 years (range 1–79 years) (P < 0.001). There was a significant increase in the median age of donors of kidney (33 to 51 years, P < 0.001), liver (41 to 53 years, P < 0.001) and lung (40 to 49.5 years, P < 0.001). The number of donors dying from trauma decreased (34.5% to 20%, P < 0.001), while those with anoxic brain damage increased (14.5% to 25%, P < 0.001). The percent of male donors decreased over the study period, from 63% to 53%. An increase was noted in the mean number of organs transplanted per donor, from 3.29 to 3.82 per donor, due mainly to a significant increase in the utilization of lungs (31.5% to 51.3%, P < 0.001) and livers (76.3% to 82.4%, P < 0.001) while heart utilization decreased significantly since 2006 (40.9% to 17.5%, P < 0.001). 

Conclusion: Trends in the heart-beating, brain-dead organ donor pool in Israel over the past 10 years reveal significant changes in demographic characteristics which in the future will impact on the number of organs available for transplantation. 

 

Objectives: To evaluate health utilization patterns in two primary care clinics in southern Israel: one under continuous attacks of Qassam rockets as compared with a similar clinic not under a rocket threat.

Methods: We conducted a retrospective cross-sectional study in two primary care clinics in southern Israel, with 11,630 persons listed in the two clinics during the entire study period. The primary outcome measures were total annual number of visits per person to the clinic and for specific diagnoses, and the number of drug prescriptions issued, emergency room (ER) visits, hospitalization days, cardiac catheterizations and coronary bypass surgeries.

Results: In both clinics there was an increase over time in the mean annual number of visits per person. During the years of severe attacks there was an increase in visits with a chief complaint of depression and anxiety and an increase in the number of anxiolytic prescriptions in the study clinic compared with the control. During the same period there was a decrease in the number of ER visits in the study clinic compared with the control.

Conclusions: The population under continuous life-threatening events showed more depression and anxiety problems. Under severe bombardment, the residents prefer not to leave home, unless necessary.

Background: During military escalations emergency departments provide treatment both to victims of conflict-related injuries and to routine admissions. This requires special deployment by the hospitals to optimize utilization of resources.

Objectives: To evaluate “routine” visits to the ED[1] during Operation Cast Lead in Israel in 2008–2009.

Methods: We obtained data regarding routine visits to the ED at Soroka University Medical Center throughout OCL[2]. The visits one month before and after OCL and the corresponding periods one year previous served as controls.

Results: The mean number of daily visits throughout the study period (126 days) was 506 ± 80.9, which was significantly lower during OCL (443.5 ± 82) compared with the reference periods (P < 0.001). Compared to the reference periods, during OCL the relative rates were higher among Bedouins, visitors from the region closest to the Gaza Strip (< 30 km), patients transported to the ED by ambulance and patients of employment age; the rates were lower among children. No difference in the different periods was found in the rate of women patients, distance of residence from Beer Sheva, rate of patients referred to the ED by a community physician, and hour of arrival. The overall in-hospital admission rate increased during OCL, mainly in the internal medicine and the obstetric departments. There was no change in the number of in-hospital births during OCL; however, the rate of preterm labors (32–36 weeks) decreased by 41% (P = 0.013).

Conclusions: Throughout OCL the number of routine ED visits decreased significantly compared to the control periods. This finding could help to optimize the utilization of hospital resources during similar periods.

Background: Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve prognosis in congestive heart failure and are the treatment of choice in these patients; despite this, the rates of ACE-I[1] usage in heart failure patients remain low in clinical practice.

Objectives: To evaluate the rate of ACE-I/ARB[2] treatment in hospitalized patients with CHF[3], and analyze the reasons for non-treatment.

Methods: We prospectively evaluated 362 consecutive patients hospitalized with CHF. Patients were evaluated for ACE-I/ARB usage at discharge and were followed for 1 year.

Results: At hospital discharge 70% of the patients were prescribed ACE-I/ARB treatment. Only 69% received recommended target or sub-target dosages, proven to improve prognosis. This decreased to 63% and 59% at 6 months and 12 months of follow-up respectively, due to a shift from sub-target levels to low dosages. Justified reasons for under-treatment were apparent in only 25% not optimally treated discharged patients and this decreased to 12% and 4% at 6 and 12 months follow-up, respectively. Common reasons for non-treatment at discharge were hyperkalemia and elevation in serum creatinine, while hypotension and cough were more prominent at follow-up. Clinical parameters associated with increased treatment rates were ischemic heart disease and the absence of chronic renal failure. Patients receiving treatment had lower hospitalization and mortality rates.

Conclusions: ACE-I/ARB treatment is still underutilized in patients discharged from hospital with a diagnosis of CHF. Increasing the awareness of the importance of these drugs may increase the number of patients treated.

Background: The national program for the prevention of Down syndrome includes screening (using the triple test) and invasive diagnostic tests in women at risk for a Down syndrome pregnancy. However, despite the program, the majority of Down syndrome infants are born alive (approximately 1/1000 live births)

Objectives: To determine whether the relatively high incidence of Down syndrome at birth in Israel is the result of failure of the preventive program or due to informed choices of the mothers.

Methods: We conducted a retrospective study using the national registry of Down syndrome for the years 1997 and 2004, according to the mothers' religion and place of residence and the reasons for prenatal diagnosis.

Results: Most of the babies affected with Down syndrome are born in religious or traditional conservative communities where termination of pregnancy is usually not an option.

Conclusions: In a pluralistic society like Israel with its diverse communities and dissimilar religious backgrounds and traditions, the different attitudes concerning utilization of the national program should be respected. It is necessary to tailor different approaches and solutions for the various ethnic and religious communities according to their need.
 

Background: Healthcare behavior occurs within the context of the family unit. Little research has investigated the influences among adult family members regarding their use of medical care services.

Objectives: To investigate the effects of maternal attendance patterns and maternal self-assessed health status on those of adult children.

Methods: This study was a retrospective cohort, analyzing both patient records for physician visits and mailed self-administered questionnaires regarding subjective health assessment. We evaluated a unique study group of multi-generational families with free and equal access to medical services at a primary care kibbutz clinic in Israel. This enabled an exclusive focus on the association between the use of healthcare by mothers and their grown children.

Results: Controlling for the subjects' age, gender and number of chronic diagnoses, a significant association exists between the family physician visit rates of a mother and those of her grown offspring (P = 0.03). Low self-health assessment is associated with higher levels of physician utilization (P = 0.003). Maternal self-health evaluation is associated with her adult children's own self-health evaluation (odds ratio 5.9, P = 0.04) and their rates of physician utilization (one additional offspring visit per year for low maternal self-health, P = 0.02).

Conclusions: A mother’s behavior patterns measured via self-rated health status and physician visit rates serve as a proxy for maternal attitudes regarding healthcare, and these attitudes are possibly imparted to her children for life. This study provides unique evidence for a maternal health behavior effect on grown children, and enables a more complete understanding of families attending the primary care clinic.
 

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[1] 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[2] (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 policy will likely improve quality of care and reduce costs to the health fund.

Background: In Israel, preventive services for mothers and children are provided mainly by the Ministry of Health through a network of Maternal and Child Health clinics, and partly by municipalities and health maintenance organizations. Utilization of the MCH[1] clinics for prenatal care has declined during the last decades.

Objective: To study the utilization and satisfaction with prenatal care services following the introduction of the National Health Insurance Law.

Methods: The study population comprised a national sample of Jewish and Arab women who were interviewed by telephone regarding the following: main service utilized for prenatal care, physician and nursing visits, satisfaction with care, and demographic and other characteristics. The response rate was 92% among Jewish women and 88% among Arab women.

Results: Twenty percent of the Jewish and 52% of the Arab women selected MCH clinics as the main service for prenatal care. The great majority of the study population attended the HMO[2] services (clinics, independent physicians, women’s health centers), while 7% of the Jewish and 4% of the Arab women visited a private clinic. The predisposing factors affecting the women's choice were educational level, ethnic group, religiosity, district of residence, and type of HMO. The mean number of physician visits was more than the eight visits recommended. Forty percent of the sample visited with three or more physicians at different services. More than 50% of the women had no appointment with a nurse, mainly those who chose the services of an HMO clinic, independent physician, or private physician. Satisfaction with the physician, nurse, and physical structure of the main service chosen for prenatal care was high.

Conclusions: Since the majority of women preferred the HMO services, the merging of prenatal care with curative care provided by the HMOs has to be considered. Public health nurses should be integrated in the service, and their specific role needs to be defined.

Background: Due to multiple chronic illness and disability, the elderly consume a disproportionately large share of medications.

Objectives: To assess the patterns and determinants of drug use among the community dwelling old-old population.

Methods: The study population included 1,369 old-old persons from the baseline data of the Cross-Sectional and Longitudinal Aging Study (CALAS), which is based on a national random stratified sample of the Israeli Jewish population aged 75–94 years.

Results: The mean number of drugs used by the study population was 3.3, and only 12.5% did not consume any drugs. Multivariate linear regression analysis showed that women used significantly more drugs than men, and that those born in Europe took significantly more drugs than those born in Israel and Asia-Africa. The number of medical conditions was the strongest predictor of drug use. Hospitalizations during the last year and frequent visits to family physician were also significant factors related to drug use. All variables combined explained 40% of the variance in drug use by the old-old. The most commonly used therapeutic groups were cardiovascular drugs (53%), psychotropic drugs (31%), analgesics (30%), and gastrointestinal drugs (28%).

Conclusions: Our data indicate that in addition to the association of drug use with health status and healthcare utilization, the number and type of drugs taken vary with gender and place of birth.

Background: Alternative medicine use is increasing worldwide and the associated expenditures are significant. In Israel 19% of patients who consulted their family physician had also sought treatment by an alternative medicine practitioner.

Objectives: To explore the correlation between different modalities of healthcare utilization, health behavior, and health belief among adult members of a kibbutz. This unique study population enabled the use of a simplified quantitative model due to the minimal individual differences in cost and access.

Methods: Healthcare utilization data were obtained for 220 kibbutz members aged 15–70 years from patient medical files and self-administered questionnaires over a 45 month period. Patient visits to the family practitioner and other specialist physicians were tallied, and individuals reported alternative medicine consultations during the previous year. Multiple regression analysis was used to control for age, chronic disease, and other background characteristics.

Results: The mean number of patient FP visits was 3.6 per patient per year. Women and chronic disease sufferers visited the doctor more frequently. A patient’s number of FP visits and other specialist physician visits were closely correlated, with each specialist physician consult resulting in an additional 0.64 FP visit for a given individual (P=0.007). Our analysis indicated that self-reported alternative therapy utilization was positively associated with the number of FP visits; patients reporting alternative therapy use visited their primary care physician once additionally per year (P=0.03). Low self-rated health status was correlated with increased likelihood of alternative therapy use (borderline significance).

Conclusion: These results suggest that a patient who seeks treatment from one type of healthcare practitioner will seek out other practitioners as well. This study supports the notion that unconventional therapies are used in conjunction with, rather than instead of, mainstream medical care.