Israel Medical Association Journal

Objectives: To describe how an HMO[1] used its health information technology in a way that enables its management to receive updated online information on the demands of the insured, according to their distribution throughout the country during the time of the war in Lebanon in July-August 2006.

Methods: Data were derived from the computerized medical records of Maccabi Healthcare Services – the second largest HMO in Israel, providing care to more than 1.7 million members nationwide. Data on healthcare utilization by northern members were compared to the geographic distribution of clinics.

Results: The war was characterized by the massive evacuation of citizens southwards. During this period there was an abrupt decline in the utilization of medical services by northern members in the northern region. This decline returned to normal 10 days after the ceasefire. A reciprocal increase was noted in the use of health services by citizens from the north in other regions. This increase returned to normal after the war. No such pattern was noticed during the same period in 2005.

Conclusions: Real-time surveillance of trends in consumption of health services by citizens in times of regular daily living as well as during emergencies and wars is a vital management tool for medical directors responsible for providing health services.

Objectives: To evaluate the criteria used to select surgical versus medical management for SICH.

Methods: We retrospectively reviewed the files of 149 consecutive patients admitted with SICH[1] from January 2004 through January 2006 to our medical center. Their mean age was 66 (range 3–92 years), and 62% were male. SICH localization was lobar in 50% of patients, thalamus in 23%, basal ganglia in 15%, cerebellum in 13%, intraventricular in 6%, and pontine in 1%. Mean admission Glasgow Coma Score was 9 (range 3–15). Risk factors included hypertension in (74%), diabetes mellitus (34%), smoking (14%) and amyloid angiopathy (4%). Fifty percent of patients were on anticoagulant/antiplatelet therapy, including enoxaparin (3%), warfarin (7%), warfarin and aspirin (9%), or aspirin alone (34%).      

Results: Craniotomy was performed in 30% of patients, and ventriculostomy alone in 3%. Rebleed occurred in 9% of patients. Six months after the treatment 36% of operated patients were independent, 42% dependent, and 13% had died. At 6 months, 37% of non-operated patients were independent, 15% dependent, and 47% had died.

Conclusions: One-third of the SICH patients, notably those who were experiencing ongoing neurologic deterioration and had accessible hemorrhage, underwent craniotomy. The results are good, considering the inherent mortality and morbidity of SICH.

Objectives: To evaluate the safety and efficacy of external counter-pulsation therapy in heart failure patients.

Methods: Fifteen symptomatic heart failure patients (subsequent to optimal medical and device therapy) underwent 35 hourly sessions of ECPT[1] over a 7 week period. Before and after each ECPT session we performed pro-B-type natriuretic peptide and brachial artery function studies, administered a quality of life questionnaire, and assessed exercise tolerance and functional class.

Results: Baseline left ventricular ejection fraction was 28.1 ± 5.8%. ECPT was safe and well tolerated and resulted in a reduction in pro-BNP[2] levels (from 2245 ± 2149 pcg/ml to 1558 ± 1206 pcg/ml, P = 0.022). Exercise duration (Naughton protocol) improved (from 720 ± 389 to 893 ± 436 seconds, P = 0.0001), along with functional class (2.63 ± 0.6 vs. 1.93 ± 0.7, P = 0.023) and quality of life scores (54 ± 22 vs. 67 ± 23, P = 0.001). Nitroglycerine-mediated brachial vasodilatation increased (11.5 ± 7.3% vs. 15.6 ± 5.2%, P =0.049), as did brachial flow-mediated dilation (8.35 ± 6.0% vs. 11.37 ± 4.9%, P = 0.09).

Conclusions: ECPT is safe for symptomatic heart failure patients and is associated with functional and neurohormonal improvement. Larger long-term randomized studies with a control arm are needed to confirm these initial encouraging observations.

In Israel, updating of the National List of Health Services is performed on a yearly basis in a systematic and structured mechanism for almost a decade. The existence of such a mechanism is vital for keeping medicine up to date, since many innovative and breakthrough medical technologies continuously and frequently evolve. The 2006 update is unique in several aspects, relating both to the mechanism and to the decision-making process. In this article we describe notable issues that arose during the current process: modifications to the update mechanism, the four-phase increase in allocated resources to fund the addition of new medical technologies (including the addition of finances at the expense of the 2007 planned budget), and public funding for high-cost therapies. Finally, we discuss the impact of medical advances on healthcare costs and a suggested constant annual addition to the budget.

Background: Israel, as a country of immigration, has a heterogeneous distribution of risk for human immunodeficiency virus. Therefore, general population-based surveys of sexual behaviors among young adults may be useful for guiding prevention policy. To the best of our knowledge, the present survey is the first one among Israeli adults ever published.

Objectives: To survey knowledge, attitudes and practices regarding sexually transmitted infections in Israeli adults in order to target the future AIDS public campaigns for the general population.

Methods: A national sample of 800 individuals, aged 18–45, was interviewed telephonically in September 2000.

Results: The average number of sexual partners reported in the previous 3 months was 1.3. Accurate knowledge on HIV[1] transmission modes was expressed by 99% of respondents for unprotected sexual intercourse, 97% for re-use of needles and syringes, and 85% for mother-to-child infection. However, incorrect notions on transmission were also prevalent (34% for insect bites, 29% for kissing and 21% for public toilets). Prevention of STIs[2] and prevention of pregnancy were the most common reasons for using condoms (72–73%); HIV prevention was the motivation for 39%. Fifty percent of single individuals without steady partners always/usually used condoms. It was decided that women need empowerment to negotiate condom use.

Conclusions: Gaps were found between knowledge (at high level), attitudes (perceiving greater risk for others than themselves) and behavioral practices (combining low level of partner exchange with widespread disregard for safe sex). Promptly implemented, these findings will serve as a baseline for further surveys.

Background: Endobronchial stents are used to treat symptomatic patients with benign or malignant airway obstructions.

Objectives: To evaluate the safety and outcome of airway stent insertion for the treatment of malignant tracheobronchial narrowing.

Methods: The files of all patients with malignant disease who underwent airway stent insertion in our outpatient clinic from June 1995 to August 2004 were reviewed for background data, type of disease, symptoms, treatment, complications, and outcome.

Results: Airway stents were used in 34 patients, including 2 who required 2 stents at different locations, and one who required 2 adjacent stents (total, 37 stents). Ages ranged from 36 to 85 years (median 68). Primary lung cancer was noted in 35% of the patients and metastatic disease in 65%. Presenting signs and symptoms included dyspnea (82%), cough (11.7%), hemoptysis (9%), pneumonia (5.9%), and atelectasis (3%). The lesions were located in the left mainstem bronchus (31%), trachea (26%), right mainstem bronchus (26%), subglottis (14.3%), and bronchus intermedius (2.9%). Conscious sedation alone was utilized in 73% of the patients, allowing for early discharge. Eighteen patients (50%) received brachytherapy to the area of obstruction. Complications included stent migration (one patient) and severe or minimal bleeding (one patient each). Ninety-four percent of the patients reported significant relief of their dyspnea. Three of the four patients who had been mechanically ventilated before the procedure were weaned after stent insertion. Median survival from the time of stent placement was 6 months (range 0.25–105 months).

Conclusion: Stent placement can be safely performed in an outpatient setting with conscious sedation. It significantly relieves the patient's symptoms and may prolong survival.
 

Background: Anti-influenza vaccination has proven cost-effective for society. In Israel, however, vaccination rates remain relatively low in comparison to other countries.

Objectives: To analyze the socioeconomic and health status factors affecting the decision to be vaccinated against flu and to compare these factors to results from other countries in order to determine which segments of the adult population should be targeted for increased coverage in influenza vaccination programs.

Methods: Our source was the 1999/2000 Health Survey of the Central Bureau of Statistics for the group aged 25 and above, comprising 16,033 individuals. We used statistical methods such as the Probit regression model to estimate the effects of socioeconomic and health status variables on the decision to get a flu shot. The variables included gender, age, marital status, education, ethnic origin, religious affiliation and housing density, as well as chronic illnesses, smoking, hospitalizations, membership in health management organizations and kibbutz membership.

Results: Our findings indicate that being a post-1990 immigrant from the former Soviet Union, living in a densely populated house, being unmarried and smoking heavily are important factors in predicting the decision not to be vaccinated. In contrast, chronic illness, previous hospitalizations, older age, and kibbutz membership have a positive effect on the decision to take the vaccine.

Conclusions: It is necessary to identify the socioeconomic and health variables marking population sectors that are less likely to be vaccinated in order to design a suitable policy to encourage vaccination.

Background: The rate of trauma in the elderly is growing.

Objectives: To evaluate the characteristics of non-hip fracture-associated trauma in elderly patients at a level I trauma center.

Methods: The study database of this retrospective cohort study was the trauma registry of a level I trauma center. Trauma patients admitted from January 2001 to December 2003 were stratified into different age groups. Patients with the diagnosis of hip fracture were excluded.

Results: The study group comprised 7629 patients. The non-hip fracture elderly group consisted of 1067 patients, 63.3% women and 36.7% men. The predominant mechanism of injury was falls (70.5%) and most of the injuries were blunt (94.1%). Injury Severity Score was found to increase significantly with age. The average mortality rate among the elderly was 6.1%. Age, ISS[1], Glasgow Coma Score on admission, and systolic blood pressure on admission were found to be independent predictors of mortality.

Conclusions: Falls remain the predominant cause of injury in the elderly. Since risk factors for mortality can be identified, an effective community prevention program can help combat the future expected increase in morbidity and mortality associated with trauma in the elderly.

Objectives: To assess the effects of the recently introduced co-payment for consultant specialist services on patients' utilization of these services in southern Israel.

Methods: Computerized utilization data on specialists' services for 6 months before and 6 months after initiation of co-payment were retrieved from the database of Israel's largest health management organization.

Results: A decrease of 4.5% was found in the total number of visits to Soroka Medical Center outpatient clinics and of 6.8% to community-based consultants. An increase of 20.1% was noted in the number of non-actualized visits at the outpatient clinics. A decrease of 6.2% in new visits was found in the hospital outpatient clinics and of 6.5% in community clinics. A logistic regression model showed that the residents of development towns and people aged 75+ and 12–34 were more likely not to keep a prescheduled appointment.

Conclusion: After introduction of a modest co-payment, a decrease in the total number of visits to specialists with an increase in "no-shows" was observed. The logistic regression model suggests that people of lower socioeconomic status are more likely not to keep a prescheduled appointment.