Zohar Nachum MD, Izhar Ben-Shlomo MD, Ehud Weiner MD, Moshe Ben-Ami MD and Eliezer Shalev MD
Background: Pregnant diabetic women are often subjected to frequent and prolonged hospitalizations to assure tight glycemic control, but in recent years attempts have been made at ambulatory control. The financial and social advantages of ambulatory management are obvious, but no report to date has prospectively compared its efficacy with that of hospitalization.
Objectives: To evaluate the efficacy and cost of ambulatory care as compared to repeated hospitalizations for management of diabetes in pregnancy.
Methods: We conducted an 8 year prospective controlled study that included 681 diabetic women, experiencing 801 singleton pregnancies, with commencement of therapy prior to 34 gestational weeks. During 1986–1989, 394 pregnancies (60 pre-gestational diabetes mellitus and 334 gestational diabetes mellitus) were managed by hospitalization, and for the period 1990–1993, 407 pregnancies (61 PGDM and 346 GDM) were managed ambulatorily. Glycemic control, maternal complications, perinatal mortality, neonatal morbidity and hospital cost were analyzed.
Results: There was no difference in metabolic control and pregnancy outcome in women with PGDM between the hospitalized and the ambulatory groups. Patients with GDM who were managed ambulatorily had significantly lower mean capillary glucose levels, later delivery and higher gestational age at induction of labor as compared to their hospitalized counterparts. In this group there were also lower rates of neonatal hyperbilirubinemia, phototherapy and intensive care unit admissions and stay. The saved hospital cost (in Israeli prices) in the ambulatory group was $6,000 and $15,000 per GDM and PGDM pregnancy, respectively.
Conclusions: Ambulatory care is as effective as hospitalization among PGDM patients and more effective among GDM patients with regard to glycemic control and neonatal morbidity. This is not only more convenient for the pregnant diabetic patient, but significantly reduces treatment costs.
Sophia Eilat-Tsanani MD, Mordechai Sorek MD, Nir Gay MD, Ora Chaimovitch MD, Lev Kulton MD and Hava Tabenkin MD MSc
Background: Breast cancer is the most common malignancy among women in Israel and throughout the world. Israeli women aged 50–75 years are advised to undergo a mammographic screening examination every 2 years. However, the lack of a structured referral system is reflected in the low utilization rate of mammography.
Objectives: To describe an innovative program in which family physicians in an urban clinic developed a model framework for referrals, coordinated with radiologists and surgeons, aimed at increasing compliance among women referred for mammography.
Methods: A community-based study was conducted, outside of the regular reception hours, in a neighborhood practice with a population of 527 women aged 50–75. A referral system under the supervision of family physicians was designed, and the women received appointments for mammography at specified days and hours. The results of the examination were sent to the physician who used dedicated time to continue the diagnostic and/or therapeutic process, as appropriate. At the physician’s instructions a research assistant contacted the women who did not keep their appointments and scheduled a second appointment.
Results: In 1993, the year prior to the study, when women referred themselves for mammography, the utilization rate was 9%. During the study year the utilization rate was 77%. Women born in Europe or America had higher compliance rates than women born in Asia or Africa (81% vs. 72%, respectively). Married women were more compliant than unmarried women (81% vs. 70%, respectively). No correlation was found between compliance and age, family history of cancer in general, or breast cancer in particular. Six new cases of breast cancer were detected.
Conclusions: The initiative of family physicians increased the utilization of mammography among women under their care. Family physicians allocated time outside of their regular reception hours for the program. A relatively large number of new malignancies were found, but this impression should be confirmed or negated by a large-scale study using the same methods.
Yaacov Fogelman MD and Ernesto Kahan MD MPH
Background: The prevalence of attention deficit-hyperactivity disorder and its pharmacologic treatment have increased dramatically in the past decade in the United States and Britain. We examined the use of methylphenidate hydrochloride for the treatment of ADHD in children in northern Israel.
Methods: We evaluated all prescriptions for methylphenidate filled in 1999 for children aged 5–18 years residing in northern Israel who were insured by Clalit Health Services, a health maintenance organization that covers approximately 70% of the population.
Results: Methylphenidate was prescribed to 1.45% of the children in northern Israel in 1999, an increase of 20% in the overall prevalence of methylphenidate use since 1992. Eighty-two percent were boys. The rate of prescription varied widely by type of settlement, from 0.2% in Arab cities and towns to 5.7% in kibbutzim. Primary care physicians wrote 78% of all the prescriptions.
Conclusions: The increase in methylphenidate use was much smaller in northern Israel than in most other developed regions and countries. More efforts at diagnosis and treatment of attention deficit disorders may need to be directed at Arab populations and those with inadequate medical services.
Sasson Nakar MD, Shlomo Vinker MD, Eliezer Kitai MD, Eli Wertman MD and Michael Weingarten MD
Background: Migration leads to changes in almost all areas of life including health. But how far are health beliefs also preserved, and how far are they affected by the process of acculturation to the host society?
Objectives: To examine the difference between behavior and attitudes towards conventional and traditional medicine among elderly Yemenite immigrants.
Methods: A community-based study was conducted in the Yemenite neighborhoods in the city of Rehovot. All inhabitants of Yemenite origin over the age of 70 were identified from the population register, excluding those who were institutionalized or demented. Social work students interviewed them at home. The questionnaire inquired after health problems in the preceding month. For each of these problems, the respondent was asked whether any mode of treatment had been employed – Yemenite folk remedies, conventional medical care, or other. Their attitudes towards Yemenite folk medicine and conventional medicine were recorded. Socioeconomic data included their current age, age at immigration, year of immigration, marital status, gender, religiosity, and education.
Results: A total of 326 elderly people were identified who fulfilled the selection criteria, of whom 304 (93%) agreed to be interviewed. Of these, 276 (91%) reported at least one health problem in the preceding month, providing 515 problems of which 349 (68%) were reported to a conventional medical doctor while 144 (28%) were treated by popular folk remedies. Fifty-nine problems (11.5%) were treated by specifically Yemenite traditional remedies, mostly by the respondents themselves (38/59) rather than by a traditional healer. Immigrants who arrived in Israel over the age of 30 years, as compared to respondents who immigrated at an earlier age and grew up in Israel, were more likely to use traditional Yemenite remedies (24.4% vs. 8.2%, P<0.005).
Conclusion: Aged Yemenite Jews in Israel prefer modern medicine. The earlier the immigrant arrived in Israel, the more positive the attitude towards modern medicine and the less use made of traditional Yemenite healing.
John Yaphe MD MClSc, Moshe Schein MB ChB MS and Pnina Naveh RN
Background: The recent influx of Ethiopian immigrants to Israel has created challenges for healthcare workers. Qualitative research methods have proven to be of value in providing useful data in cross-cultural medical settings.
Objective: To learn about parents' perception of the health of their children among a group of Ethiopian immigrants in Israel.
Methods: Ethiopian parents of children under age 3 registered with a family medicine clinic in Jerusalem were invited to participate in two focus groups. Transcripts of the group discussions were analyzed to reveal themes relating to children's health.
Results: Analysis of the transcripts revealed five themes relating to the health of children in two domains: the intra-familial and the extra-familial. Specific themes that emerged in the intra-familial domain were: the role of traditional medicine, gender-specific roles in child care, and decision-making in seeking extra-familial medical help. Themes in the extra-familial domain were recognition of illness and the meaning of symptoms, and notions of prevention and resistance to illness. The collected data found application in the daily clinical work of the researchers and enriched understanding of their patients.
Conclusions: Ethiopian immigrants to Israel share special perceptions of their children’s health that differ from prevailing beliefs in Israel. Focus groups provide health workers with a wealth of data on these beliefs that will enable them to offer more culturally sensitive care.
Howard Tandeter MD, Mirta Grynbaum MD and Jeffrey Borkan MD PhD
Background: Bloodletting is practiced in Ethiopia. Physicians in Israel engaging in transcultural encounters with Ethiopian immigrants are generally unaware of these ethnomedical beliefs and practices.
Objective: To assess the past and present use of bloodletting among Ethiopian immigrants in Israel.
Methods: We interviewed a sample of 50 adult patients of Ethiopian origin about present and past use of bloodletting. A second consecutive sample of 10 adult patients of Ethiopian origin who often asked their doctors to perform blood tests were identified and interviewed. Data analysis was performed by "immersion-crystallization" analysis.
Results: More than half of the interviewed patients reported the use of bloodletting. Scars were commonly present on their upper extremities. A qualitative analysis identified the different reasons for the use of bloodletting, the technique used and its appreciated efficacy. We also found an unexpected cultural synergy between traditional bloodletting and western medical blood sampling.
Conclusions: Some Ethiopian immigrants continue to perform traditional bloodletting in their new country of residency, a practice that local physicians may not be aware of. Bloodletting-type scars on the upper extremities may be common in these patients. Patients may ask for blood sampling as a culturally accepted way to perform bloodletting (synergy).
Asher Elhayany, MD
One of the most important issuesfor a country, its population and doctors is the effective use of its health system. The tremendous waste of resources. To combat this, and at the same time ensure that medical quality plays a role when making decisions on interventions, it is essential to equip doctors and clinic directors with information on the quality of the medical care they are providing. In order to assist clinic directors in maitaining medical quality, Clalit Health Services has developed comparative medical indices enabling doctors to compare their performance to that of their colleagues, as well as to the standard and their performance over time. The development of an index to evaluate the quality of medical treatment offered in clinics provides doctors and the health system with an essential tool to lessen the existing variation among doctors and to enhance and evaluate performance.
Rachel Dahan, MD, Shmuel Reis, MD, Doron Hermoni, MD and Jeffrey Borkan, MD
Rachel Dahan, MD, Shmuel Reis, MD, Doron Hermoni, MD and Jeffrey Borkan, MD
Paul E. Slater, MD, MPH and Alex Leventhal, MD, MPH, MPA
Israel Rabinowitz, MD and Shmuel Reis, MD
Yuri Viner, MD, Dan Miron, MD, Emanuel Gottfried, MD, Dora Segal and Anthony Luder, MBBS (UK)
Rasmi Abu-Ras, MD, Klari Felser, MD and Menachem Rottem, MD
Howard Tandeter, MD and Martine Granek-Catarivas, MD
In countries in which a primary care-oriented system has developed, general practitioners, family physicians, and other primary care doctors are the keystone of an approach that aims to achieve high quality and satisfaction with relatively low costs. Despite this new trend, medical schools still produce excessive numbers of sub-specialists rather than prinary care physicians. Among multiple reasons influencing a career choice either towards or away from primary care (institutional, legislative, and market pressures), the present article discusses ways in which medical school curricula may affect students in their perceptions of the role of primary care physicians. Since students are greatly influenced by the cultures of the institutions in which they train, the negative attitude of university towards family medicine may negatively affect the number of students going into this specialty. Examples from Israeli faculties are presented.