Israel Medical Association Journal

Objectives: To evaluate the quality of care of diabetic patients in primary care and diabetes clinics in the community in central Israel.

Methods: We conducted a retrospective cross-sectional study of a random sample of 209 diabetic patients in a district of the largest health management organization in Israel. Patients were divided into two groups – those treated only by their family physician and those who had attended diabetes clinics. Data included social demographics, medications, risk factors, quality of follow-up, laboratory tests, quality of diabetes control and blood pressure control, and complications of diabetes.

Results: Of the 209 patients 38% were followed by a diabetes clinic and 62% by a family physician. Patients attending the specialist clinic tended to be younger (P = 0.01) and more educated (P = 0.017). The duration of their diabetes was longer (P < 0.01) and they had more diabetic microvascular complications (P = 0.001). The percentage of patients treated with insulin was higher among the diabetes clinic patients (75% vs. 14%, P = 0.0001). More patients with nephropathy received angiotensin-converting enzyme inhibitors in the diabetes clinic (94% vs. 68%, P = 0.02). Follow-up in the specialist clinic as compared to by the family physician was better in the areas of foot examination (P < 0.01), fundus examination (P = 0.0001), and hemoglobin A1c testing (P = 0.01). On a regression model only fundus examination, foot examination and documentation of smoking status were significantly better in the diabetes clinic (P < 0.05).

Conclusion: There is still a large gap between clinical guidelines and clinical practice. Joint treatment of diabetes patients between the family physician and the diabetes specialist may be a proposed model to improve follow-up and diabetes control. This model of treatment should be checked in a prospective study.

Objectives: To assess user satisfaction and clinical short-term effectiveness of a computerized store and forward teledermatology service in urban and rural units.

Methods: A multi-center, prospective, uncontrolled, cohort pilot trial was conducted for a period of 6 months. Primary care physicians referred patients to a board-certified dermatologist using text email accompanied by digital photographs. Diagnosis, therapy and management were sent back to the referring PCP[1]. Patients were asked to evaluate the level of the CSAFTD[2] service, effect of the service on accessibility to dermatologists, respect for privacy, availability of drugs, health improvement and overall satisfaction. PCPs assessed the quality of the teledermatology consultations they received, the contribution to their knowledge, and their overall satisfaction.

Results: Tele-diagnosis alone was possible for 95% (n=413) of 435 CSAFTD referrals; 22% (n=95) of referrals also required face-to-face consultation. Satisfaction with CSAFTD was high among patients in both rural and urban clinics, with significantly higher scores in rural units. Rural patients rated the level of service, accessibility and overall satisfaction higher than did urban patients. PCPs were satisfied with the quality of the service and its contribution to their knowledge. Rural physicians rated level of service and overall satisfaction higher than the urban physicians. Tele-referrals were completed more efficiently than referral for face-to-face appointments.

Conclusions: CSAFTD provided efficient, high quality medical service to rural and urban military clinics in the IDF[3].

Objectives: To determine the prevalence of abnormal coagulation studies in ED[1] patients evaluated for suspected ACS[2], and to investigate whether abnormal international normalized ratio/partial thromboplastin time testing resulted in changes in patient management and whether abnormal results could be predicted by history and physical examination.

Methods: In this retrospective observational study, hospital and ED records were obtained for all patients with a diagnosis of ACS seen in the ED during a 3 month period. ED records were reviewed to identify all patients in whom the cardiac laboratory panel was performed. Other data included demographics, diagnosis and disposition, historical risk factors for abnormalities of coagulation, ED and inpatient management, INR[3]/PTT[4], platelet count and cardiac enzymes. Descriptive statistical analyses were performed.

Results: Complete data were available for 223 of the 227 patients (98.7%). Of these, 175 (78.5%) patients were admitted. The mean age was 64.2 years. Thirteen patients (5.8%) were diagnosed with acute myocardial infarction. Of the 223 patients, 29 (13%) and 23 (10%) had INR and PTT results respectively beyond the reference range. Seventy percent of patients with abnormal coagulation test results had risk factors for coagulation disorders. The abnormal results of the remaining patients included only a mild elevation and therefore no change in management was initiated.

Conclusions: Abnormal coagulation test results in patients presenting with suspected ACS are rare, they can usually be predicted by history, and they rarely affect management. Routine coagulation studies are not indicated in these patients.

Background: The proportion of motorcyclists injured in road accidents in Israel is larger than their proportion among road users.

Objectives: To identify factors contributing to the risk of injury for motorcyclists as compared to drivers of other motor vehicles.

Methods: We retrieved and analyzed National Trauma Registry data on drivers, aged 16 and above, who were involved in traffic accidents and hospitalized between 1 January 1997 and 30 June 2003.

Results: The study group comprised 10,967 patients: 3,055 (28%) were motorcyclists and 7,912 (72%) were drivers of other motor vehicles. A multiple logistic regression revealed that Tel Aviv, the busiest metropolitan city in Israel, is a risk for motorcycle injury as compared to other regions; males have an increased risk compared to females; and age is a protecting factor since the risk of injury as a motorcyclist decreases as age increases. Nevertheless, the population of injured motorcyclists in Tel Aviv was significantly older (mean age 32.5 years vs. 28.6 elsewhere; t-test P < 0.0001). Twenty percent (n=156) of the injured motorcyclists in Tel Aviv were injured while working, compared to 9.5% (n=217) in other regions (chi-square P < 0.0001). Motorcycle injuries in Tel Aviv were of lower severity (7.7% vs. 16.4% according to the Injury Severity Scale 16+, c2 P < 0.0001), and had lower inpatient death rates (1.2% vs. 2.5%, c2 P = 0.001).

Conclusions: Tel Aviv is a risk for motorcycle injury compared to other regions, males have an increased risk compared to females, and age is a protecting factor. The proportion of motorcyclists in Tel Aviv injured while working is double that in other regions