A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus: a 1-year prospective randomized intervention study.

BACKGROUND: The appropriate dietary intervention for overweight persons with type 2 diabetes mellitus (DM2) is unclear. Trials comparing the effectiveness of diets are frequently limited by short follow-up times and high dropout rates. AIM: The effects of a low carbohydrate Mediterranean (LCM), a traditional Mediterranean (TM), and the 2003 American Diabetic Association (ADA) diet were compared, on health parameters during a 12-month period. METHODS: In this 12-month trial, 259 overweight diabetic patients (mean age 55 years, mean body mass index 31.4 kg/m(2)) were randomly assigned to one of the three diets. The primary end-points were reduction of fasting plasma glucose, HbA1c and triglyceride (TG) levels. RESULTS: 194 patients out of 259 (74.9%) completed follow-up. After 12 months, the mean weight loss for all patients was 8.3 kg: 7.7 kg for ADA, 7.4 kg for TM and 10.1 kg for LCM diets. The reduction in HbA1c was significantly greater in the LCM diet than in the ADA diet (-2.0 and -1.6%, respectively, p < 0.022). HDL cholesterol increased (0.1 mmol/l +/- 0.02) only on the LCM (p < 0.002). The reduction in serum TG was greater in the LCM (-1.3 mmol/l) and TM (-1.5 mmol/l) than in the ADA (-0.7 mmol/l), p = 0.001. CONCLUSIONS: An intensive 12-month dietary intervention in a community-based setting was effective in improving most modifiable cardiovascular risk factors in all the dietary groups. Only the LCM improved HDL levels and was superior to both the ADA and TM in improving glycaemic control.

A modified Mediterranean diet is associated with the greatest reduction in alanine aminotransferase levels in obese type 2 diabetes patients: results of a quasi-randomised controlled trial.

AIM: The aim of the study was to compare the effect of different dietary interventions on alanine aminotransferase (ALT) in obese patients with diabetes. METHODS: A post hoc analysis of an open label, parallel design, quasi-randomised (allocation by alternation), controlled trial, conducted in Israel. Obese patients with diabetes (n = 259), treated in the community, were centrally allocated to one of three diets: (1) the 2003 recommended American Diabetes Association diet (ADA): 50-55% carbohydrate, 30% fat and 20% protein, n = 85; (2) a low glycaemic index (LGI) diet: 50-55% LGI carbohydrate, 30% fat, 15-20% protein, n = 89; or (3) a modified Mediterranean diet (MMD): 35% LGI carbohydrate, 45% fat that was high in monounsaturated fat, 15-20% protein, n = 85. ALT was measured at 6 and 12 months. RESULTS: ALT levels decreased in all arms; however, the MMD was associated with the lowest ALT levels at month 6 (n = 201: ADA n = 64, LGI n = 73, MMD n = 64) and month 12 of follow-up (n = 179). At 12 months mean ALT levels were 19.8 +/- 1.4 U/l in the ADA diet arm (n = 54), 18.0 +/- 1.5 U/l in the LGI diet arm (n = 64) and 14.4 +/- 1.7 in the MMD arm (n = 61, p < 0.001). Evidence for an effect of diet on ALT levels persisted when controlling for post-randomisation changes in waist to hip ratio, BMI, homeostasis model assessment (HOMA) or triacylglycerol. CONCLUSIONS: A Mediterranean diet may have a beneficial effect on liver steatosis in obese patients with diabetes. Results of trials assessing the effect of dietary composition on clinical outcomes should be awaited before a decisive conclusion can be reached. In addition to clinical outcomes, such studies should address the issue of primary prevention of steatosis in high-risk and healthy individuals.

Newspaper advertising by health maintenance organizations during the reform of healthcare services in Israel.

BACKGROUND: On 1 January 1995 a new mandatory National Health Insurance Law was enacted in Israel. The new law fostered competition among the four major Israeli healthcare providers (HMOs or sick funds) already operating in the market due to the possibility that an unlimited number of patients and the relative budget share would shift among the HMOs. This led them to launch advertising campaigns to attract new members. OBJECTIVES: To examine newspaper advertising activities during the early stages of healthcare market reform in Israel. METHODS: Advertising efforts were reviewed during a study period of 24 months (July 1994 to June 1996). Advertisements were analyzed in terms of marketing strategy, costs and quality of information. RESULTS: During the study period 412 newspaper advertisements were collected. The total advertising costs by all HMOs was approximately US$4 million in 1996 prices. Differences were found in marketing strategy, relative advertising costs, contents and priorities among the HMOs. CONCLUSIONS: The content of HMOs' newspaper advertising was consistent with their marketing strategy. The messages met the criteria of persuasive advertising in that they cultivated interest in the HMOs but did not provide meaningful information about them. Future developments in this area should include consensus guidelines for advertising activities of HMOs in Israel, instruction concerning the content of messages, and standardization of criteria to report on HMO performance.

A screening process predicts success rates in residency re-training among new immigrant physicians in Israel.

OBJECTIVES: To evaluate predictors of success in training programs for Israeli international medical graduates (IMGs) from the former USSR. SUBJECTS: IMGs up to the age of 45 who passed a national licensing examination and a Hebrew knowledge exam were eligible for participation. INTERVENTION: Each IMG participated in one of three programs that offered similar academic activities. In two programs there was a preliminary selection process and one program had supplementary teaching hours. MAIN OUTCOME MEASURES: Resident's self-evaluation of skills compared with evaluation by department heads. The evaluation included eight clinical skills, a general evaluation, and the passing rate for Phase I of the National Certification Exam. FINDINGS: A total of 176 IMGs, all graduates from medical schools in USSR who immigrated to Israel from 1990 to 1996, and 20 heads of the participating departments completed the questionnaires. The response rate was 64% among the residents and 71% among the department heads. All residents had a similar level of self-esteem regarding clinical skills and considered themselves equal to or better than Israeli-trained residents. The department heads did not concur with this assessment, particularly for residents who participated in the program with no preliminary selection. Participants in the programs with preliminary selection received better evaluations from department heads than those in the program without and had significantly greater success in the written part of the board certification examination (p < 0.05). DISCUSSION AND CONCLUSIONS: Re-training programs for IMGs should include a preliminary process for participant selection. The training program should be implemented in academic departments, in which case supplementary teaching hours are not required.

Primary care physicians in Israel: self-perception of their role in the healthcare system and policy makers' and patients' perception of them as gatekeepers.

BACKGROUND: The rapidly increasing costs of healthcare pose a major challenge to many governments, particularly in developed countries. Health policy makers in some Western European countries have adopted the policy of a strong primary healthcare system, partly due to their recognition of the value of primary care medicine as a means to restrain costs while maintaining the quality and equity of healthcare services. In these countries there is a growing comprehension that the role of the family physician should be central, with responsibility for assessing the overall health needs of the individual, for coordination of medical care and, as the primary caregiver, for most of the individual's medical problems in the framework of the family and the community. OBJECTIVES: To describe primary care physicians in Israel from their own perception, health policy makers' opinion on the role PCPs should play, and patients' view on their role as gatekeepers. METHODS: The study was based on three research tools: a) a questionnaire mailed to a representative sample of all PCPs employed by the four sick funds in Israel in 1997, b) in-depth semi-structured interviews with key professionals and policy makers in the healthcare system, and c) a national telephone survey of a random representative sample of patients conducted in 1997. RESULTS: PCPs were asked to rank the importance of 12 primary functions. A total of 95% considered coordination of all patient care to be a very important function, but only 43% thought that weighing economic considerations in patient management is important, and 30.6% thought that 24 hour responsibility for patients is important. Also, 60% of PCPs have undergone specialty training and 94% thought that this training is essential. With regard to the policy makers, most preferred highly trained PCPs (board-certified family physicians, pediatricians and internists) and believed they should play a central role in the healthcare system, acting as coordinators, highly accessible and able to weigh cost considerations. Yet, half opposed a full gatekeeper model. They also felt that the general population has lost faith in PCPs, and that most have a low status and do not have adequate training. Regarding the patients' viewpoint, 40% preferred that the PCP function as their "personal physician" coordinating all aspects of their care and fully in charge of their referrals; 30% preferred self-referral to sub-specialists, and 19% preferred their PCP to coordinate their care but wanted to be able to refer themselves to specialists. CONCLUSIONS: In order to maintain high quality primary care, it is important that all PCPs have board certification. In addition, PCP training systems should emphasize preventive medicine, health promotion, health economy, and cost-effectiveness issues. Efforts should be made to render PCPs a central role in the healthcare system by gradually implementing the elements of the gatekeeper model through incentives rather than regulations.

The use of medical quality indices as a performance-enhancement tool for community clinics.

One of the most important issues for a country, its population and doctors is the effective use of its health system. The extensive variation in doctors' performance leads to a 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 maintaining 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.

Effects of a fundholding discontinuation. An Israeli health maintenance organization natural experiment.

OBJECTIVE: To evaluate the effects of fundholding on cost containment and after termination of the project. DESIGN AND SETTING: Primary care practices participating in the project were allocated an itemized budget. Practices assumed authority for hospitalization, drugs, ambulatory medical diagnostic, consultant services and acquisition of minor equipment. Financial incentives were offered, but no penalties were imposed on practices where expenditure exceeded budget. SUBJECTS: Nine primary care practices in southern Israel. MAIN OUTCOME MEASURE: Total expenditure and a breakdown of expenditure per capita. RESULTS: Fundholding practice expenditure was compared with expenditure in the district as a whole. During the study period, total expenditure in fundholding practices rose by 12%, whereas that of the district rose by 37%. With discontinuation of the project, expenditure of the designated practices returned to the original levels, equivalent to those of the district. CONCLUSION: Fundholding is an efficient method of cost-containment. The effect will be long lasting only if motivation is maintained.

Variations in referrals to consultants: a study of general practitioners' characteristics in southern Israel.

The rate at which primary physicians refer patients to consultants varies considerably, not only within different regions, but also among practices within defined areas. Differences also have been identified between doctors within the same practice. This variation in referral rates is a source of concern because of the costs generated and implications for quality and quantity of care. Many studies that tried to identify the sources for this variation explained only part of it; however, these studies were based on small numbers.

[Comparison between every-day and every-3-days fluoxetine in young, moderately depressed out-patients].

Fluoxetine is now a well-known and often-used specific serotonin reuptake inhibitor (SSRI) and antidepressant. It has a very long active half-life, from 2-16 days. Our hypothesis was that sufficient therapeutic effectiveness would be achieved by prescribing the drug less frequently than once a day. To establish whether there is a difference between fluoxetine given daily or every 3 days, we assigned 25 outpatients with mild to moderate, acute major depressions (DSM-IV) to receive fluoxetine (20 mg), either each day or every 3 days. The study was open-labelled, using for assessment the HAM-D, GHQ-28 side-effect checklist and clinical judgment questionnaires. Follow-up lasted 6 months. Results indicated no differences in the clinical outcomes, except for slightly fewer side-effects in the study group. Although the open label design limits drawing definitive conclusions, our preliminary results provide more information, and support our hypothesis that low-dosage fluoxetine is beneficial. However, more comprehensive, double-blind studies are necessary to confirm our preliminary results.

The influence of budget-holding on cost containment and work procedures in primary care clinics.

In 1990, Kupat Holim Clalit (KHC), Israel's largest health insurance fund, initiated a demonstration program for transforming primary care clinics in the Negev district of southern Israel into autonomous budget-holding units. Four program components were implemented in nine clinics: allocation of a fixed budget; expansion of day-to-day decision-making authority; establishment of a computerized information system for producing monthly reports on expenditure; and provision of incentives for budgetary responsibility (returning part of a clinic's savings for use at its discretion). The demonstration program had three objectives: budgetary control and cost containment; improvement of services and increased client satisfaction; and improvement in the motivation, initiative, responsibility, and satisfaction of clinic staff. This report presents interim findings from an evaluation study of the budget-holding program conducted in 1991-1992. The report considers three questions: How was the demonstration program implemented? Did work procedures in the clinics change following implementation of the program? How did budget-holding influence levels of expenditure in the clinics? The program components were implemented gradually in the nine clinics during 1991-1992. Not all, however, were fully implemented. The staff survey conducted after implementation of the program identified a number of changes in the work procedures of the clinics: heightened cost consciousness, discussion of the monthly expenditure reports, emphasis on the need to economize, and attempts to economize. Data on expenditure in the budget-holding clinics were analyzed and compared to data on expenditure in primary care clinics in the Negev district as a whole. It was found that while the average quarterly per capita expenses in the district increased in real terms from 1991-1992, expenses in the budget-holding clinics remained stable or, in some cases, actually decreased. While we cannot conclude categorically from the existing data that the budget-holding program is responsible for the unique patterns of expenditure in the nine clinics, we can confidently state that work procedures in the nine clinics changed following implementation of the program and that the clinics achieved cost containment relative to the district as a whole. Findings from the various research tools support one another, and reinforce the conclusion that budget-holding can potentially promote cost containment.

The validity of self-reports on chronic disease: characteristics of underreporters and implications for the planning of services.

Data on the prevalence of chronic morbidity are valuable for identifying health care needs and for designing services to meet these needs. Morbidity data are frequently collected through surveys based upon self-reports of disease. However, there is evidence in the literature that people tend to underreport the presence of chronic disease. Our study identified factors related to the underreporting of chronic disease. We interviewed a proportional stratified sample of 521 sick-fund members from two typical urban primary care clinics in Israel. The respondents' self-reports were compared to the diagnoses recorded in medical sources of information. Our findings show that more than half of the respondents with chronic diseases failed to report at least one disease. By using multivariate analysis, we were able to untangle the interrelated effects of age and multiple disease. The findings indicate that "number of diseases"--a variable not taken into account in previous studies--had the greatest effect on underreporting. When controlling for number of diseases, age had an independent effect, although a much smaller one. We also found that the rate of underreporting varies by type of disease. We conclude that chronic morbidity estimates based upon self-reports may lead to the deficient planning of health care services. If possible, alternative sources should be used for collecting morbidity data, especially from patients with multiple diseases and from the elderly. Further research is needed in order to improve estimates of chronic morbidity.

[An autonomous primary care clinic within a health maintenance organization].

The health system in Israel, as elsewhere in the world, is facing crises of organization and economics. Israel's largest HMO, which insures some 70% of the population, is a highly centralized body that makes policy decisions without consulting the community-based primary care teams. We describe the process of extending autonomy to a primary care clinic with the object of lowering costs and allowing its staff to prioritize the problems of the patient population and the community they serve.

[Utilization of emergency services in primary care clinics].

Utilization of emergency services (ES) by primary care physicians was retrospectively surveyed in a regional hospital. Referrals and self-referrals from an urban university clinic, a community clinic, a smalltown clinic and a rural community clinic were included. There was an average referral and self-referral rate of 38/100/year. Both referrals and proportion of self-referrals were inversely related to the distance between primary care clinic and the ES. Most referrals and self-referrals occurred on week-days during the hours primary care clinics were open. About 13% of ES visits resulted in hospitalization, with no significant differences between the different types of clinic or the hour of referral. We conclude, that hospital-based ES are utilized not only to provide emergency care, but also as support systems for primary care clinics, especially those readily accessible to the ES.