Cost-Utility Analysis of Open Radical Hysterectomy Compared to Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer.

We aimed to investigate the cost-effectiveness of open surgery, compared to minimally invasive radical hysterectomy for early-stage cervical cancer, using updated survival data. Costs and utilities of each surgical approach were compared using a Markovian decision analysis model. Survival data stratified by surgical approach and surgery costs were received from recently published data. Average costs were discounted at 3%. The value of health benefits for each strategy was calculated using quality-adjusted life years (QALYs). Incremental cost-effectiveness ratio, calculated using the formula (average cost minimal invasive surgery-average cost open surgery)/(average QALY minimal invasive surgery-average QALY open surgery), was used for cost-effectiveness analysis. One-way sensitivity analysis was conducted for all variables. Open radical hysterectomy was found to be cost-saving compared to minimally invasive surgery with an incremental cost-effectiveness ratio of USD -66 and USD -373 for laparoscopic and robotic surgery, respectively. The most influential parameters in the model were surgery costs, followed by the disutility involved with open surgery. Until further data are generated regarding the survival of patients with early-stage cervical cancer treated by minimally invasive surgery, at current pricing, open radical hysterectomy is cost-saving compared to minimally invasive radical hysterectomy, both laparoscopic and robotic.

Healthcare policy changes in an era of health workforce shortage.

In their recent IJHPR article, Wimpfheimer and colleagues outline the implications for the field of anesthesia of two major healthcare policy changes in Israel: The Yatziv Reform in licensing foreign medical graduates and the efforts to reduce residents' on-call shift duration. We argue that these reforms are necessary to strengthen the healthcare workforce and improve the quality of care in the long term, even though they may limit the availability of healthcare personnel for several years, particularly in the field of anesthesia. In this commentary, we examine the background to these policy changes, their likely impact on the medical workforce in Israel in general, and propose steps to reconcile these reforms with the global and national shortage of physicians. We urge policymakers to allocate the required resources and begin preparing for an era of continuous mismatch between physician supply and demand, which will necessitate creative solutions, increased reliance on technology, and the introduction of paramedical professionals to help offload tasks and better utilize the scarce physician workforce.

The price of internship through COVID-19: 1st year physicians report substantial mental health symptoms during the pandemic.

OBJECTIVES: To examine the prevalence of mental health symptoms among medical interns working for the first time as physicians in a large tertiary hospital in Israel during the 1st COVID year. METHODS: All interns who worked for at least 2 months during the 1st COVID year (March 2020-February 2021) at the Tel-Aviv Sourasky Medical Center (TASMC), a large tertiary general hospital in Israel were approached simultaneously during April-May 2021, and were requested to fill in an online survey. In each questionnaire, the interns were asked to refer to the worst time they endured the symptoms described. Included were all medical. Depression and anxiety symptoms, post-traumatic stress symptoms and Burnout measures were evaluated using validated questionnaires. Depressive/anxiety symptoms were defined as primary end measures. We assessed the association between depression and anxiety symptoms, and demographic, post-traumatic and burnout measures. RESULTS: 145 out of 188 interns completed the study (77% overall response rate). The mean age was 30.36 ± 2.97. Almost half the interns (47%) reported depression/anxiety symptoms. The high depression/anxiety group was characterized by a lower mean age (29.87 ± 2.93 vs. 30.92 ± 2.91, p = 0.041), higher post-traumatic symptoms (15.62 ± 13.32 vs. 3.63 ± 5.59, p < 0.0001) and higher scores in 2/3 burnout subscales - emotional exhaustion (5.09 ± 1.29 vs. 3.61 ± 1.38, p = 0.000001) and depersonalization (3.83 ± 1.71 vs. 2.94 ± 1.46, p = 0.002). 11.4% of interns in the full sample reported they used cannabis or alcohol as "self-medication". CONCLUSIONS: medical interns serving for their first year as physicians during the COVID pandemic, developed mental symptoms in alarming numbers. The findings point to a crucial need to implement active interventions to protect these doctors, so that they can safely embark on their medical careers, specifically in times of global health crises.

A critical assessment of the quality of radiation therapy in Israel: time to initiation of treatment of spinal cord compression as an index of efficiency.

INTRODUCTION: Radiotherapy departments function under workload pressure. We examined the process from referral to treatment initiation for spinal cord compression (SCC), one of the most daunting clinical scenarios in oncology. METHODS: We identified 235 patients with SCC, treated between 2013-2015. Two physicians classified cases as "emergent" or "urgent" (treatment within 24 or 72 h, respectively). RESULTS: The distribution of referrals over the week was uniform for inpatients. In contrast, there was a referral peak (62.27%) during the first two workdays for emergency ambulatory patients (p = 0.011). There were few weekend referrals in all groups (3.0%). There was a statistically shorter interval between referral and treatment for emergent versus urgent cases (0.94 days vs. 4.17 days; p < 0.0001, Bonferroni correction p < 0.0005). CONCLUSION: Time elapsed between referral and treatment of SCC may constitute a quality index in neuro-oncology. Modern departments of radiotherapy should determine the degree to which they can successfully implement such treatment. Patients with cancer and their physicians should be taught to recognize signs of SCC to expedite intervention.

[SOCIAL IMPACT BONDS FOR HEALTH PROMOTION AND PREVENTIVE MEDICINE].

INTRODUCTION: The World Health Organization (WHO) has declared obesity a global epidemic. WHO sheds much light on this matter in its publications on health promotion and preventative medicine. Lack of physical activity, an unbalanced diet and an unhealthy lifestyle are the leading causes of developing obesity and chronic diseases. In Israel, the growing rate of obesity is a reason for concern. About 500,000 diabetics, mainly as a result of obesity, live in Israel today and by 2030 the number is expected to rise to 2,000,000. Every third child born is expected to develop diabetes by the time they reach the age of 40 unless a profound change is made in health policy. The State of Israel recognizes its responsibility in promoting awareness against obesity as well as its role in prevention. In spite of the country's recognition of the problem, it still has not managed to implement long term solutions which address the issue. Therefore, creative and innovative solutions are called for. The social impact bond (SIB), a newly developed financial model is a possible solution. This model suggests the entry of private investors into the public sector, a field which is within the responsibility of the government. The private investor will be in charge of running a social program on a topic which will be finalized with the government. The private investor and the government will have a contract outlining the program and the criteria for the evaluation and the success of the program. To note, the private investor will only be paid according to the success of the program. Thus the purpose of SIB is in motion processes and is set to serve as a model for several years, and then the authorities will take over the responsibility and continue with the program that the SIB handled. In March 2016, a new SIB was launched in Israel to prevent Type 2 diabetes. This involves 2250 pre-diabetic adults who are at risk to develop Type 2 diabetes and will be identified by their Health Maintenance Organizations (HMOs, Clalit and Leumit) through blood tests. The participants will take part in an intensive intervention wellness program during 3 years. This SIB aims to prevent the onset of diabetes. If successful, and a significant reduction in Type 2 diabetes is found, there will be substantial savings for the HMOs and the National Insurance Institute, which will in turn repay the investors for their expenses, according to the signed contract. This SIB will serve as a pilot project for diabetes prevention and if successful, this model can be adopted for other projects in preventive medicine and health promotion. Thereby, we may be facing a dramatic change in the paradigm of funding national health services in Israel.

[Development of an evidence-based managerial decision aid to assist in the provision of secondary medical services in the Israel Defense Forces (IDF)].

BACKGROUND: Increasing global expenditures on health, together with increased patient demand for quality and service, have created a need for health care management tools based on economic and quaLity-based criteria. Despite the recognition of this need, decision-support tools are Lacking. In the Israel Defense Forces (IDF), policy change and budgetary and quality constraints necessitated the development of an evidence-based managerial decision aid, to assist in providing medical services at acceptable quality and availability leveLs, while addressing economic concerns. OBJECTIVE: To develop a decision-support model for the IDF Medical Corps, that balances the conflicting considerations of service avaiLabiLity and cost. METHODS: The authors developed a manageriaL model to characterize regional secondary medical care, and to compare it to country-wide patterns and to historic regional patterns. Secondary care systems were then analyzed by specialty. Finally, the relative costs of medical encounters for each speciaLty were anaLyzed. RESULTS: Core specialties examined included dermatology, orthopedics and otolaryngology. Two-thirds of all referrals to core specialists were made to intra-organizational resources. Furthermore, several intra-organizationaL clinics were found to have short waiting times and low output indices. In response to the application of the model, IDF Medical Corps policy was updated and suppliers were reprioritized, yielding substantial savings of up to NIS 5.5 million in 2006 alone. This cost saving enabled budgetary reallocation and alternative investment in the emergency and primary health care systems. CONCLUSION: Applying efficient managerial tools can lead to cost savings and to increased quality and availability of services. These tools must effectively follow changes in the dynamics of the health care system. These changes are to be impLemented rapidly, in order to provide practical guidance for medical administrators and to enable them to infLuence the real-time utiLization of medical services.

Scintigraphic characteristics of non-ossifying fibroma in military recruits undergoing bone scintigraphy for suspected stress fractures and lower limb pains.

INTRODUCTION: Non-ossifying fibroma (NOF) is the most common fibrous bone lesion in children and young adults. This benign lesion is not a true neoplasm but is considered a developmental defect. Clinically, the lesion is asymptomatic and has a predilection for the long bones, particularly the femur and the tibia. NOF that ossify can show increased uptake on bone scintigraphy. Although the radiographic and histopathological findings of NOF have been well described, the scintigraphic findings of the abnormality have only been incidentally mentioned in the literature. AIM: To document the scintigraphic features of NOF in a group of military recruits undergoing bone scintigraphy for suspected stress fractures. Features to differentiate co-existent NOF and stress fractures lesions are discussed. MATERIALS AND METHODS: Eighty-three military recruits, 67 male and 16 female, aged 18 to 22 years (mean, 19.4 years), who underwent Tc-methylene diphosphonate bone scans for suspected stress fractures or because of pain of the lower limbs had 91 focal lesions on bone scan which on further evaluation demonstrated characteristic radiographic findings of NOF. We evaluated the anatomical site of the lesions, documented the intensity of uptake on bone scan and compared the findings with the radiographic description of the lesions. Comparison with the characteristic scintigraphic pattern of co-existent stress fracture lesions and with previously reported data was performed. RESULTS: A total of 91 NOF lesions were detected. Overall, 89% of NOF were located about the knee. Anatomic distribution of NOF lesions was as follows: 43 (47.3%, R=25, L=18) were located in the postero-medial aspect of the distal femur, 18 (19.8%, R=12, L=6) in the postero-medial aspect of the proximal tibia, 11 (12%, R=5, L=6) in the postero-lateral aspect of the distal femur, 10 (11%, R=4, L=6) in the postero-lateral aspect of the distal tibia, 4 (4.4%, R=2, L=2) in the postero-lateral aspect of the proximal tibia, 3 (3.3%, L=3) in the antero-central aspect of proximal tibia, 1 (1.1%, L=1) in the antero-lateral aspect of distal femur, 1 (1.1%, L=1) in the medial-central aspect of the proximal tibia. In this series NOF lesions were not found in the fibula. Eighty five of 91 (93.4%) of all NOF were located at the metaphysis of the long bones, 2/91 (2.2%) were located at the meta-diaphyseal region of the long bones and only 4/91 (4.4%) of the lesions were located at the diaphysis. All the NOF showed variable degrees of focal increased tracer uptake on bone scan. The bone scan appearance of the focal lesions was: faint uptake in 29 (31.9%), mild uptake in 27 (29.7%), moderate uptake in 28 (30.7%) and intensely increased uptake in seven (7.7%). The radiographic description of the NOF was: lucent NOF three (3.3%), mixed sclerotic and lucent 68 (74.7%) and sclerotic in 20 (22%). Most of the NOF which demonstrated moderate or intensely increased tracer uptake had mixed lucent and sclerotic radiographic appearance (healing). Most of the sclerotic lesions (healed) showed faint uptake. Co-existent stress fractures were predominantly located in the diaphysis of the long bones, characteristically in the postero-medial aspect of the mid-third of the tibia or femur. CONCLUSIONS: Military recruits undergoing bone scan for suspected stress fracture might have incidental findings which require further evaluation. Focal lesions on bone scan located about the knee in the lateral aspect of the distal femur or lateral aspect of the proximal tibia in the metaphyseal region of these bones are not compatible with the characteristic scintigraphic features of stress fracture. Such a finding should raise the suspicion for other bony lesions such as NOF, which is commonly located in this region. During the healing phase of the NOF which commonly occur in the age range of this group, the lesion shows mild-to-moderate increased tracer uptake on bone scan. Plain film radiography is usually diagnostic and patients are followed up conservatively. Some NOF lesions are still indistinguishable from stress fracture or splints on bone scan.

Characteristics of skeletal stress fractures in female military recruits of the Israel defense forces on bone scintigraphy.

AIM: Clinical surveys on stress fractures (SF) in female military recruits are scarce. The aim of this study was to characterize the scintigraphic findings and classify the distribution and pattern of SF in a group of female recruits of the Israel Defense Forces (IDF). MATERIALS AND METHODS: The bone scans of 146 female recruits (age range, 19-20.6 years) with suspected SF were assessed retrospectively. The SF lesions were classified qualitatively into 4 grades of bone response according to the classification criteria introduced by Zwas et al. SF location and distribution were analyzed, and in several cases, the abnormalities were correlated radiographically. RESULTS: One hundred forty-six female recruits were examined, of which 93 (64%) had bone scan findings of SF with a total of 247 SF. Forty-eight patients (with or without SF) had shin splints, 32 had thigh splints, and 34 had normal scans. Several SF were detected in sites that were not clinically suspected. Thirty-nine percent of the SF were located in the feet (tarsal bones 22.7%, metatarsal 16.2%), 36.8% in tibiae (predominantly in the midthird), 15.7% in femurs, 6.5% in the pubic and sacroiliac regions, and 2% in the fibula. SF in the tibiae and femurs were mainly located in the posterior aspect of the medial cortical region. Forty-nine percent of the patients had bilateral SF. The SF were classified on a 4-grade scale: 41.3% were grade I, 37.2% grade II, 15.8% grade III, and 5.7% grade IV. Thirty-three percent of the patients had one site of SF, 31% had 2 sites, 7.5% had 3 sites, 12% had 4 sites, 7.5% had 5 sites, and 9% had more than 5 sites of SF. Different grades of lesions were often found in the same patient. Sixty-five percent of the patients had SF in the feet, 59% in the tibiae, 26% in the femurs, 14% in the pubic or sacroiliac regions, and 5% in the fibula. Radiography was performed in 15% of the patients. Only one patient had a positive finding on radiography. CONCLUSIONS: This study shows that lower leg SF are not uncommon in female military recruits. We clearly distinguished between SF and shin splints, which have important clinical consequences on treatment. Most of the SF were mild (grade I and II) located in the feet and tibiae. This study supports the experience gained in other studies, and emphasizes the significant number of pubic and sacroiliac SF in female soldiers, which is significantly higher in comparison with previous reports on male soldiers.