The Impact of Change in Hospital Admissions When Primary Care Is Provided by a Single Primary Care Physician: A Cohort Study Among HMO Patients in Israel.

OBJECTIVES: An Israeli health maintenance organization (HMO) changed its policy from freedom of choice in choosing any primary care physician (PCP) to provide health care to one provider allocated to the patients. We examined outcome measures before and after the intervention in the study population. DESIGN: During a 2.5-year period (from June 2013 to December 2015), continuity of care by PCPs was achieved by a single provider. The change was computed for each participant according to the most visited PCP in the last year. PARTICIPANTS: A total of 208,286 patients aged 20 and older fulfilled the inclusion criteria. MAIN OUTCOME MEASURES: Future likelihood of hospitalization, number of PCP visits, and medication use before and after the intervention. RESULTS: After controlling for demographics, high continuity of care before and after intervention was associated with a lower likelihood of hospitalization for any condition (adjusted odds ratio [OR] = 0.90; 95% confidence interval [CI], 0.85-0.95; p = 0.003). No significant change was recorded for number of ambulatory visits or medication use. CONCLUSIONS: Changing Leumit HMO policy to continuity of care with a single provider is associated with a decreased future likelihood of hospitalization. This suggests that policies that encourage patients to concentrate their care with a single provider may lead to lower hospitalization rates and possibly lower healthcare costs.

Does a policy that requires adherence to a regular primary care physician improve the actual adherence of patients?

BACKGROUND: Continuity of care by the same personal physician is a key factor in an effective and efficient health care system. Studies that support the association between high adherence and better outcomes were done in settings where allocation to the same physician was a long-term policy. OBJECTIVES: To evaluate the influence that changing organizational policy from the free choice of a primary care physician to a mandatory continuity of care by the same physician has on adherence to a personal physician. METHODS: A cross-sectional study based on electronic databases; comparison of adherence and demographic characteristics (sex, age, and socio-economic status) of 208,286 Leumit enrollees who met the inclusion criteria, according to change in the adherence to a personal physician. To evaluate adherence, we used the Usual Provider of Care (UPC) index, which measures the number of visits made to the personal doctor out of the total primary care physician visits over the same period. The patients were divided into groups according to their UPC level. RESULTS: The data shows that 54.5% of the patients were high adherers even before the organizational change; these rates are similar to those published by various organizations worldwide, years after mandating continuity of care by the same physician. In the year following the intervention, only 34.5% of the patients changed the level of their adherence group. Of these, 64% made a shift to a higher adherence group. Before the intervention, the high adherers were older (mean age 57.8 vs. 49.3 years in the low adherers group) and from a higher SES (mean SES status 9.32 vs. 8.71). After the intervention, a higher proportion of older patients and patients from a higher SES changed their adherence to a higher group. Sex distribution was similar over all the adherence level groups and did not change after the intervention. CONCLUSIONS AND POLICY IMPLICATIONS: A policy change that encouraged adherence to an allocated primary care physician managed to improve adherence only in specific groups. Health organizations need to examine the potential for change and the groups they want to influence and direct their investment wisely. TRIAL REGISTRATION: retrospectively registered.

Antioxidant effect of polyphenolic glabridin on LDL oxidation.

This study was conducted to determine the effect of a natural polyphenolic isoflavone antioxidant (Glabridin) on low-density lipoprotein (LDL) oxidation. Determination of the extent of LDL oxidation was done by measuring the formation of Thiobarbituric acid reactive substances (TBARS). After oral administration of licorice-root ethanol extract to healthy subjects for 6 months, the subjects' oxidative stress level as well as plasma LDL oxidation reduced by 20%. We concluded that dietary consumption of glabridin protects LDL from oxidation.

Correlations of work, leisure, and sports physical activities and health status with socioeconomic factors: a national study in Israel.

OBJECTIVE: To evaluate levels of physical activities at work, leisure, and sports and to correlate them with socioeconomic and health factors. METHODS: Validated questionnaire administered to a random sample of 406 adults. Items covered demographic data, health status, smoking, and duration, frequency, intensity of physical activities. Indices of physical activity at work, leisure, and sports were analysed. RESULTS: Adults (both sexes) with poor self perceived health status and less than 13 years of education, regardless of their body mass index, perform no or few physical activities during their leisure time. CONCLUSIONS: The correlations of physical activity with socioeconomic and health factors differ significantly for work, leisure, and sports. Physicians should differentiate physical activities by type and intensity during anamneses.

Managing obesity: a survey of attitudes and practices among Israeli primary care physicians.

OBJECTIVES: To document and assess Israeli family physicians' (FPs) knowledge, attitudes and practices regarding the management of overweight and obesity. METHODS: Anonymous questionnaires were completed by 510 family physicians (82% compliance rate). The questionnaires were distributed in various continuous medical education sites of FPs in Israel. The measures included attitudes to and resources of knowledge on weight management, views regarding the prescription of drugs, approaches to and strategies recommended for weight loss. RESULTS: In all, 73% of FPs viewed weight management as important and reported that they often treated cases of overweight and obesity, including for patients without concomitant risk factors. The medical advice most frequently offered is: increase physical activity, decrease number of total calories (eat less) and consultation with a dietitian (95, 81 and 58% respectively). However, most responders (72%) believed that they had limited efficacy in treating obesity and considered themselves not well prepared by medical school to treat overweight patients. Some 60% reported feeling that they have insufficient knowledge regarding nutritional issues. Regarding pharmacotherapy for treating obesity, only 66% knew the drugs' prescription indications. However, the vast majority (87%) knew about the gradual increase of weight after stopping drug treatment. CONCLUSIONS: Knowledge gaps and ambivalent attitudes toward obesity management were found. More education focusing on obesity, from medical school to post-graduate learning, seems warranted based on these findings.

Methylphenidate use for attention deficit hyperactivity disorder in northern Israel--a controversial issue.

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.

The prevalence of a history of child sexual abuse among adults visiting family practitioners in Israel.

OBJECTIVE: To determine the prevalence of a history of child sexual abuse (CSA) in a random sample of adult patients presenting for routine health care to family practice clinics in Israel. METHOD: One thousand and five randomly selected patients aged 18 to 55, attending 48 clinics, participated in this questionnaire study. RESULTS: Twenty-five percent indicated that they had been sexually abused as children. More women reported CSA (p < .0001 ) than men, as did women originating from Western countries (p = .02) and those with more than 12 years of education (p = .01). There were no significant associations between CSA and the other socio-demographic variables examined. Fondling was the most common and intercourse the least common activity experienced. Forty-five percent of the perpetrators were previously known. The mean age at which the child sexual abuse began varied between 10 and 14. Only 45% of the subjects had ever told anyone about the experience. CONCLUSIONS: Since no other prevalence study has been reported to date in Israel, these findings suggest that as in other Western countries CSA is a relatively common problem. Family physicians and other health professionals should be aware of this high prevalence and its known potential for initial and long-term deleterious outcomes.

High prevalence of vitamin D deficiency among Ethiopian women immigrants to Israel: exacerbation during pregnancy and lactation.

A population of 125 adult Ethiopian women immigrants to Israel was screened for serum levels of calcium, phosphorus, and alkaline phosphatase. Five women (prevalence of 4%) had hypocalcemia and in one of them osteomalacia was found. In the other 120 subjects normal values were recorded. All five patients had low serum levels of 25 hydroxy (OH) vitamin D3 and high parathyroid hormone (PTH) levels. In four of the five patients, clinical and biochemical manifestations of vitamin D deficiency were detected during pregnancy or lactation. Treatment with vitamin D2 for 4-13 months resulted in clinical improvement and partially corrected the biochemical abnormalities, but low serum vitamin D levels and elevated PTH levels persisted. We conclude that vitamin D deficiency among female Ethiopian immigrants to Israel can be ascribed either to dark skin or low calcium and vitamin D intake, or both. As far as we known this is the first report of vitamin D deficiency among such immigrants. Our study suggests the need to be alert to the possibility of vitamin D deficiency in Ethiopian women who have immigrated to Israel, in particular those who are pregnant or are breast-feeding.

PIP: A population of 125 adult Ethiopian women immigrants to Israel was screened for serum levels of calcium, phosphorus, and alkaline phosphatase. After the first instance of hypocalcemia was observed at a clinic in Afula Ilit (northern Israel), case finding was initiated among the 131 adult Ethiopian subjects 20 years or older. Over the course of 4 years, 125 patients (95%) were investigated. In 5 patients for whom these values deviated from the norm, values of parathyroid hormone (PTH), 1,25 hydroxy (OH) D, and 25 OH D were determined. Their diet was assessed for vitamin D-fortified foods and calcium intake. 5 subjects (prevalence of 4%) had hypocalcemia with normophosphatemia, 2 of them also having elevated levels of alkaline phosphatase. In 1 of them osteomalacia was found. Before and after treatment, high serum PTH and 1,25 OH D and low 25 OH D were found in all patients. All 5 patients had low serum levels of 25 hydroxy (OH) vitamin D3 and high parathyroid hormone (PTH) levels. In 4 of the 5 patients, clinical and biochemical manifestations of vitamin D deficiency were detected during pregnancy or lactation. Treatment with vitamin D2 for 4-13 months resulted in clinical improvement and partially corrected the biochemical abnormalities, but low serum vitamin D levels and elevated FTH levels persisted. Vitamin D deficiency among female Ethiopian immigrants to Israel can be ascribed either to dark skin or to low calcium and vitamin D intake, or to both. As far as it is known this is the first report of vitamin D deficiency among such immigrants. The study suggests the need to be alert to the possibility of vitamin D deficiency in Ethiopian women who have immigrated to Israel, in particular those who are pregnant or are breast-feeding.

Characteristics of registered clinic patients who have not visited their family physician for 3 years.

The objective of this study was to obtain and critically evaluate data on the health characteristics and the need for medical assistance in patients aged 40 years and over, from six urban and rural medical practices in northern Israel, who have not consulted their family physician for at least 3 years. A health questionnaire was completed by means of telephone calls and personal contacts, regarding 139 non-visitors (out of 1847 patients aged 40 and over). The health characteristics and prevalence of medical and social problems were compared to regular clinic attenders. Questionnaires of 101 non-attenders were completed for a response rate of 73% (101/139). The non-attendance rate was 7.5% (139/1847) and there was a low rate of morbidity. The majority (81%) were 40-59 years old and only 16% had had previous illnesses. Only 10% took medications regularly, most of them medical personnel. Twenty-eight of the non-attenders were employees of the regional health care system. Most of these individuals coped with chronic illnesses by consulting the regional hospital's outpatient clinics. Non-attenders could be characterized as less prone to health problems. Most of them seemed remarkably fit and were not suffering unduly as a result of their lack of medical attention.

[Primary care consultation rates among the middle aged and elderly].

The consultation rate among family physicians has been widely discussed in the literature, but very few studies have been done in Israel. We analyzed the pattern of visits to the family physician of 1,860 patients aged 40 years and older in 3 urban clinics, 2 kibbutzim and 1 rural clinic with a total population of 6,700. The consultation rate rose steadily with age. It was 3.4 per year at age 40-49, and 5.6 at ages 70 and over, with a mean annual rate of 4.6. 77% of the screened population consulted the physician in 1 year and 91.4% in 3 years. Only 9.6% did not visit their physicians in the 3 years. About two-thirds visited the physician 1-4 times a year, and only 2% visited more than 15 times. In urban practices women attended more often than men but there was no significant sex difference in the rural practices. As a result of the greater visit rates of the elderly, they consumed a larger share of medical services. The mean consultation rate in this survey is similar to that in England and in other Western countries. However, it is relatively low in comparison to other studies in Israel. This may be due to the different practice setting and the use of a different sampling frame.