Depressive symptoms and use of health services among older adults in Israel.

OBJECTIVES: Depressive symptoms are often undetected, particularly among older adults. The purpose of this study is to provide information on the prevalence, characteristics, and patterns of depressive symptoms among older adults residing in the community in Israel, and their health-care utilization. METHODS: A cross-sectional survey was conducted among a random sample of 2502 members of one HMO in Israel, aged 65+. They were interviewed by telephone with the GDS-15 scale, which serves as the gold standard for depressive symptoms. Data from the computerized medical records of the HMO were added to the interview file, including the diagnosis of depression, purchase of antidepressant medication and use of services. RESULTS: The average age of respondents was 73; 54% were women. They tended to be older, living alone, suffering from falls and from sleep disorders, and to have poor subjective health status. 24% scored 6+ on the GDS scale. A significant association was found between a GDS score of 6+ and increased hospitalizations, visits to the emergency room and/or to family physicians and specialists. CONCLUSION: We found a high prevalence of depression. Its negative effects on the individual and increased costs to the health system, supports the screening and treatment of the disease in the older population. This problem should be a national priority, with screening and treatment becoming part of the national quality of care indicators which would then be implemented by the HMOs as part of an integrated disease management program for the elderly.

Israeli general practitioners' dissatisfaction with their own primary healthcare.

Background: Many physicians treat themselves despite established guidelines against such practice. Aims: To examine whether general practitioners (GPs) are satisfied with their personal primary care and how this could be improved. Methods: We sent a questionnaire to GPs in Israel. We examined the gap between preference to use formal medical care and use in practice, satisfaction with physicians' primary healthcare, self-prescribing and ways to improve physician access to care. Results: There were 203 respondents (response rate 203/985; 21%). Sixty-one per cent reported not having a GP. Older respondents were less likely to have their own GP. Thirty-seven per cent of physicians reported receiving less formal medical care than they desired. This gap was higher in those reporting self-prescription of benzodiazepines and anti-depressants (P < 0.05) and was significantly associated with dissatisfaction with primary healthcare. Odds for being satisfied with personal care was reduced by more than 85% in GPs who reported receiving less formal medical care than they desired (odds ratio 0.146; 95% confidence interval 0.064-0.333). Conclusions: Our findings inform the profile of physician self-treatment and the dissatisfaction associated with it. Dissatisfaction was associated with a gap between desired and actual care rather than with having or not having a personal GP. There was no consensus regarding what would assist physicians to access GPs.

Development of an unsupportive social interaction scale for patients with diabetes.

OBJECTIVES: The positive aspects of social support and its impact on health have been studied extensively. However, there may also be negative effects of social environments on the diabetic patient. This study developed and validated a new diabetic unsupportive social interaction scale (USIS), including two subscales: interference and insensitivity. METHODS: A list of 22 items depicting unsupportive interactions associated with management of diabetes was developed. A telephone survey was administered to 764 Israelis with diabetes. The questionnaire included the USIS and questions about social networks, social support, health behaviors, and health. The characteristics, validity, and reliability of the scale were tested. RESULTS: A principal component analysis was performed for extraction of two factors describing unsupportive social interaction concepts: interference and insensitivity. Cronbach's alpha for the full 15-item scale was 0.84, indicating internal consistency. The two subscales were calculated to have Cronbach's alphas of 0.85 and 0.73, respectively. The USIS showed construct validity as it was associated with social support, some measures of social networks, subjective measures of health, and health behaviors. Arabs, older respondents, those defining themselves as more religious, and the less educated reported higher rates of unsupportive interactions. CONCLUSION: This study suggests a new concept of unsupportive interactions including interference and insensitivity. These unsupportive interactions may adversely affect patients' ability to adhere to treatment and may undermine their health in various ways. Identifying these problems may enable clinicians to help patients cope with their unsupportive environments.

An intensive family intervention clinic for reducing childhood obesity.

BACKGROUND: Childhood and adolescent obesity constitute a significant public health concern. Family health care settings with multidisciplinary teams provide an opportunity for weight loss treatment. The objective of this study was to examine the effect of intensive treatment designed to reduce weight using a parent-child lifestyle modification intervention in a family health care clinic for obese and overweight children who had failed previous treatment attempts. METHODS: This was a practice-based 6-month intervention at Maccabi Health Care Services, an Israeli health maintenance organization, consisting of parental education, individual child consultation, and physical activity classes. We included in the intervention 100 obese or overweight children aged 5 to 14 years and their parents and 943 comparison children and their parents. Changes in body mass index z-scores, adjusted for socioeconomic status, were analyzed, with a follow-up at 14 months and a delayed follow-up at an average of 46.7 months. RESULTS: The mean z-score after the intervention was lower in the intervention group compared to the comparison group (1.74 and 1.95, respectively; P = .019). The intervention group sustained the reduction in z-score after an average of 46.7 months (P < .001). Of the overweight or obese children, 13% became normal weight after the intervention, compared with 4% of the comparison children. CONCLUSION: This multidisciplinary team treatment of children and their parents in family health care clinics positively affected measures of childhood obesity. Additional randomized trials are required to verify these findings.

Socioeconomic status and gender affects utilization of Medical Nutrition Therapy.

AIMS: To identify socioeconomic status and gender inequalities in long and short-term Medical Nutrition Therapy among Israeli adult patients with diabetes. METHODS: An analysis of data was performed on 90,900 patients over the age of 18 who were registered as patients with diabetes mellitus in Maccabi Healthcare Service Register which is the second largest health maintenance organization in Israel. Socioeconomic Rank for each patient was determined from the Israel Central Bureau of Statistics by geographical area of residence. Medical Nutrition Therapy was defined by the number of visits with registered dietitians. Short-term therapy was defined as one visit and long term therapy as two or more visits during the previous two years. Newly diagnosed patients were compared with veteran patients. RESULTS: Only 25.8% of the patients with diabetes received nutrition therapy during the previous two years. Newly diagnosed patients received therapy more frequently than veterans. We found that long term therapy was positively dependent on socioeconomic rank. Women under the age of seventy five had a higher chance of receiving therapy compared to men. CONCLUSIONS: A nationwide nutritional counseling service is available and accessible to all patients with diabetes. However, the patients with higher socioeconomic rank have a higher rate of persistence with long-term nutritional therapy.

Reducing resistance to diabetes treatment using short narrative interventions.

OBJECTIVE: This article presents a narrative-based technique, which allows medical personnel to empower patients with diabetes and improve adherence. METHODS: The study was undertaken in Maccabi Healthcare Services, among 123 patients diagnosed with diabetes. Four empathic narratives were constructed, referring to different factors influencing resistance to treatment, as were identified by the Resistance to Treatment Questionnaire. Each narrative contains statements typical for patients whose resistance to treatment is influenced by a particular factor. An Empathic Narratives Evaluation Questionnaire was designed for this study. It contained three items, assessing the correlation of a specific empathic narrative with the patient's attitude and their reasons for resistance to treatment. The patients were asked to indicate whether they recognize these narratives as describing their reasons for resistance. Three empathic narratives were read to each patient: two narratives were matched for the two major categories of resistance for each patient and one narrative related to a category of resistance that received the lowest score. RESULTS: The narratives were found to correspond to the core reasons for resistance to diabetes treatment. Significant difference was found also between the scores of the empathic narrative related to the second strongest reason for resistance to treatment and the empathic narrative related to the weakest reason for resistance to treatment. This finding supports testimonial validity of the narratives. CONCLUSION: Short narrative interventions demonstrated in this study can be used by health care professionals as a working tool that provides the possibility reducing the patient's reasons for resistance to treatment.

Does low socioeconomic status affect use of nutritional services by pre-diabetes patients?

PURPOSE: This paper's aim is to identify whether community-level socioeconomic status (SES) predicts: screening test for pre-diabetes; actual diagnosis of pre-diabetes; or nutritional counseling. DESIGN/METHODOLOGY/APPROACH: This is an analysis of 1,348,124 insured adults receiving medical care from Maccabi Healthcare Services (MHS) in 107 MHS clinics throughout Israel. The research population comprised 79 percent of the MHS members over 18 years of age in 2004-2006. Area level socioeconomic data were drawn from the Israel Central Bureau of Statistics SES index for every geographical area and each MHS clinic in the study was coded from: - 1.03 to 2.73 (- 1.03 indicating low SES and 2.73 + high SES) according to the SES index for the location. The fasting glucose laboratory test was used for analysis. Pre-diabetes diagnosis was based on a fasting glucose above 100 mg/dl. Nutritional counseling was defined by dietitian visits in the claims database. FINDINGS: The percentage of insured individuals who underwent blood glucose testing during the study increased with age from 67 percent at ages 18-45 to92 percent for age 65 and over. The percentage of individuals diagnosed with pre-diabetes also increased with age, rising from 4 percent in the younger group to 14 percent in those aged 46-65 and to 14-16 percent of 65 and older. The percentage of individuals with pre-diabetes who visited a dietitian was 16-27 percent for those under 65 and 14-17 percent for those over 65 (males and females, respectively). Individuals living in lower socioeconomic areas were less likely to have blood tests. Among tested patients, the prevalence of pre-diabetes was higher in areas of lower SES and their dietitian visits were less frequent. PRACTICAL IMPLICATIONS: In lower SES index areas, there is a need for better identification and treatment of patients. ORIGINALITY/VALUE: The paper shows that a proactive approach is needed both to detect pre-diabetes and to encourage patients to receive nutritional treatment.

The effect of commitment to the organization on physicians' familiarity with guidelines for diabetes in managed care organizations.

Despite continuous efforts, healthcare organizations still find it difficult to influence physicians to follow clinical guidelines. Previous studies have not taken into account the organizational context of the physicians' practice. We conducted a survey of a representative sample of 743 primary care physicians employed in Israel's 2 largest managed care health plans. The findings indicated that "commitment to the health plan" and "perceived monitoring by the health plan" had an independent positive effect on familiarity with guidelines for treating diabetes. We propose that managers of healthcare organizations consider enhancing physicians' commitment to the organization as a means for increasing their adherence with clinical guidelines, thereby improving the quality of care provided to diabetic patients.