Attitudes of EAPD members toward using the "knee-to-knee" position.

AIM: This survey assessed the attitude of paediatric dental EAPD members toward using "knee-to-knee" positioning for dental examinations and minor procedures in infants and toddlers. METHODS: An anonymous electronic online questionnaire was distributed among EAPD members. The survey consisted of 12 questions and assessed demographic characteristics, professional experience and attitudes toward the use of the "knee-to-knee" position. RESULTS: Of the 162 respondents, 148 (91%) reported using "knee-to-knee" positioning for dental examination. In addition, 97 (63%) reported performing other procedures in the "knee-to-knee" position. Fluoride application and oral hygiene instructions were the most common procedures performed in the "knee-to-knee" position. CONCLUSIONS: Most of the paediatric dentists who responded to this survey reported performing dental examinations in toddlers up to 2 years old using the "knee-to-knee" position. Majority of respondents also used this position to instruct parents regarding oral hygiene and to apply fluoride varnish.

Dentists, dental hygienists and dental students' knowledge regarding recommended fluoride concentration in toothpaste for children.

PURPOSE: The objective of this study was to assess the knowledge of dentists, dental hygienists and dental students regarding the Israeli Ministry of Health guidelines for using fluoridated toothpaste. MATERIALS AND METHODS: An anonymous questionnaire was distributed to dentists, dental hygienists, and dental students in their final years at the Hebrew University-Hadassah School of Dental Medicine. Participants were queried regarding their knowledge of Ministry of Health fluoride concentration guidelines in toothpaste by the following age categories: under 2 years, 2-6 years, and above 6 years. RESULTS: Thirty-two paediatric dentists (specialists and residents), 63 general dentists, 68 dental hygienists, and 69 students responded to the survey. Analysis of survey respondent's knowledge of Ministry of Health fluoride toothpaste guidelines by age group found that 81%, 75% and 88% of participants selected a fluoride concentration within the recommended range for those under 2 years, 2-6 years and greater than 6 years, respectively. Only 58% of respondents were aware of the recommended fluoride concentration for all three age groups. Among respondents who answered all three questions, there was a significant association between correctly answering the fluoride questions and respondent's profession (P = 0.026), with a larger percentage of paediatric dentist (76%) and dental students (66%) correctly answering all three questions. CONCLUSIONS: Israeli dental practitioners should be educated about the Israeli Ministry of Health fluoride concentrations in toothpaste guidelines. The guidelines should be emphasised at annual meetings and in continuing education courses.

"Knee-To-Knee" Position for Minor Procedures in Infants and Toddlers- Dentists Attitudes.

OBJECTIVE: The objective of this survey was to assess attitudes of pediatric dentists in Israel toward using "knee-to-knee" positioning for dental examinations and for minor procedures in infants and toddlers. STUDY DESIGN: An anonymous questionnaire was distributed among specialists in pediatric dentistry. Eleven questions accessed demographic data, professional experience and attitudes toward the use of the "knee-to-knee" position. RESULTS: Of 68 respondents, 66 (97%) reported using "knee-to-knee" positioning for dental checkups. In addition, 52 (76%) reported performing other procedures in the "knee-to-knee" position. Fluoride application and oral hygiene instructions are the most common procedures performed in the "knee-to-knee" position. CONCLUSIONS: "Knee-to-knee" positioning was found very convenient for dental examinations and other simple procedures in very young children.

Perioperative noninvasive cardiac output monitoring in parturients with singleton and twin pregnancies undergoing cesarean section under spinal anesthesia with prophylactic phenylephrine drip: a prospective observational cohort study.

Purpose: Spinal anesthesia is considered the gold standard anesthetic technique for cesarean deliveries (CDs) but is associated with a high rate of hypotension. The recent international consensus recommends continuous prophylactic phenylephrine infusion (PPI) administered throughout CD to prevent hypotension. However, little information is available on the hemodynamic profiles of women with twin pregnancies as compared to singleton pregnancies perioperatively. Therefore, in this study, we aim to compare maternal hemodynamic changes both intraoperatively and postoperatively with the use of the NICAS bioimpendence monitor in healthy singleton versus twin parturients undergoing CD deliveries with spinal anesthesia with PPI. Materials and methods: After IRB approval and signed informed consent, healthy term women with either twin or singleton pregnancies undergoing spinal anesthesia for uncomplicated CD were enrolled. The following data were collected - cardiac output (CO), stroke volume (SV), mean arterial pressure (MAP), and total peripheral resistance (TPR). Measurements were measured at five time points: (1) before arrival in OR, (2) after spinal anesthesia with PPI, (3) after beginning of oxytocin infusion, (4) in post anesthesia care room, (5) 24 hours postoperatively, and (6) 48 hours postoperatively. All parturients received standardized spinal solution consisting of 12 mg hyperbaric bupivacaine, 20 µg fentanyl and 100-µg preservative-free morphine. PPI administered was titrated to preserve blood pressure to 20% of baseline blood pressure and stopped at the end of surgery. Oxytocin was administered as a continuous infusion (20-units/1000 cm3 Ringer's lactate) at a rate of 100 cm3/h. Results: One hundred and thirty seven parturients with singleton pregnancies and 27 parturients with twin pregnancies completed the study. There were no significant differences between groups in age or BMI. Intraoperatively, there was no difference in any hemodynamic parameter. However, postoperatively at all three times women with twin pregnancies had higher MAP, lower CO and higher TPR compared with parturients with singleton pregnancies. Conclusions: There were significant hemodynamic changes postoperatively but not intraoperatively in parturients with twin pregnancies compared to women with singleton pregnancies. These changes need to be further investigated.

Topical capsaicin--a novel and effective treatment for idiopathic intractable pruritus ani: a randomised, placebo controlled, crossover study.

PURPOSE: Pruritus ani is a common and embarrassing proctological condition which can be very difficult to treat. We report the results of a double blind placebo controlled study of treatment with capsaicin. METHODS: Firstly, a pilot open study was carried out on five patients to establish which of two doses was the most acceptable by comparing effectiveness and side effects. Secondly, a double blind, placebo controlled, crossover study of topical capsaicin was performed. This study involved two four week treatment phases separated by a one week washout phase. Forty four patients were randomised to receive locally either active capsaicin (0.006%) or placebo (menthol 1%) ointment over a four week period (22 patients per group). After four weeks of treatment and a one week washout period, the placebo group began to receive capsaicin while the treated group received placebo (menthol 1%) for another four weeks. At the end of the controlled study, responders from both groups continued with capsaicin treatment in an open labelled manner. RESULTS: Thirty one of 44 patients experienced relief during capsaicin treatment periods and did not respond to menthol; all patients not responding to capsaicin also failed on menthol (p<0.0001). In 13 patients, treatment with capsaicin was unsuccessful: eight patients did not respond to capsaicin treatment, one responded equally to capsaicin and placebo, and four others dropped out because of side effects. During the follow up period (mean 10.9 (SD 5.8) months), 29 "responders" needed a mean application of capsaicin every day (1.6 (SD 1.2); range 0.5-7 days) to remain symptom free (or nearly symptom free). CONCLUSION: Capsaicin is a new, safe, and highly effective treatment for severe intractable idiopathic pruritus ani.

Risk-adjusted capitation. The Israeli experience.

As in a number of countries during the 1990s, Israel's health system has been undergoing structural reform based on public contracting and regulated markets. The main element of the reform was the enactment of the National Health Insurance Law (NHI), which went into effect on 1 January 1995. According to the Law, the sick funds receive risk-adjusted capitation payments, which place them fully at risk for the cost of supplying a legally mandated basket of health benefits. The paper analyses the effects of the NHI on the Israeli competitive health insurance market and discusses the major policy issues facing the Israeli system.

The effect of health on acute care supplemental insurance ownership: an empirical analysis.

The empirical effect of health status on private insurance ownership is a mixture of the effect of health on the demand for insurance (subjected to adverse selection) and its effect on the insurer's underwriting practice (subjected to risk-selection). Using bivariate partial observability probit models, this paper provides an empirical identification of health effects on the probability of application and on the probability of rejection in the Israeli market for acute care supplemental health insurance. The analysis shows that while the reduced-form health effect on ownership is negligible, the structural effects are sizeable and indicate that sicker individuals are more likely to apply, but are also more likely to be rejected. The policy implications of the above findings are discussed in the context of the Israeli health system.

A note on risk adjustment and fair compensation.

This note comments on the application of results from the theory of fair compensation to risk adjustment. It argues that the main flaw of such application lies in the consideration of health plans merely as administrative social agents, through which money flows from a central fund to providers of medical care, ignoring their economic behaviour. However, it is that behaviour which raises the issue of risk selection to begin with. With linear health expenditure function, the fair compensation axiomatic solution is shown to be equivalent to the solution of a simple optimal regulation problem. That equivalence permits the analysis of several further issues related to risk adjustment and to the application of the theory of fair compensation to it.

Horizontal equity in medical care: a study of the Israeli public's views.

BACKGROUND: With market failures characterizing the health care sector, societies are continuously searching for ways to achieve an efficient and fair allocation of resources. A natural source of opinion on the desired allocation of health resources is the public. In fact, several governments have recently involved the general public in decisions about resource allocation in their health systems. OBJECTIVES: To investigate the views of the Israeli Jewish public aged 45-75 on horizontal equity in medical care; specifically, the characteristics (including a lottery) for determining which of two individuals with similar medical need should be treated first, against a background of limited resources. METHODS: A sample of 2,030 individuals was chosen to represent a population of about 800,000 urban Jewish Israelis aged 45-75. Data were collected in face-to-face full sit-down interviews by trained interviewers between October 1993 and February 1994. RESULTS: The three most preferred prioritizers were chances of recovery, number of dependants, and young age. Random prioritization was preferred by only 8% of the population. Age, level of education and religiosity were the main characteristics associated with the choice. CONCLUSIONS: The Israeli adult public does not favor strict horizontal equity in health care. As in other social programs, "equals" were defined in a multi-criteria manner, based on both medical need and other personal characteristics. The preferred prioritizers seem to reflect universal tastes and cast doubt on the traditional distinction between efficiency and equity and between horizontal and vertical equity when applied to health care.

Inferring capitation rates from aggregate health plans' costs.

Setting risk-adjusted capitation rates in health systems with centralized financing and decentralized delivery is one of the most intriguing policy issues. The common practice to set capitation group rates is based on individual data collected from either population surveys or medical records, using a single-and in most cases arbitrary-set of relative unit costs of services. This paper presents a method for estimating group-specific mean costs and capitation rates using a panel of aggregate cost data of the competing health plans and the composition of their populations. This method is used to estimate mean costs and capitation rates for the Israeli health care system. The limited data available severely constrains the range of estimable models, however, the results evoke some questions with regards to reimbursement and rates presently used, as well as to the methodology used to estimate them.

Do we know what global ratings of health-related quality of life measure?

Information is lacking about the public's perception of the term health-related quality of life (HRQL). Specifically, what are the relations between the domains included in the operational definition of HRQL tools and global health ratings. The purpose of this analysis was to identify factors associated with global rating of HRQL. We conducted a survey of a representative sample of 2,030 Israeli adults, aged 45-75 years. Multiple linear regression analysis was used to identify associations between the dependent variable, the global rating, and socio-economic details, presence of disease states, and each of the domains of the SF-36. The results demonstrate that the model explains only 52% of the variance of the global rating score. The general health domain of the SF-36 explains the vast majority of the variance, 38.5%. Another important explanatory variable was physical functioning domain, which explains 7.0% of the variance and to a lesser extent vitality. The other domains of the SF-36, socio-economic details and presence of disease states contribute only small percentages to the total explained variance of the global ratings of HRQL. It seems that there is a considerable difference between the operational definition of the research community of HRQL and the public perception of this term.

The competing effects of disease states on quality of life of the elderly: the case of urinary symptoms in men.

During the period 1993-1994 we conducted a study in Israel on a national-based sample of 960 men to examine the relationships between urinary symptoms and various domains of quality of life (QoL). Regression analyses were performed for each of the eight SF-36 domains, separately for the entire population and for those--without any co-morbidity. The dependent variable was the SF-36 domain scores. The independent variables included age, origin, education, employment and economic status, the degree of disturbance caused by urinary symptoms and the existence of co-morbidities. There was a significant difference between the entire population and the population without co-morbidities. In the entire population we found that severely bothersome urinary symptoms were related to scores on three QoL domains (social function, role-emotional and mental health) but there was no association with physical functioning and general health perceptions. In men without co-morbidity, urinary symptoms were substantially related to physical functioning and general health perceptions. These findings indicate that the relative weight of the impact of a symptom or disease on QoL domains is changed by the presence of other competing factors, such as co-morbidities or sociodemographic attributes.

Survival vs. quality of life: a study of the Israeli public priorities in medical care.

Public opinion has become one of the primary inputs in setting priorities, rationing and allocating health resources. The present study focuses on the priorities of the Israeli public aged 45-75 in allocating scarce medical resources between prolonging survival (the 'Rule of Rescue') and preventing a severe and permanent disability (quality of life). The findings indicate that the 'Rule of Rescue' is dominant for more than a quarter of the population even when death is postponed by only one month. More than a tenth of the population are ready to adopt prioritization by lottery. Economic condition, gender and health status have no effect on priority choices. The main determinants of the choices are age and religiosity, with older individuals more likely to choose random prioritization and religious people tending to prefer saving life even when the opportunity costs are high.

Addressing the inequity of capitation by variable soft contracts.

In the search for greater efficiency and cost-containment, many health systems have introduced the practice of medical care providers operating under a fixed budget, often referred to as the capitation or fundholding contract. Although the capitation contract seems equitable at first glance, the sequential decision-making practice of providers-shaped by their rate of present-preference and their attitude toward the risk of running out of budget-may result in serious violations of basic equity principles. We propose a variable soft (or mixed) payment contract (VSC), where the share of the retrospective payment increases over time, as a way to make the contracts more equitable. We also discuss how the parameters of the capitation contract (length of the budget period, soft or hard contracts, solo vs. consortium practice etc.), which are usually set by efficiency criteria, may have serious implications with regard to the equity of the system.

Subjective health status and health values in the general population.

OBJECTIVE: To explore the relationship between rating-scale evaluation of health-related quality of life ("health value") and two subjective evaluations of health: the SF-36 profile and the five-category perception of general health (excellent, very good, good, fair, and poor). METHODS: This relationship was explored by linear and nonlinear regression analysis of data obtained through face-to-face interviews with a sample of 2,030 persons aged 45-75 years representing the Israeli Jewish urban population in that age group. RESULTS: The main outcome is a mapping assigning health values to the subjective health-status scores, e.g., "good" general health is equivalent to a health value of 76-81, depending on the functional form of the relation. "Poor" health is equivalent to a value of 45-61. The R2 is about 0.3. While the eight scales of the SF-36 were found to be linearly related to health value (R2=0.51), the two summary measures-physical component scale (PCS) and mental component scale (MCS)-were not. The scales measuring general health, vitality, and physical functioning were the main determinants of health value, while the role-performance scales were insignificant. The PCS had a larger effect than the MCS. DISCUSSION: These relationships provide deeper insight into the structure and meaning of the two health-status measures in the general population. They also place earlier determinations of these relationships among sick persons in a broader context and raise several further questions regarding the relationship between health values and health status.

Birth weight, maternal age, and education: new observations from Connecticut and Virginia.

It has been well established that increased maternal education, income, and social status contribute to increased birth weight, as well as reduced risk for low or very low birth weight offspring. However, there remains controversy about the mechanism(s) for this effect, as well as the interactions between these factors, maternal age, and race. Presented here is the analysis of a large, recent sample of over 20,000 consecutive live births in 12 hospitals, about half in Connecticut and half in Virginia, including a maternal population that is educationally and racially diverse. Although information on potentially relevant details such as prenatal care, smoking, occupation, and neighborhood is lacking the data set, there is sufficient information to explore the previously noted strong effect of maternal education on birth weight, as well as the large racial difference in outcome at every educational level after adjustment for the effects of age, marital status, state of residence, and gender of the offspring. However, this relationship was not monotonic, and there were differences in the effect between the white and black families, with black women showing a linear and consistent benefit from education across the range, while whites show a sharp benefit from completion of primary education, less from subsequent schooling. A surprising result was the apparent negative impact of very advanced education (>16 years), with lowered birth weights and higher risk of low birth weight offspring in the women with post-college training. The data also shed some addition light on the effect of age and birth weight. Whites show established improvement in birth outcome to about age 30, with slight decline thereafter, whereas in blacks there was progressive decline in birth weight with rising age starting in adolescence, as previously demonstrated by Geronimus. An additional unexpected observation was a sizable difference between births in Connecticut (larger, fewer low birth weight) than Virginia, correcting for all other covariates. It is hypothesized that this may reflect differences in services used, prenatal care in particular given similarities in smoking rates and other predictors. Because of the non-representativeness of and the limited information available in the present study, the conclusions should be taken as hypotheses for further research rather than definitive.

Validation of the 36-item short-form Health Survey (Hebrew version) in the adult population of Israel.

OBJECTIVES: In the past few years, the SF-36 Health Survey has drawn considerable attention from researchers in non-English-speaking countries. This report contributes to the growing body of literature on this instrument by reporting the results of a national study conducted in Israel. The study examined the psychometric properties of the Hebrew translation based on a sample of the adult population of Israel and evaluated the results from a cross-national perspective. METHODS: The sample included 2,030 adults drawn from the Jewish population, aged 45 to 75 years. The SF-36 Health Survey was administered in face-to-face interviews as part of a broader health study. RESULTS: The pattern of correlations among items and the internal consistency scores pointed to high reliability. Confirmatory factor analysis using the Amos 3.61 program supported the hypothesized factorial structure. Specifically, the items clustered around eight health dimensions, as was found in studies in other societies. Clear and statistically significant differences in the SF-36 Health Survey scores were found among age groups and population groups distinguished by the degree of chronic health problems. CONCLUSIONS: Results of the analysis indicate that the instrument provided an appropriate measure of general health status. The findings clearly indicate that the translation into the Hebrew language and the application of the instrument to a culturally heterogeneous population did not diminish the qualities of the instrument. They also point to certain items that might be modified to reduce problems of synonimity and embeddedness.

The SF-36 profile and health-related quality of life: an interpretative analysis.

The purpose of this investigation was to explore the relationship between the SF-36 scales and a direct, category-scaling, self-evaluation of health-related quality of life in a sample of healthy persons. The study of the relationship between the two provides a deeper insight into the structure and meaning of the SF-36 profile and explores its interpretability in terms of a comprehensive, subjective evaluation of health. Furthermore, this study leads to a preliminary interpretation of the profile in terms of a utility scale.

Supplemental health insurance ownership in Israel: an empirical analysis and some implications.

Many Western nations are implementing (or considering) changes in their health care systems. An integral component of these changes (or debates) refers to the functioning and regulation of the supplementary health insurance market. However, only limited empirical evidence exists on the functioning of the market, which is prone to the problems of moral hazard, adverse selection and risk selection. This paper presents an empirical analysis of ownership patterns of four supplementary insurance policies (acute care, nursing care, dental care and emergency intensive care) in the Israeli population aged 45- 75 in 1993. It further discusses some social policy and regulation issues related to the supplemental health insurance market in the post-1995 era of the Israeli National Health Insurance.

Underutilization of health services among patients with urinary symptoms: results of a population-based survey in Israel.

BACKGROUND: Although there is firm evidence concerning the relatively-high rates of overutilization of prostate surgery among elderly men, only minimal efforts have been made to evaluate the existence and extent of underutilization. This assessment, accomplished by our study, may have a significant impact on health services planning and budgeting. METHODS: The study population comprised a nationwide representative sample of 960 Israeli men, aged between 45 and 75 years. Data were accumulated by personal interviews conducted at the homes of the individuals by trained staff. The questions included in the questionnaire aimed at describing the sociodemographic and clinical status. The responses to questions regarding male urinary symptoms were obtained by personal reports. RESULTS: Forty-three percent of the subjects reported having experienced urinary symptoms, but only 4.6% were severely bothered by the symptoms on a daily basis, and 8.9% were moderately bothered. Only 55.4% of patients with bothersome urinary symptoms visited their general practitioners, while only 39.7% were referred to a urologist because of their complaints. CONCLUSIONS: Elderly men bothered by urinary symptoms frequently do not seek health care. An educational program regarding the potential benefit of medical interventions for benign prostatic hypertrophy may significantly improve their quality of life.