The landscape of medical care consumption in Israel: a nationwide population cross-sectional study.

BACKGROUND: The Ecology of medical care was first published in 1961. The graphical square model showed that 75% of the population in the US and England experience a feeling of illness during a given month, 25% seek medical help and only one percent are hospitalized. In 2001, Green and colleagues found the same findings despite the many changes that occurred over the past decades. The frequency of illness, the desire for assistance and the frequency of seeking and getting medical assistance may differ in different populations due to cultural, economic, social, demographic background and local Health policy. This work describes the ecology of medical care consumption in Israel for the first time and examines the socio-demographic effects on consumption. METHODS: This is a Nationwide cross-sectional study. A telephone survey was conducted among a representative sample of the adult population (> 15 years) in Israel. Subjective morbidity rate in the preceding month, the rate of those considering medical assistance and those who got assistance were calculated. Correlation between socio-demographic variables and patterns of morbidity and medical care consumption was examined using a t-test and chi square for continuous quantitative and categorical variables. Logistic regression was used for multivariate analysis. RESULTS: A total of 1862 people participated; 49.5% reported having symptoms in the previous month, 45% considered seeking medical advice, 35.2% sought out medical assistance and only 1.5% were hospitalized. The vast majority chose to contact their family physician (58%) and the primary care setting provided their needs in 80% of the cases; Subjective morbidity and medical care consumption differed significantly between Israeli Jews and Arabs. Gaps in the availability of medical services were observed as residents of the periphery forewent medical services significantly more than others (OR = 1.42, p = 0.026). CONCLUSIONS: Subjective morbidity is less common in Israel than in other countries, but paradoxically consumption of medical services is higher. An Israeli who feels ill will usually consider receiving assistance and will indeed receive assistance in most cases. However, a greater tendency to forego medical services in the periphery indicates barriers and inequality in the provision of health services. Different cultural perceptions, lack of knowledge and low accessibility to medical services in the periphery probably contribute to the contrast shown between low consumption of medical services and high prevalence of chronic illness in Arab society. The prevailing preference for family medicine and its ability to deal with most requests for assistance suggest that strengthening family medicine in the periphery may reduce those barriers and inequalities.

Academic activism on behalf of children during the COVID-19 pandemic in Israel; beyond public health advocacy.

Among the challenges presented by the SARS-CoV2 pandemic are those related to balancing societal priorities with averting threats to population health. In this exceptional context a group of Israeli physicians and public health scholars (multidisciplinary academic group on children and coronavirus [MACC]) coalesced, examining the role of children in viral transmission and assessing the necessity and consequences of restricted in-class education. Combining critical appraisal and analytical skills with public health experience, MACC advocated for safe and monitored school re-opening, stressing the importance of education as a determinant of health, continuously weighing this stance against evolving COVID-19-risk data. MACC's activities included offering research-based advice to government agencies including Ministries of Health, Finance, and Education. In a setting where government bodies were faced with providing practical solutions to both decreasing disease transmission and maintaining society's vital activities, and various advisors presented decision-makers with disparate views, MACC contributed epidemiological, clinical and health policy expertise to the debate regarding school closure as a pandemic control measure, and adaptations required for safe re-opening. In this paper, we describe the evolution, activities, policy inputs and media profile of MACC, and discuss the role of academics in advocacy and activism in the midst of an unprecedented public health crisis. A general lesson learned is that academics, based on the rigor of their scientific work and their perceived objectivity, can and should be mobilized to pursue and promote policies based on shared societal values as well as empiric data, even when considerable uncertainty exists about the appropriate course of action. Mechanisms should be in place to open channels to multidisciplinary academic groups and bring their input to bear on decision-making.

Chronic drug treatment among hemodialysis patients: a qualitative study of patients, nursing and medical staff attitudes and approaches.

BACKGROUND: Dialysis patients have a high pill burden, increasing their care complexity. A previous study in our institution's dialysis unit found notable discrepancies between medication prescriptions, purchases and patient reports of medication use: overall adherence to medication was 57%, on average; staff reported patients took 3.1 more medication types than actual purchases; concordance of patient purchases and nurse reports was found in 5.7 out of 23.6 months of patient follow-up. We sought to investigate patients and staff concepts and attitudes regarding medication care and to understand better the previously identified inconsistencies. METHODS: We performed a qualitative research based on the grounded theory approach, using semi-structured, in-depth, interviews with patients and staff from the same dialysis unit studied previously, at the Hadassah Medical Center, Jerusalem, Israel. RESULTS: Though all respondents described a seemingly synchronized system of care, repeated questioning revealed that staff distrust patient medication reports. Patients, on their part, felt that their monitoring and supervision were bothersome and belittling. Along with patients, nurses and physicians, we identified a "fourth" factor, which influences medication care - the laboratory tests. They serve both as biological parameters of health, but also as parameters of patient adherence to the prescribed medication regimens. CONCLUSIONS: Participant responses did not clearly resonate with previous findings from the quantitative study. The central role of laboratory tests should be carefully considered by the staff when interacting with patients. An interaction process, less adversarial, centering on the patient attitudes to medication care, might establish better communication, better cooperation and better patient outcomes.

When COVID-19, constitutional crisis, and political deadlock meet: the Israeli case from a disproportionate policy perspective.

This article describes the efforts made by the Israeli government to contain the spread of COVID-19, which were implemented amidst a constitutional crisis and a yearlong electoral impasse, under the leadership of Prime Minister Benjamin Netanyahu, who was awaiting a trial for charges of fraud, bribery, and breach of trust. It thereafter draws on the disproportionate policy perspective to ascertain the ideas and sensitivities that placed key policy responses on trajectories which prioritized differential policy responses over general, nation-wide solutions (and vice versa), even though data in the public domain supported the selection of opposing policy solutions on epidemiological or social welfare grounds. The article also gauges the consequences and implications of the policy choices made in the fight against COVID-19 for the disproportionate policy perspective. It argues that Prime Minister Netanyahu employed disproportionate policy responses both at the rhetorical level and on the ground in the fight against COVID-19; that during the crisis, Netanyahu enjoyed wide political leeway to employ disproportionate policy responses, and the general public exhibited a willingness to tolerate this; and (iii) that ascertaining the occurrence of disproportionate policy responses is not solely a matter of perception.

The more health policies change, the more they change the same way.

In a series of articles over the last 5 years, Richard Saltman, one of the foremost scholars in the field of comparative health systems has begun to question whether traditional pillars of these systems are in need of fundamental restructuring. In the wake of the financial crisis of 2008, Saltman argued for new modes of financing to cope with austerity, and re-examination of the concept of social solidarity. In a recent piece in this journal, he considers the challenges posed by the information revolution. This commentary raises questions regarding the particular impact of the information revolution as opposed to pressures that have beset health systems for several decades, and examines Saltman's policy prescriptions in light of previous attempts to restructure health systems. It is suggested that whatever the path forward for health systems, failure to address the cultural gap between medicine as a profession and medical managerialism explains past reform shortcomings and is likely to hinder any restructuring responses to the information revolution.

Taking the measure of the profession: Physician associations in the measurement age.

Systematic measurement of healthcare services enables evaluation of health professionals' quality of work. Whereas policy makers find measurement a useful mechanism for quality improvement, a public choice perspective implies that physicians would resent such an initiative, which undermines their professional autonomy. In this article, we compare two healthcare systems of economically developed countries - Israel and the UK. Both systems share common features such as universal coverage, strong state intervention, and enthusiasm for New Public Management. In both countries, quality measurement was introduced in acute care hospitals at around the same time. However, while the UK succeeded in establishing a framework of surgical outcome measures during the 2000s, a similar initiative in Israel failed completely during the 1990s. We also refer to subsequent quality indicator efforts in Israel, in both community and hospital frameworks, that were more successful, but in a way that reinforces our central thesis. We contend that differences in reform outcomes stem from the medical profession's reaction to government's endeavors. This response, in turn, hinges on the professional organizations' relative institutional position vis-a-vis state authorities. This study constitutes a unique investigation of the medical profession's response to critical quality measurement reforms. Most importantly, it stresses the institutional position of medical associations as the primary factor in explaining cross-case variation in government's success in introducing quality measurement.

What should health insurance cover? A comparison of Israeli and US approaches to benefit design under national health reform.

What health insurance should cover and pay for represents one of the most complex questions in national health policy. Israel shares with the US reliance on a regulated insurance market and we compare the approaches of the two countries regarding determining health benefits. Based on review and analysis of literature, laws and policy in the United States and Israel. The Israeli experience consists of selection of a starting point for defining coverage; calculating the expected cost of covered benefits; and creating a mechanism for updating covered benefits within a defined budget. In implementing the Affordable Care Act, the US rejected a comprehensive and detailed approach to essential health benefits. Instead, federal regulators established broadly worded minimum standards that can be supplemented through more stringent state laws and insurer discretion. Notwithstanding differences between the two systems, the elements of the Israeli approach to coverage, which has stood the test of time, may provide a basis for the United States as it renews its health reform debate and considers delegating decisions about coverage to the states. Israel can learn to emulate the more forceful regulation of supplemental and private insurance that characterizes health policy in the United States.

Expensive lifesaving treatments: allocating resources and maximizing access.

Avisar et al. present an exemplary model for outreach aimed at ensuring that a maximum of patients eligible for expensive Hepatitis C (HPC) drugs receive treatment. We enlarge the picture to put their model in the political, economic and regulatory framework for financing and providing these drugs in Israel and a number of other countries. We then return to delivery system level and consider issues such as cost of outreach, the need for health care coordinators and dealing with Hepatitis C patients not yet entitled to receive the drugs under national health coverage determinations.Regarding national coverage decisions, we find that countries such as Australia, New Zealand, the United Kingdom and Israel all extended coverage for Hepatitis C drugs, given the clear high effectiveness of the latter. However, to limit budget impact, all these countries target coverage to patients based on disease genotype and stage.The model presented by Avisar et al., while impressive, leaves some items to address. These include: whether all resources allocated to HPC drugs are actually used for this purpose, the roles of outreach to HPC patients who do not meet the guidelines for treatment, and a comparison of the effectiveness of the model vs. a variety of costs associated with it.

The oncology nurse coordinator: role perceptions of staff members and nurse coordinators.

BACKGROUND: There is extensive evidence that the role of nurse coordinators is beneficial for patients. Nurse coordinators are more available to patients compared to general registered nurses, know better to control symptoms and work as team players with multiple care providers. Despite its significance, there is a dearth of literature on the subject in Israel and a lack of clarity regarding the definitions of the role in terms of responsibilities and authorities. The aim of the study is to: To examine how the role of nurse oncology coordinator is implemented in various fields of oncology and to describe the actual performance of different kinds of oncology nurse coordinators and staff perceptions regarding this role in one tertiary hospital in Jerusalem. METHODS: A phenomenological approach was used to explore the participants' experiences and views of nurse coordinators' performance. We conducted a qualitative study using in-depth semi-structured interviews. Interviewees included 30 employees from different levels of the hospitals, and leading figures associated with oncology medicine outside of the hospital: Nurses and physicians of the Sharett Oncology Institute of Hadassah Ein Kerem Hospital in Jerusalem, the administrative staff of Hadassah Ein Kerem Hospital, head nurses of the Israel Cancer Association, the chairperson of the Non-Profit Organization of Oncology Nurses, nurse directors at the Ministry of Health Nursing Division, and seven nurse coordinators at Hadassah Ein Kerem Hospital in diverse fields of oncology. RESULTS: The nurse coordinator is perceived as an important staff member providing care to cancer patients. Several key elements were found to be common features in the work of all nurse coordinators: emotional support, guidance to patients, and coordination of patients' care. CONCLUSIONS: The nurse coordinator plays a noteworthy role in the health care system. In view of the variety of roles that the nurse coordinator assumes in different units, performance standards must be adapted to the performance areas for each unit, as well as nurses' professional development requirements. Changes in a service organization and careful attention to the continuum of care highlight the need to develop and to strengthen the role of a nurse who coordinates treatment over the entire continuum of care, both in the hospital and in the community.

Violence against physicians and nurses in a hospital: How does it happen? A mixed-methods study.

BACKGROUND: Violence against medical personnel is unexpected in hospitals which are devoted to healing, and yet, it is frequent and of concern in the health system. Little is known about the factors that lead to hospital violence, and even less is known about the interactions among these factors. The aim of the study was to identify and describe the perceptions of staff and patients regarding the factors that lead to violence on the part of patients and those accompanying them. METHODS: A mixed-methods study in a large, general, university tertiary hospital. A self-administered survey yielding 678 completed questionnaires, comprising 34% nurses and 66% physicians (93% response rate). Eighteen in-depth interviews were conducted separately with both victims and perpetrators of violent episodes, and four focus-groups (N = 20) were undertaken separately with physicians, staff nurses, head-nurses, and security personnel. RESULTS: Violence erupts as a result of interacting factors encompassing staff behavior, patient behavior, hospital setting, professional roles, and waiting times. Patients and staff reported similar perceptions and emotions regarding the episodes of violence in which they were involved. Of 4,047 statements elicited in the staff survey regarding the eruption of violence, 39% referred to staff behavior; 26 % to patient/visitor behavior; 17% to organizational conditions, and 10% to waiting times. In addition, 35% of the staff respondents reported that their own behavior contributed to the creation of the most severe violent episode in which they were involved, and 48% stated that staff behavior contributed to violent episodes. Half of the reasons stated by physicians and nurses for violence eruption were related to patient dissatisfaction with the quality of service, the degree of staff professionalism, or an unacceptable comment of a staff member. In addition, data from the focus groups pointed to lack of understanding of the hospital system on the part of patients, together with poor communication between patients and providers and expectations gaps. CONCLUSIONS: Our various and triangulated data sources show that staff and patients share conditions of overload, pressure, fatigue, and frustration. Staff also expressed lack of coping tools to prevent violence. Self-conscious awareness regarding potential interacting factors can be used to develop interventions aimed at prevention of and better coping with hospital violence for both health systems' users and providers.

Workplace violence in a tertiary care Israeli hospital - a systematic analysis of the types of violence, the perpetrators and hospital departments.

BACKGROUND: Worldwide, there is a widespread and disturbing pattern of violence towards healthcare workers. However, violent occurrences in Israeli hospitals have often been unrecognized and underreported. Moreover, most studies have not sufficiently differentiated among the different types of violence. To examine the different types of violence experienced by nurses and physicians, the types of perpetrators and the specialty fields involved. METHODS: A quantitative questionnaire was used to assess the incidence of a "basket" of violent behaviors, divided into eight types of violent manifestations. The study population consisted of 729 physicians and nurses in a variety of hospital divisions and departments (surgery, oncology, intensive care, ambulatory services including day care, and emergency room) in a large general hospital. Six hundred seventy-eight of them responded to the survey for a response rate of 93%; about two thirds of respondents (446) were nurses and about one third (232) were physicians. The questionnaires were completed during staff meetings and through subsequent follow-up efforts. RESULTS: In the 6 months preceding the survey, the respondents experienced about 700 incidents of passive aggressive behavior, 680 of verbal violence and 81 of sexual harassment. Types of violence differed between patients and companions; for example, the latter exhibited more verbal, threatening and passive aggressive behaviors. Violence was reported in all departments (ranging from 52-96%), with the departments most exposed to violence being the emergency room and outpatient clinics. Nurses in the emergency room were 5.5 times at a higher risk of being exposed to violence than nurses in the internal medicine department. Nurses were exposed to violence almost twice as much as physicians. There was a positive association between the physician's rank and his/her exposure to violence. A multiple regression model found that being older reduced the risk of being exposed to violence, for both physicians and nurses. CONCLUSIONS: These findings suggest that uniform definitions of a range of different violent behaviors and assessments of their prevalence are important to creating an improved discourse about hospital violence in both research and operational settings. The study findings could assist policy makers in the Israeli healthcare system in implementing interventions on a national level and can promote leaders' commitment to violence prevention and management. This is an important contribution, as executive commitment is necessary and critical for the necessary organizational changes to occur.

Revealed Opportunism: How Physicians "Game" Prior Authorization Protocols Until They Are Rescinded.

BACKGROUND: Prior authorization (PA) is a management technique that has been implemented to manage the utilization of expensive drugs and to improve the precision of drug prescribing. PA requirements may incentivize physicians to document adverse effects, sometimes falsely, to meet the eligibility requirements. OBJECTIVES: To identify documentation patterns that may facilitate the quantitative analysis of physician gaming and underreporting behaviors associated with the prescribing of angiotensin-converting enzyme (ACE) inhibitors in a primary care setting, and to evaluate the effect of a PA requirement on the documentation of adverse events as a way to receive approval for more expensive drugs. METHODS: We conducted a retrospective analysis of physician electronic reporting of adverse effects associated with ACE inhibitors before and after the revocation of a PA requirement for angiotensin receptor blockers (ARBs) between 2004 and 2013 in an Israeli HMO. The data were stratified into 2 groups-patients who were newly prescribed an ACE inhibitor or those who had been receiving an ACE inhibitor for at least 1 year. The annual rate of adverse events related to ACE inhibitors (ie, the number of reported cases of adverse events per 1000 patients receiving an ACE inhibitor) was calculated from data captured on the date the events were first reported for the 5 years before and 5 years after the revocation of the PA constraint. RESULTS: A total of 151,845 patients treated with ACE inhibitors were identified during the 10-year study period. The reported adverse events among patients newly treated with an ACE inhibitor peaked in 2007 to 10 cases per 1000 patients, and gradually decreased to 4.6 cases in 2012, which was the year after the PA requirements for the ARBs valsartan and candesartan were rescinded by the HMO. Among previously treated patients, adverse events rates decreased from a high of 5.4 per 1000 patients in 2008 to 1.9 in 1000 patients in 2012, the year after the PA restraints for the last 2 ARBs with a requirement were revoked. CONCLUSIONS: The PA requirement influenced physician propensity for reporting drug side effects, possibly encouraging reporting inaccuracies. The decline in the incidence of reported side effects, in both subpopulations in the study, with the revocation of the PA requirement confirms our hypothesis that physicians were incentivized to document the side effects related to ACE inhibitors to meet the eligibility requirements for the approval of an ARB by the HMO.

Governance: Blending Bureaucratic Rules with Day to Day Operational Realities Comment on "Governance, Government, and the Search for New Provider Models".

Richard Saltman and Antonio Duran take up the challenging issue of governance in their article "Governance, Government and the Search for New Provider Models," and use two case studies of health policy changes in Sweden and Spain to shed light on the subject. In this commentary, I seek to link their conceptualization of governance, especially its interrelated roles at the macro, meso, and micro levels of health systems, with the case studies on which they report. While the case studies focus on the shifts in governance between the macro and meso levels and their impacts on achievement of desired policy outcomes, they also highlight the need to better integrate the dynamics of day to day operations within micro organizations into the overall governance picture.

Being a legal guardian - the nursing perspective.

BACKGROUND: Surrogate decision making is common in public healthcare worldwide. In Israel any incompetent adult patient requires a Legal Guardian (LG), appointed by the court, for approval of invasive none-life saving procedures. Usually, the LG is a close family member of the patient. Nurses are the most available healthcare providers to the families and the LG during the process of appointment and afterwards. The patient's family is often anxious or even depressed, and thus the perceptions and behavior of nurses charged with providing support are crucial. In a previous study based on interviews of LGs we found that the most difficult issues for the LGs were decision related issues, family related issues and appointment bureaucracy issues. OBJECTIVE: To qualitatively assess nurses attitudes regarding the difficulties that families and LGs face during and after appointments and to compare the findings to previously accessed LG attitudes. RESEARCH DESIGN: After IRB approval, demographic and semi-structured questionnaires were used to assess the attitudes of a convenience sample of 34 nurses who were participating in a critical care training course (41 % of the respondents were from the ICU, 47 % from medical or surgical wards, and 12 % from other departments at secondary and tertiary hospitals in Israel.) regarding LGs difficulties. After reading and analyzing the responses provided by the nurses, the authors categorized the pertinent topics raised using content analysis. Nurses' perceptions were also compared to those of LGs reported in previous research by the authors. RESULTS: Three main themes emerged: 1. Decision related issues; namely coping with the complexity of end of life decision issues; 2. Family related issues; namely, family dynamics related to the various decisions regarding LG identity and patient care; and 3. Bureaucracy issues; namely, the formal process related to LG appointment and decisions. Regarding the first two themes, the feelings of the nurse respondents were quite similar to those of LG respondents from our earlier research. The third theme - bureaucracy issues - was never mentioned by the nurses, as opposed to LGs who mentioned it frequently. This suggests that the nurses did not consider it to be an important issue. CONCLUSIONS: The difficulties of decision making as well as family support and responsibility of LGs are well known by nurses. The appointment and bureaucracy issues were neglected by nurses, although they are very important to the LGs. Improvement of this parameter of care is needed. Possible directions for improvement include raising awareness of nurses regarding the appointment process and alleviation of bureaucracy. Further research is required to identify appropriate strategies for improving these aspects of care.

Health information technology implementation - impacts and policy considerations: a comparison between Israel and Portugal.

The use of Information and Communications Technology (ICT) in health systems is increasing worldwide. While it is assumed that ICT holds great potential to make health services more efficient and grant patients more empowerment, research on these trends is at an early stage. Building on a study of the impact of ICT on physicians and patients in Israel, a Short Term Scientific Mission (STSM) sponsored by COST Net in conjunction with CIES/ISCTE IUL (Portugal) facilitated a comparison of ICT in health in Israel and Portugal. The comparison focused on patient empowerment, physician behavior and the role of government in implementing ICT. The research in both countries was qualitative in nature. In-depth interviews with the Ministry of Health (MOH), the private sector, patients associations, health plans and researchers were used to collect data. Purposeful sampling was used to select respondents, and secondary sources were used for triangulation. The findings indicate that respondents in both countries feel that patient empowerment has indeed been furthered by introduction of ICT. Regarding physicians, in both countries ICT is seen as providing more information that can be used in medical decision making. Increased access of patients to web-based medical information can strengthen the role of patients in decision making and improve the physician-patient relationship, but also shift the latter in ways that may require adjustments in physician orientation. Physician uptake of ICT in both countries involves overcoming certain barriers, such as resistance to change. At the national level, important differences were found between the two countries. While in Israel, ICT was promoted and adopted by the meso level of the health system, in particular the health plans and government intervention can be found in a later stage, in Portugal the government was the main developer and national strategies were built from the beginning. These two approaches present different advantages and disadvantages. Government involvement in earlier stages could provide benefit in terms of interoperability of systems between different healthcare organizations. However, innovation could be slowed down due to government bureaucracy or lack of leadership. The work provides information in order to understand and improve ICT services. Additionally, it provides input regarding impact of ICT on the physician/patient relationship and national policies in the area.

Saltman on solidarity.

Richard Saltman suggests that solidarity, a cherished notion at the heart of West European health care systems is being reconsidered in the light of today's austere economic conditions. Solidarity, he argues, has always been a flexible moral guideline, one that allows for policy responses, such as limitations on health benefits or increased out of pocket payments, that challenging fiscal conditions are said to demand. Here we consider what the basic elements in solidarity - universality, redistribution, and uniformity-- mean in health as compared to other social policy realms such as pensions. Traditionally, the commitment to solidarity said little about the contents of services, but the latter is perhaps subject to increasing scrutiny under the health policy microscope. Saltman is right to emphasize the conceptual and cross-national flexibility of solidarity, but the notion retains a solid and durable core that continues to give valuable direction to policymakers in search of acceptable strategies and structures for decision making.