Introduction of hospital quality measures may lead to a temporary decrease in patient outcomes.

OBJECTIVES: To analyse the impact of hospital quality indicators on hip fracture mortality in Israel. STUDY DESIGN: A retrospective observational study. METHODS: Data were collected on all patients aged ≥65 years with an isolated hip fracture in the years 2010-2016 from the Israel's National Trauma Registry. These data were then cross checked with information on co-morbidities and medication intake from the Clalit medical fund. All successfully matched patients constituted the study population. The main outcome measures were in-hospital and 1-year mortality. Trend analysis of surgery on hip fractures within 48 h of hospitalisation (referred to as early hip fracture surgeries) and mortality was performed. The introduction of the proportion of early hip fracture surgeries as an official quality parameter in 2013 was considered an intervention. RESULTS: The proportion of early hip fracture surgeries continuously increased during the study period and, after the introduction of the quality measure, a significant increase in the uniformity of practice among hospitals was observed. The mortality trend was not related to the early surgeries trend, with a sharp upward spike detected in 2014, followed by a gradual return to previous levels in the subsequent years. The analysis has shown that when adjusting for demographic factors and co-morbidity, both in 2010-2013 and in 2015-2016, a clear benefit in survival existed for patients who were operated on within the first 48 h. In 2014, which was the first year of open publication of achieved quality measures reported in the media, no such benefit was found. CONCLUSIONS: Even when an improvement in a promoted practice is achieved, its positive impact on clinical outcomes may be delayed, possibly indicating the need for a learning period.

New developments in ochronosis: review of the literature.

Ochronosis commonly affects all connective tissue. Recognition of changes secondary to the deposition of ochronotic pigments has increased with advances in diagnostic technology, allowing both improved imaging and early biochemical and genetics-based diagnosis of alkaptonuria, the cause of ochronosis. Successful symptomatic treatment of ochronotic arthropathy with joint replacement has been documented, and a new pharmacotherapeutic agent, nitisinone, is currently under investigation for both prevention and treatment of ochronosis. This review of the literature highlights recently recognized complications, new diagnostic techniques, and treatment options.

Achilles tendon pain and related pathologies: diagnosis by ultrasonography.

BACKGROUND: When encountering complaints of pain in the area of the Achilles tendon, the clinician seldom reaches a correct and precise diagnosis based solely on the grounds of physical examination and standard X-rays. OBJECTIVES: To assess the usefulness of ultrasound in diagnosing pathologies of the Achilles tendon. METHODS: We conducted a retrospective review of patients presenting at our orthopedic clinics. RESULTS: Sonography was used to evaluate 41 patients with achillodynia. This modality enabled the diagnoses of 19 abnormal tendons (46%), peritendinous and other lesions; a complete rupture in two patients (5%); a partial rupture of the Achilles tendon in 3 (7%); various degrees of calcification of the tendon in 7 (17%); and peritendinous lesions discerned by the tendon's hypoechoic regions with disorganized arrangement of collagen fibrils in 4 patients (10%). Other lesions included tendonitis (3 patients, 7%), retrocalcaneal bursitis (3 patients, 7%), lipoma (1 patient, 2%), and foreign bodies (2 patients, 5%). The mean diameter of the pathological tendons was 10.4 +/- 2.7 mm, while normal tendons measured 5.2 +/- 0.8 mm (P < 0.001). CONCLUSION: As in many other soft tissue lesions, ultrasonography is a useful tool in the evaluation of the underlying pathology in patients presenting with achillodynia.

Management of severe hypokalemia in hospitalized patients: a study of quality of care based on computerized databases.

BACKGROUND: While administrative databases are used to assess general indicators of quality of care, a detailed audit of the process of clinical care usually requires review of hospital medical records. OBJECTIVE: To evaluate the feasibility of assessing the management of severe hypokalemia using computerized administrative and laboratory databases. METHODS: The study included all patients hospitalized in 1997 who experienced serum potassium levels of less than 3.0 mmol/L at Hadassah University Hospital, Jerusalem, Israel, a tertiary care center. Using the computerized databases, we measured the following: (1) whether a subsequent serum potassium test was performed, (2) time to the subsequent test and to normalization of the serum potassium level, (3) achievement of normokalemia, and (4) in-hospital mortality. In a random subsample of 100 patients, these measures were compared with the blinded assessment of the quality of medical management of hypokalemia, as determined from medical records, using predetermined criteria for adequate management. RESULTS: The computerized databases revealed that severe hypokalemia occurred in 866 patients (2.6% of the yearly hospitalizations): 55 patients (6.4%) had no subsequent serum potassium levels measured, and 260 (30.0%) were discharged from the hospital with a subnormal potassium level. The mean time to a subsequent test was 20 hours, and to normokalemia, 50 hours; both intervals varied by department. In-hospital mortality was 20.4%, or 10-fold that of the entire hospitalized population. A review of hospital medical records revealed inadequate clinical management of hypokalemia in 24%, which was associated with nonperformance of a subsequent test (likelihood ratio, 8.4), failure to normalize the serum potassium level (likelihood ratio, 4.2), discharge from the hospital with a subnormal potassium level (likelihood ratio, 2.1), and in-hospital death (likelihood ratio, 2.5), all of which could be determined by the computerized databases. CONCLUSIONS: The computerized laboratory database is useful in ascertaining the prevalence of severe hypokalemia and in assessing shortcomings in its management. Databases can be used to derive valid and efficient measures of the quality of the clinical management of electrolyte disorders.

Mortality differentials among women: the Israel Longitudinal Mortality Study.

The first aim of this study was to examine differentials in mortality among Israeli adult women with respect to ethnic origin, marital status, number of children and several measures of socio-economic status; the second was to compare mortality differentials among women with those found for Israeli men. Data are based on a linkage of records from a 20% sample of the 1983 census with the records of deaths occurring until the end of 1992. The study population includes 79,623 women and the number of deaths was 14,332. Measures of SES included education, number of rooms, household amenities and possession of a car. Results indicated higher mortality among women originating from North Africa compared with Asian and European women. Adjustment to SES eliminated the excess mortality among North African women and revealed a lower mortality of Asian women, relative to Europeans. Among women aged 45-69, substantial and consistent mortality differentials were evident for all SES indicators examined where mortality declined with improved socio-economic position. Mortality was related to women's childbearing history, with the highest mortality among childless women. Mortality differentials among women aged 70+ were generally narrower than those found for younger women. Gender differences in mortality differentials varied by the socio-demographic indicator and age.

Bone allograft in revision total knee replacement.

Revision total knee replacement (TKR) is often associated with the necessity to reconstruct a certain amount of bone loss. In a retrospective study we reviewed the records of 137 patients who had undergone revision TKR in our department between 1990 and 1996, due to loosening or inflection. Bone allografts were used in 91 patients (67%) to accomplish stable, new prostheses. Three types of bone loss were identified in this group: Type I - minor, Type II - moderate, and Type III - large bone defects, located on either side of the knee joint - A, or both sides - B.The treatment results of these 91 patients, according to the type of bone loss, are presented, showing good functional outcome when utilizing bone allografts in revision TKR. However, careful preoperative planning, identification of bone loss type, and a well-equipped bone bank are mandatory to the success of the operation.

Expanding portal haematomata as a complication of knee arthroscopies in persons with haemophilia.

Recurrent haemarthroses stimulate the hypertrophy of synovial tissues that if left in situ will eventually cause joint destruction. Synovectomies have been the cornerstone of joint preservation and a number of different methods exist. We report two patients who suffered complications after an arthroscopic procedure. No previous complications of this nature have been reported in the literature.

Preadmission screening of patients scheduled for hip and knee replacement: impact on length of stay.

OBJECTIVE: An evaluation of the impact of a social work preadmission program on length of stay (LOS) of orthopedic patients undergoing elective total hip or total knee replacement surgeries (under diagnosis-related groups [DRGs]) at the Hadassah Ein-Kerem Hospital in Jerusalem is Israel. INTERVENTION: The social work interventions included preadmission psychosocial evaluation and preliminary discharge planning, coordination of nursing and physiotherapy evaluations, ensuring completion of all medical tests prior to admission, and additional psychosocial follow-up during hospitalization to carry out the original discharge plan or prepare alternatives. PATIENTS: The intervention patients were divided into two groups in order to see changes over time: May through December 1994 (n = 48), and January through December 1995 (n = 81). The comparison groups included patients operated on at the same hospital during 1993 (n = 51) and during January through April 1994 (n = 21) and at the Hadassah Mount Scopus Hospital during the same time periods. Patients in the comparison groups received usual social work intervention, as necessary, only after hospitalization. RESULTS: Mean LOS was reduced significantly in the intervention patient groups, as compared to the preintervention patient groups in the same hospital, from 14.2 days (standard deviation [SD], 4.7) in 1993 and 14.7 (SD, 5.1) in January through April 1994 to 10.9 (SD, 3.0) in May through December 1994 and to 9.1 (SD, 2.8) in 1995 (P < .01). Length of stay also was reduced in the comparison hospital, but by 1995 was longer than in the intervention patients. No differences in LOS by gender, age, or marital status were found. Length of stay was significantly longer for those undergoing total hip replacement as compared to those undergoing total knee replacement in all the groups. CONCLUSIONS: Preadmission screening and case management by a social worker can contribute to the efforts to decrease LOS of orthopedic patients by early multidisciplinary evaluations, discharge planning, and coordination of services.

Pregnancy during residency--an Israeli survey of women physicians.

The objective is to assess the impact of workload on pregnancy among women physicians in public hospitals in Israel. A self-administered, cross-sectional study of pregnancies among women physicians in public hospitals was conducted. An 82-item questionnaire was mailed to women physicians in the three largest university hospitals in Israel. The questionnaire assessed demographic data, pregnancy course, perceived stress, and complications during pregnancy. Response rate was 52% (207/400). The complication rates were compared with rates in the Jewish population and expressed as mean +/- SD. Mean number of pregnancies during residency was 1.3 +/- 1.2. Mean age at the first delivery was 27 +/- 3.2 years. There was a significant difference in the rates of stillbirth (32/1000 births versus 3.7/1000, p < 0.001) and premature delivery (12.4% versus 7.6%, p = 0.0014) between women physicians and the general population. There was no significant difference in the proportion of spontaneous abortions (12.7%), pregnancy induced hypertension (3.2%), hyperemesis gravidarum (3.2%), and diabetes (1%). Seven percent of women physicians changed their specialty due to pregnancy while in residency. Our results suggest that working long hours in a stressful occupation in a hospital environment has an adverse effect on pregnancy course and is associated with increased rates of stillbirth and premature delivery.

Survey of injuries and protective gear worn by in-line skaters in public parks.

In-line skating, also known as rollerblading, has become popular as a recreational activity as well as a mode of transportation. Increased participation has been accompanied with a marked rise in major and minor injuries. The objective of this study was to survey active in-line skaters and to describe their demographic features, formal training, protective gear used, and a history of incurred injuries. A questionnaire was distributed to randomly selected in-line skaters in a large public park in New York City. Of the 223 skaters who responded, 128 were male and 95 were female. Ages ranged from 12 to 64 (mean, 29) yr. Some kind of injury was reported by 87 (39%) of the participants. The majority of those injuries occurred when the skaters were beginners (46). Skin abrasions and musculoligamentous injuries were the most common. Only 15 (17.2%) sought medical treatment, and of these, 5 were treated for fractures: 3 at the wrist and 1 each at the ankle and knee. The knee was the most commonly injured part of the body (24.7%), followed by the elbow and wrist. Approximately 5% of all injuries involved the head. Many skaters did not wear helmets or knee pads, even though they owned this equipment. There was a strong preference for wearing wrist pads, either alone or with other protective gear. This suggests that skaters have learned that the wrist is particularly vulnerable to serious injury and should be protected.

Rationing: how and who?

Rationing health services, in the sense of denying care deemed of positive benefit by at least some health system actors, is a problem that politicians would like to avoid. Health policy analysis has offered a number of approaches, such as global budgeting, technology assessment, managed competition, legal recourse and public participation as palliatives for this difficult problem. Each of these approaches on its own falls short, but no country has yet designed a process for explicit rationing. Israel, in the context of its recent health reform, has gone as far as any country in this direction. However, significant political leadership will be required to frame the public discussion of these difficult issues.

Newly implemented health system reform in Israel: physicians' attitudes.

OBJECTIVE: To explore the attitudes of Israeli physicians towards the feasibility and potential consequences of the newly implemented health care reform. DESIGN: Physicians' attitudes were examined soon after the enactment of a National Health Insurance Law, the first element of the reform to be implemented. SETTING: A nationwide mail survey. SUBJECTS: A random sample of 2000 practicing physicians. MAIN OUTCOME MEASURES: Attitudes towards the health care system prior to the reform; predicted effects of the reform on health care and medical practice. RESULTS: Most of the respondents think that the system requires a change. Quality of community-based care is expected to increase, in contrast to hospital care. The reform is believed to exert an adverse effect on medical practice. Attitude is significantly influenced by practice setting and speciality: community setting and general practice correlate with less desire for a major change. Specialists believe that reform elements which will shift the balance towards the hospitals will have the greatest benefit on the health system. GPs, compared to specialists, are more optimistic regarding quality and accessibility of services (P<0.01). CONCLUSIONS: Our survey suggested that Israeli physicians favor a change in the health care system, despite a perceived adverse effect of the reform on medical practice. Since the reform is believed to shift the balance from the hospitals to the community, respondents support changes that will compensate for the imbalance.

Twenty-five years of clinical experience with bone banking in Israel.

BACKGROUND: Bone banking and the clinical use of banked tissue are the most common forms of allopreservation and transplantation in modern medicine. OBJECTIVES: This article reviews 25 years (1973-98) of experience in bone banking in Israel. METHODS: A nationwide survey on the clinical application of the banked musculoskeletal tissues during 1996 was conducted by means of a written questionnaire sent to all orthopedic departments in Israel. RESULTS: The response rate to the questionnaire was 84%. A total of 257 cases were allocated bone allografts: the majority comprised 225 spongy bones, 26 were massive bone allografts and 6 were soft tissue allografts. CONCLUSION: Improvement of quality control and quality assurance of the banked tissues, together with development of skills in the use of osteoinductive and osteoconductive materials, cast the future of musculoskeletal tissue banking.