Patients' perceptions of radical prostatectomy for localized prostate cancer: a qualitative study.

BACKGROUND: Radical prostatectomy is one option for treating localized prostate cancer, but it can cause functional impairment of the urogenital system. OBJECTIVES: To describe the outcomes of radical prostatectomy as perceived by the patients, and their ways of coping with them. METHODS: We conducted a qualitative study of 22 men with localized prostatic cancer 1 year after surgery. The key questions related to the effect of the disease and the surgery on their lives and their view on the value of the surgery. RESULTS: The surgery was perceived as a necessary solution for the diagnosed cancer. All the participants suffered from varying degrees of urinary incontinence and erectile dysfunction. Urinary incontinence caused severe suffering. The impaired sexual ability affected relations with partners and led to feelings of shame and guilt and a decreased sense of self-esteem. In retrospect, the participants still viewed the surgery as a life-saving procedure. Faith in the surgeon contributed to their affirmation of the decision to undergo surgery despite the difficulties. CONCLUSIONS: Patients were prepared to suffer the inevitable physical and psychological sequelae of radical prostatectomy because they believed the surgery to be a definitive solution for cancer. Surgeons advising patients with localized prostatic cancer on treatment options should address these difficult issues and provide psychological support, either themselves or in collaboration with professionals.

Acute cough: the use of antibiotics and health care services in an urban health centre in Israel.

BACKGROUND: Acute cough, often caused by a viral respiratory infection, is a common symptom in primary care. Although clinical guidelines recommend symptomatic treatment for acute cough, antibiotics are frequently prescribed. OBJECTIVE: To determine antibiotic prescribing for acute cough at the initial consultation and to follow subsequent medical consultations and use of medications. METHODS: The study population included all adult patients with acute cough who visited general practitioners from one health centre (HC) during four months. Information was gathered from medical charts and telephone interviews conducted two weeks later. RESULTS: Fifty six of three hundred and thirty eight participants (16.6%) received antibiotics at the initial visit. Eighty three participants made subsequent visits to the HC, 40 participants visited physicians outside the HC and nine participants visited both. During two weeks after the initial visit, 35 participants were prescribed antibiotics (eight in the HC, 27 outside the HC). Total antibiotic use rose to 27% (91/338) during the study period. At that time 98 (29%) of the participants reported they were still ill. Multivariate analysis showed that expectation to receive antibiotics was reported at a higher rate by the participants who received it, as compared to those who did not (32.2% versus 13.2%, OR: 2.3; 95% CI: 1.2-4.8). Receiving antibiotics was also associated with use of health services (20.3% versus 9.9%, OR: 2.7; 95% CI: 1.2-6.2). CONCLUSIONS: Patient activism during the course of acute cough is associated with increased antibiotic use.

Rehabilitation of elderly patients in the community following surgery for hip fracture - utilization of personal and health care services.

PURPOSE: To assess the change in utilization of personal and health care services following surgery for hip fracture in elderly patients rehabilitated in the community. METHODS: A descriptive study of patients hospitalized in the orthopedic surgery ward for traumatic hip fracture. The first interview took place after surgery and included functional and medical data, and details on utilization of personal and health care services in the month prior to surgery. The second interview took place at home three months after discharge from the hospital and documented corresponding data for the last month. RESULTS: The study included 91 elderly patients. The mean number of contacts with health care providers increased from 4.6/month before HF to 6.4/month during rehabilitation; in particular an increase in home visits by primary care nurses and physicians from 0.4 to 1.0 visit/month (p < 0.001). Personal care showed a greater increase from 32.5 to 95.0 weekly hours (p < 0.001). Multivariate analyses showed that the increase in primary care visits was associated with chronic co-morbidity and being single, while the increase in personal care was associated with medium dependence level and an ambulatory rehabilitation setting. CONCLUSIONS: During the rehabilitation period in the community there was an increase in non-rehabilitative services-medical and personal. Morbidity and functional data could predict the increase in use at time of discharge from hospital.

Factors associated with hypertensive patients' compliance with recommended lifestyle behaviors.

BACKGROUND: A crucial element in controlling blood pressure is non-pharmaceutical treatment. However, only a few studies specifically address the question of hypertensive patients' compliance with physicians' recommendations for a healthy lifestyle. OBJECTIVES: To explore factors associated with hypertensive patients' compliance with lifestyle recommendations regarding physical activity, smoking cessation and proper diet. METHODS: We performed a secondary data analysis of a representative sample of 1125 hypertensive patients in Israel's two largest health funds. Data were collected in 2002-2003 by telephone interviews using structured questionnaires. The response rate was 77%. Bivariate and multivariate analysis was conducted. RESULTS: About half of the hypertensive patients reported doing regular exercise and adhering to a special diet; 13% were smokers. About half reported receiving counseling on smoking cessation and diet and a third on physical exercise. A quarter reported receiving explanations regarding self-measurement of blood pressure and signs of deterioration. Multivariate analysis revealed that patients' beliefs about hypertension management, their knowledge on hypertension and its management, and physician counseling on a healthy lifestyle and self-care, have an independent effect on compliance with recommended lifestyle behaviors. CONCLUSIONS: The low counseling rates suggest that there may be a need to improve physicians' counseling skills so that they will be more confident and effective in delivering this service to their patients. A model based on educating both physicians and patients may contribute to improving the care of hypertensive patients.

[How family physicians estimate their knowledge and skills in musculoskeletal problems?].

UNLABELLED: Musculoskeletal conditions are common reasons for consultation in primary care and constitute 14-28% of primary care visits and visits to emergency services. General practitioners [GP] diagnose and treat the majority of patients with musculoskeletal problems. Surveys conducted confirmed the discrepancy between the number of GP musculoskeLetal consultations and the amount of time spent on orthopedic and musculoskeletal teaching in undergraduate and postgraduate education in different countries. It would be considered negligent for a GP to be incompetent in assessing the function of the heart or lungs, yet it is quite common for students to leave medical school without being able to make a general assessment of the musculoskeletal system. This review analyses the forms and duration of medical teaching on musculoskeletal disorders in several parts of the world and in Israel. Some studies have investigated the current situation in the undergraduate education of musculoskeletal teaching. The recent survey by the Bone and Joint Decade of undergraduate teaching in different specialties in 32 countries considered that the average length of medical teaching time of orthopedics, rheumatology and physical medical rehabilitation is insufficient and usually emphasize surgically managed musculoskeletal problems that are not relevant for the future practice of most doctors. The surveys that investigate postgraduate training have tested the confidence of GPs in performing regional musculoskeletal examinations and management of specific conditions. They found the different levels of confidence between GPs in UK, Canada, USA (including Hawaii) and developing, countries, with the tests showing deficient knowledge and skills in assessment and treatment of musculoskeletal conditions. CONCLUSIONS: It should be the personal obligation of GPs to update themselves regularly and monitor their performance to ensure the appropriate care of musculoskeletal problems. This will be possibLe through increasing the curriculum time of studying musculoskeletal diseases to at least 6 weeks and developing a CME musculoskeletal program. Different CME Musculoskeletal programs are being established in Family Medicine departments in Israel. It is important to investigate all musculoskeletal programs and to develop the universal musculoskeletal program for postgraduate education.

The effect of low back pain on work absenteeism among soldiers on active service.

STUDY DESIGN: A prospective longitudinal study. OBJECTIVE: To identify factors that influence absenteeism among soldiers with acute low back pain (ALBP). SUMMARY OF BACKGROUND DATA: Recommendations for the treatment of low back pain include continuing physical activity. Ninety-seven percent of patients return to work within 1 month. METHODS: This was a prospective longitudinal study using a questionnaire to assess morbidity from ALBP and the job being carried out by the soldier at the time of referral to the army clinic and 6 weeks later. Potential associations were investigated between prolonged absenteeism and variables including disease indexes, use of healthcare services, the soldier's army job, and their satisfaction with it. RESULTS.: The study population consisted of 160 soldiers with uncomplicated ALBP. Eighty-six percent of the participants returned to their job within 6 weeks. The rates of improvement in pain, the mental functioning under pain, satisfaction with jobs, and having combat status were higher among soldiers who returned to their jobs as compared with those who did not. Those who did not return to their jobs had higher rates of utilization of healthcare services. CONCLUSION: Nondisease factors are associated with the duration of absenteeism among soldiers with ALBP. Absenteeism is directly related to use of healthcare services.

Differences in cardiovascular disease risk factor management in primary care by sex of physician and patient.

PURPOSE: The purpose of this study was to evaluate differences in the management of cardiovascular disease (CVD) risk factors based upon the sex of the patient and physician and their interaction in primary care practice. METHODS: We evaluated CVD risk factor management in 4,195 patients cared for by 39 male and 16 female primary care physicians in 30 practices in southeastern New England. RESULTS: Many of the sex-based differences in CVD risk factor management on crude analysis are lost once adjusted for confounding factors found at the level of the patient, physician, and practice. In multilevel adjusted analyses, styles of CVD risk factor management differed by the sex of the physician, with more female physicians documenting diet and weight loss counseling for hypertension (odds ratio [OR] = 2.22; 95% confidence interval [CI], 1.12-4.40) and obesity (OR = 2.14; 95% CI, 1.30-3.51) and more physical activity counseling for obesity (OR = 2.03; 95% CI, 1.30-3.18) and diabetes (OR = 6.55; 95% CI, 2.01-21.33). Diabetes management differed by the sex of the patient, with fewer women receiving glucose-lowering medications (OR = 0.49; 95% CI, 0.25-0.94), angiotensin-converting enzyme inhibitor therapy (OR = 0.39; 95% CI, 0.22-0.72), and aspirin prophylaxis (OR = 0.30; 95% CI, 0.15-0.58). CONCLUSION: Quality of care as measured by patients meeting CVD risk factors treatment goals was similar regardless of the sex of the patient or physician. Selected differences were found in the style of CVD risk factor management by sex of physician and patient.

Teamwork in treating diabetes and hypertension in Israeli managed care organizations.

PURPOSE: This article aims to analyze existing and preferred labor divisions between physicians and nurses treating patients with hypertension and diabetes in managed care organizations. DESIGN/METHODOLOGY/APPROACH: A mail survey was conducted in 2002/2003 among a representative sample of 743 physicians employed by Israel's largest managed care health plans (78 percent response rate). A telephone survey among a representative sample of 1,369 hypertensive or diabetic patients (77 percent response rate) was also used. FINDINGS: Findings reveal a conspicuous gap between actual labor division and what physicians perceive to be ideal. Possible reasons for this gap are discussed and strategies for facilitating collaboration, which would improve service quality as well as work life quality for both physicians and nurses. ORIGINALITY/VALUE: This study provides empirical data on the extent of nurse involvement in managed care organization chronic patient care, as well as comparing them to physicians' preferences regarding nurse involvement.

Determinants of quality of life in primary care patients with diabetes: implications for social workers.

Using a cross-sectional design of 400 primary care patients with diabetes, the authors evaluated demographics, health status, subjective health and mental health, health behaviors, health beliefs, knowledge of diabetes treatment, satisfaction with medical care, and quality of medical care as potential predictors of QoL and QoL in the hypothetical absence of diabetes. Those who reported difficulties meeting basic needs, diabetes-related complications, worse subjective health, and dissatisfaction with medical care were more likely to report worse QoL. Those who reported difficulties meeting basic needs, higher cholesterol level, and worse subjective health also were more likely to report better QoL in the hypothetical absence of diabetes. In addition, diabetes management played a major role in one's QoL in the hypothetical absence of diabetes: Engaging in stricter diabetes self-care and taking pharmaceutical treatment for managing diabetes were associated with better QoL in the hypothetical absence of diabetes. Providing psychosocial support geared toward diabetes self-management may improve patients' QoL. When doing so, social workers need to be aware of the potential trade-off between following medical recommendations that advocate for a strict lifestyle and patients' QoL.

Implementing QA programs in managed care health plans: factors contributing to success.

PURPOSE: The purpose of this paper is to identify the factors that contribute to the success or failure of quality assurance programs implemented by Israeli managed care health plans. DESIGN/METHODOLOGY/APPROACH: An in-depth study of seven quality assurance programs was conducted, comparing successful with unsuccessful ones using the comparative "case study" method. Employing a semi-structured questionnaire, 42 program directors and professionals in the field were interviewed. FINDINGS: A number of factors associated with the programs' success emerged. Those external to the program included: ongoing management support, resource allocation, information system support and perceived financial benefit for the organization. Internal factors included: leadership, perceived problem's importance, laying the groundwork in the field, involving field staff in planning and implementation and staff motivation. ORIGINALITY/VALUE: The study provides insights into ways to encourage the implementation of successful quality assurance programs in the special organizational context of managed care health plans. As the implementation relies heavily on data, one important precondition is the development of computerized information systems to facilitate ongoing data collection. It is also necessary from the planning stage to take into account organizational factors that affect success.

[Screening for domestic violence in primary care setting].

OBJECTIVE: To assess the dimensions of the problem of domestic violence among patients in primary care practice. The study also aimed to examine the various kinds of violence and what family physicians know about the subject as it pertains to their patients. METHODS: A detailed questionnaire was distributed, randomly and without any pre-selection process, to patients over the age of 18 as they sat in the waiting room of their family doctor's clinic. The questionnaire was filled out anonymously, placed in an envelope, which was then sealed, and handed to one of the research assistants. In about half of the cases, the family physician also completed a doctor's questionnaire pertaining to those same patients. The physicians selected for the study were those who had worked for several years in the same medical practice and knew their patients well. The study was approved by the Ethics Committee of the "Emek Medical Center" in Afula, and each patient gave his/her informed consent to participate in the study and complete the questionnaire anonymously. RESULTS: A total of 517 patient questionnaires were collected, 16 of which were disqualified due to the patients' age (below 18 years). Concurrently, the physicians conveyed information pertaining to 268 patients. Of the participants in this study: 67.1% were females and 32.9% were males; 18.6% of the participants had been exposed to some form of domestic violence in the past, while 5% were currently being exposed to domestic violence. Women were slightly more 4.8%). exposed to violence than men (women - 5.1%, men The difference was not significant (P = 0.89). A total of 72% of those currently undergoing domestic violence had also suffered from it in the past. As to the kinds of violence: 60% are subjected to threats, 24% to beatings and 16% to rape or sexual abuse. The violence is perpetrated by the spouse in 58.3% of the cases. It was revealed that 33.3% of victims of domestic violence were in need of medical attention. It was found that the lower the education, the higher the incidence of domestic violence (P = 0.014). Moreover, among workers and students there is less incidence of violence than among the unemployed, pensioners and housewives (P < 0.0001). However, 48.5% of those who completed the questionnaire think that the family physician is not the "right source" for handling cases of domestic violence. CONCLUSION: In comparison to world literature, our study apparently has an under-reporting of cases of domestic violence by the participants. On the other hand, in most cases, the family physician is unaware of these cases of violence. The fact that only one-third of the victims of violence think that the physician is the right person to turn to with this problem, suggests that a deeper probe into the subject is necessary, by studying it and explaining it effectively to the public.

The association between inquiry about emotional distress and women's satisfaction with their family physician: findings from a national survey.

BACKGROUND: Women appear to be more vulnerable than men to emotional distress (ED) However, ED often goes unrecognized by family physicians. PURPOSE: To (1) assess the rate of inquiry about ED by family physicians and (2) explore the association between physician's inquiry about ED and women's satisfaction with care. METHODS: Telephone interviews were conducted in 2003 using a structured questionnaire in a representative sample of 991 Israeli women aged 22 years or older, with a response rate of 84%. RESULTS: 33% of women reported ED during the past year but only 15% of women reported having discussed ED with their family physician in the last year. Higher rates of discussion of ED with the physician were found among women who had experienced ED (22.5%), those who had a chronic illness (20.1%) had low income (22.7%), and were Arabic (29.5%) or Russian speakers (26.3%). Multivariate analysis indicated that women who had discussed ED with their physician expressed higher satisfaction with the physicians professional level (OR = 6.85), attitude (OR = 2.45), spending enough time (OR = 2.90), and listening to the patient (OR = 3.19), compared with women who had not discussed ED with their physician. CONCLUSIONS: Given the current low rates of inquiry about ED, it appears that developing sensitivity to women's emotional concerns and encouraging physicians to inquire about ED should be given higher priority in medical education at all levels. Furthermore, since inquiry about ED not only improves the appropriateness of care but is also associated with higher satisfaction with the physician, organizations in a competitive health care environment may have a particular interest in promoting this practice.

Physicians' ability to influence the life-style behaviors of diabetic patients: implications for social work.

Diabetes is aggravated by a sedentary lifestyle, obesity and smoking. Based on a theoretical model relating attitudes and behavior, this study examined the association between physicians' self efficacy in counseling diabetic patients on life style behaviors and their counseling practices. Data were gathered from a representative sample of 743 primary care physicians in Israel's two largest health plans. The main findings were that only a small percentage of physicians felt capable of influencing their patients' life-style behaviors. Self-efficacy had an independent effect on the likelihood of counseling diabetic patients on life style behaviors, controlling for other background variables. We conclude that there is a need for enhancing physicians' life-style counseling skills, and that social workers could expand their role by training physicians to counsel effectively. This could both improve the care of diabetic patients, and strengthen the status of the social work profession in the healthcare system.

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.

Antibiotic consumption successfully reduced by a community intervention program.

BACKGROUND: The association between antibiotic use in the community and antimicrobial resistance is known. Attention has recently focused on the type of agents being prescribed. OBJECTIVES: To implement, evaluate and compare the efficacy of two community intervention programs--continuous versus seasonal medical education--oriented to primary care physicians with emphasis on the appropriate use of antimicrobial drugs. METHODS: From October 2000 to April 2003 we conducted two interventions: a) a monthly educational campaign in selected clinics promoting appropriate diagnosis of common infectious diseases and prudent antibiotic use (continuous intervention group); and b) a massive educational campaign, conducted before two consecutive winters, promoting the judicious use of antibiotics for treating respiratory infections (continuous intervention group and seasonal intervention group). Sixteen similar clinics were randomized (8 to each group). The total antibiotic use was measured as defined daily dose/1000 patients/day, and compared between the groups. RESULTS: The total use of antibiotics decreased between 1999-2000 and 2002-2003 in both groups, but slightly more significantly in the continuous intervention group. The DDD/1000 patients/day for the seasonal group in 1999-2000 was 27.8 vs. 23.2 in 2002-2003; and for the continuous group 28.7 in 1999-2000 vs. 22.9 in 2002-2003, a reduction of 16.5% and 20.0% respectively (P < 0.0001). The main change in antibiotic use was noted for broad-spectrum antibiotics. CONCLUSIONS: We present a successful community intervention program aimed to reduce unnecessary antibiotic use. Amplification of this type of intervention is imperative to stop the increase in antimicrobial resistance.

Factors affecting primary care physicians' perceptions of health system reform in Israel: professional autonomy versus organizational affiliation.

This paper examines primary care physicians' perceptions of a National Health Insurance Law that introduced managed competition into Israel's health care system, and the factors affecting their perceptions. Between April and July 1997, we conducted a mail survey of primary care physicians employed by Israel's four health plans (which are managed care organizations). Eight hundred questionnaires were returned, representing a response rate of 86%. The findings indicate that, overall most physicians support the components of the National Health Insurance Law with statistically significant differences among physicians by health plan. Multivariate analysis revealed that, contrary to theoretical expectations, a perceived decrease in professional autonomy and in the status of the profession following reform did not significantly affect attitudes toward national health insurance. These findings highlight the need for additional empirical studies to further examine theoretical contentions about the implications of infringing on the professional autonomy and the dominant status of physicians. The principal and most interesting finding of this study was the independent effect of health plan affiliation on physicians' attitudes toward each of the five components of the National Health Insurance Law, after controlling for background characteristics, for the reform's perceived effect on the physicians' autonomy and status in the health plan, and for the reform's perceived effect on the level of health plan services and the health plan's financial situation. We found that physicians' perceptions tended to conform to the formal position of their health plan, suggesting the need to analyze the attitudes of physicians in their organizational context, rather than treating them as members of a uniform professional community.

Primary care physicians' discussion of emotional distress and patient satisfaction.

OBJECTIVES: To assess: a) the prevalence and determinants of self-reported emotional distress in the Israeli population; b) the rate of self-reported discussion of emotional distress with family physicians; and c) the association between such discussions and patient satisfaction with care. DESIGN: Retrospective, cross-sectional survey that was conducted through structured telephone interviews in Hebrew, Arabic, and Russian. This study was part of a larger study assessing patients' perceptions of the quality of health services. PARTICIPANTS: A representative sample of 1,849 Israeli citizens aged 22 to 93 (response rate: 84%). INDEPENDENT VARIABLES: Gender, age, ethnicity (spoken language), education, income, self-reported chronic disease, self-reported episode(s) of emotional distress during the last year, and having discussed emotional distress with the family physician. OUTCOME MEASURE: satisfaction with care. RESULTS: 28.4% reported emotional distress and 12.5% reported discussion of emotional distress with a primary care physician in the past year. Logistic regression identified female gender, Arab ethnicity, low income, and chronic illness as independent correlates of emotional distress. These as well as Russian speakers and having experienced emotional distress during the past year were identified as independent correlates of discussion of emotional distress with the family physician. Patients who reported discussion of emotional distress with their family physician were significantly more satisfied with care. CONCLUSIONS: Encouraging physicians to detect and discuss emotional distress with their patients may increase patient satisfaction with care, and possibly also improve patients' well-being and reduce health care costs.

Health counseling for women in the absence of financial barriers: comparing reported counseling rates of women in the United States and Israel.

This study compares rates of health counseling for women in the United States and Israel and identifies factors affecting counseling rates, based on a weighted sample of 2,257 US and 848 Israeli women. In both countries, fewer than half of the women reported speaking with a physician about any of a set of preventive counseling topics (e.g., smoking, diet, exercise) during the year preceding the survey. However, US women reported significantly higher rates of health counseling than did Israeli women, even among specific risk groups (e.g., smokers). Multivariate analysis revealed that "country" had an independent effect after controlling for demographic factors. This paper highlights structural and functional barriers to counseling that persist in the Israeli system in the absence of financial barriers and discusses ways to overcome them.

The effect of postpartum depression on women's consultations with physicians.

BACKGROUND: Postpartum depression is a well-known phenomenon that occurs in about 10% of births and affects the quality of life of the mother as well as the family. As in other cases of depression, under-diagnosis of PPD may keep patients from getting proper care and increase their physical and emotional distress. OBJECTIVES: To identify patients with PPD and to describe their consultation patterns with primary care physicians for themselves and their babies. METHODS: Using a telephone survey and the Edinburgh Postnatal Depression Scale questionnaire we identified PPD in a sample of women who gave birth in HaEmek Medical Center. We also assessed the extent to which the women consulted with family physicians, gynecologists and/or pediatricians. RESULTS: The survey included 574 women, of whom 9.9% were diagnosed with PPD. There was a higher rate of PPD among Arab compared to Jewish women, among women with a prior history of depression, among women whose pregnancy was unplanned, among those who described the course of pregnancy as "difficult," and among women who described their general health as "not good." Women with PPD consulted more with family physicians and pediatricians. The reasons for the consultations are physical and emotional. There were cases of somatization manifested directly by the mother or indirectly through the baby. CONCLUSIONS: Women with PPD have higher consultation rates than those without. By asking a few simple questions it is possible to identify a significant proportion of women with PPD.