Defining localities of inadequate treatment for childhood asthma: A GIS approach

BACKGROUND: The use of Geographic Information Systems (GIS) has great potential for the management of chronic disease and the analysis of clinical and administrative health care data. Asthma is a chronic disease associated with substantial morbidity, mortality, and health care use. Epidemiologic data from all over the world show an increasing prevalence of asthma morbidity and mortality despite the availability of effective treatment. These facts led to the emergence of strategies developed to improve the quality of asthma care. THE OBJECTIVE: To develop an efficient tool for quality assurance and chronic disease management using a Geographic Information System (GIS). GEOGRAPHIC LOCATION: The southern region of Israel. January 1998 – October 2000. DATABASES: Administrative claims data of the largest HMO in Israel: drug dispensing registry, demographic data, Emergency Room visits, and hospitalization data bases. METHODS: We created a list of six markers for inadequate pharmaceutical treatment of childhood asthma from the Israeli clinical guidelines. We used this list to search the drug dispensing registry to identify asthmatic children who received inadequate treatment and to assess their health care utilization and bad outcomes: emergency room visits and hospitalizations. Using GIS we created thematic maps on which we located the clinics with a high percentage of children for whom the treatment provided was not in adherence with the clinical guidelines. RESULTS: 81% of the children were found to have at least one marker for inadequate treatment; 17.5% were found to have more than one marker. Children with markers were found to have statistically significant higher rates of Emergency Room visits, hospitalizations and longer length of stay in hospital compared with children without markers. The maps show in a robust way which clinics provided treatment not in accord with the clinical guidelines. Those clinics have high rates of Emergency Room visits, hospitalizations and length of stay. CONCLUSION: Integration of clinical guidelines, administrative data and GIS can create an efficient interface between administrative and clinical information. This tool can be used for allocating sites for quality assurance interventions

The need for routine preoperative coagulation screening tests (prothrombin time PT/ partial thromoplastin time PTT) for healthy children undergoing elective tonsillectomy and/or adenoidectomy.

Abstract In some medical centers, the routine pre-operative evaluation of healthy children undergoing elective tonsillectomy and/or adenoidectomy (T and A) includes coagulation screening tests (PT, prothrombin Time; PTT, partial thromboplastin time; and INR, international normalized ratio). In this retrospective study, we determined whether there is a positive correlation between prolonged PT/PTT/INR tests in healthy children, with no prior medical history of coagulation problems, and bleeding during surgery and/or bleeding in the month following surgery. We reviewed the records of 416 elective T and A surgeries performed at the Soroka University Medical Center in Beer-Sheva, Israel, over the course of 1999. One hundred and twenty-one (29.1%) patients had preoperative prolonged PT values but only four (3.3%) of these patients experienced light bleeding during surgery. Seven (5.8%) of the 121 patients with prolonged PT tests experienced bleeding episodes during the 1st month subsequent to the surgery. Of the 65 (15.6%) patients who had prolonged pre-operative INR values, only three (4.6%) experienced light bleeding during surgery. Two (3.1%) patients with prolonged INR values experienced light bleeding during the 1st month subsequent to surgery. Sixty-one (14.7%) patients had prolonged first preoperative PTT values, only five of whom (8.2%) experienced light bleeding during surgery. Two (3.3%) of the 61 with prolonged PTT values experienced light bleeding during the 1st month subsequent to surgery. We therefore concluded that pre-operative coagulation screening tests provide low sensitivity and low bleeding predictive value. As such, routine coagulation tests before T &A are not indicated unless a medical history of bleeding tendency is suspected

Financial Incentive Increases CPAP Acceptance in Patients from Low Socioeconomic Background

OBJECTIVE: We explored whether financial incentives have a role in patients' decisions to accept (purchase) a continuous positive airway pressure (CPAP) device in a healthcare system that requires cost sharing. DESIGN: Longitudinal interventional study. PATIENTS: The group receiving financial incentive (n = 137, 50.8±10.6 years, apnea/hypopnea index (AHI) 38.7±19.9 events/hr) and the control group (n = 121, 50.9±10.3 years, AHI 39.9±22) underwent attendant titration and a two-week adaptation to CPAP. Patients in the control group had a co-payment of $330-660; the financial incentive group paid a subsidized price of$55. RESULTS: CPAP acceptance was 43% greater (p = 0.02) in the financial incentive group. CPAP acceptance among the low socioeconomic strata (n = 113) (adjusting for age, gender, BMI, tobacco smoking) was enhanced by financial incentive (OR, 95% CI) (3.43, 1.09-10.85), age (1.1, 1.03-1.17), AHI (>30 vs. <30) (4.87, 1.56-15.2), and by family/friends who had positive experience with CPAP (4.29, 1.05-17.51). Among average/high-income patients (n = 145) CPAP acceptance was affected by AHI (>30 vs. <30) (3.16, 1.14-8.75), living with a partner (8.82, 1.03-75.8) but not by the financial incentive. At one-year follow-up CPAP adherence was similar in the financial incentive and control groups, 35% and 39%, respectively (p = 0.82). Adherence rate was sensitive to education (+yr) (1.28, 1.06-1.55) and AHI (>30 vs. <30) (5.25, 1.34-18.5). CONCLUSIONS: Minimizing cost sharing reduces a barrier for CPAP acceptance among low socioeconomic status patients. Thus, financial incentive should be applied as a policy to encourage CPAP treatment, especially among low socioeconomic strata patients

Adherence to acute otitis media treatment guidelines among primary health care providers in Israel

AIMS: To determine the appropriateness of the acute otitis media antibiotic treatment prescribed in the community in relation to the therapeutic guidelines. METHODS: Children aged 3 months-3 years diagnosed with simple uncomplicated acute otitis media in 6 community primary care clinics were enrolled. Data on the antibiotic treatment were collected using computerized medical files. RESULTS: 689 simple uncomplicated acute otitis media patients were enrolled; 597 (86.9%) were treated with antibiotics by 38 family medicine practitioners, 12 pediatricians and 7 general practitioners. 461 (77.2%) patients were <2 years of age. Amoxicillin was administered to 540 (90.5%) patients, with no differences between the various medical specialties. 127/540 (23.5%) patients did not receive the appropriate dosage; 140/413 (33.9%) patients treated with appropriate dosage did not receive the treatment for the appropriate duration of time. 258/357 (72.3%) evaluable patients <2 years of age received an antibiotic considered inappropriate to guidelines (38 not treated with amoxicillin, 94 received inappropriate dosage and 126 not treated for 10 days); 53/100 (53%) evaluable children >2 years of age received an inappropriate antibiotic treatment. CONCLUSIONS: The majority of primary care physicians treat simple uncomplicated acute otitis media with the recommended antibiotic drug. However, incorrect dosage and shorter than recommended duration of therapy may jeopardize the quality of care in children with simple uncomplicated acute otitis media

A report card on the physician work force: Israeli health care market--Past experience and future prospects

Background The worldwide shortage of physicians is due not only to the lack of physicians, but also to complex social and economic factors that vary from country to country.Objective To describe the results of physician workforce planning in a system with unintended policy, such as Israel, based on past experience and predicted future trends, between 1995 and 2020.Methods A descriptive study of past (1995-2009) and future (through 2020) physician workforce trends in Israel. An actuarial equation was developed to project physician supply until 2020.Results In Israel a physician shortage is expected in the very near future. This finding is the result of global as well as local changes affecting the supply of physicians: change in immigration pattern, gender effect, population growth, and transparency of data on demand for physicians. These are universal factors affecting manpower planning in most industrial countries all over the world.Conclusion We describe a health care market with an unintended physician workforce policy. Sharing decision makers' experience in similar health care systems will enable the development of better indices to analyze, by comparison, effective physician manpower planning processes, worldwide.Physician manpower Gender Workforce Planning Israel

Defensive medicine in Israel - a nationwide survey.

BACKGROUND: Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily as a safeguard against possible malpractice liability. We studied the extent, reasons, and characteristics of defensive medicine in the Israeli health care system. METHODS AND FINDINGS: Cross-sectional study performed in the Israeli health care system between April and July 2008 in a sample (7%) of board certified physicians from eight medical disciplines (internal medicine, pediatrics, general surgery, family medicine, obstetrics and gynecology, orthopedic surgery, cardiology, and neurosurgery). A total of 889 physicians (7% of all Israeli board certified specialists) completed the survey. The majority [60%, (95%CI 0.57-0.63)] reported practicing defensive medicine; 40% (95%CI 0.37-0.43) consider every patient as a potential threat for a medical lawsuit; 25% (95%CI 0.22-0.28) have previously been sued at least once during their career. Independent predictors for practicing defensive medicine were surgical specialty [OR=1.6 (95%CI 1.2-2.2), p=0.0004], not performing a fellowship abroad [OR=1.5 (95%CI 1.1-2), p=0.027], and previous exposure to lawsuits [OR=2.4 (95%CI 1.7-3.4), p<0.0001]. Independent predictors for the risk of being sued during a physician's career were male gender [OR=1.6 (95%CI 1.1-2.2), p=0.012] and surgery specialty [OR=3.2 (95%CI 2.4-4.3), p<0.0001] (general surgery, obstetrics and gynecology, orthopedic surgery, and neurosurgery). CONCLUSIONS: Defensive medicine is very prevalent in daily physician practice in all medical disciplines. It exposes patients to complications due to unnecessary tests and procedures, affects quality of care and costs, and undermines doctor-patient relationships. Further studies are needed to understand how to minimize defensive medicine resulting from an increased malpractice liability market

Determinants of OSAS Patients Accepting CPAP Treatment among Low Income and Average/High Income Strata.

<p>AHI – apnea-hypopnea index, BMI – body mass index, CPAP – continuous positive airway pressure, CVD – cardiovascular disease, ESS – Epworth Sleepiness Scale, Financial Incentive – received financial support, HTN – hypertension.</p><p>Area under the ROC 81.0% and 69.3% for low income and average/high income patients, respectively.</p

Flow chart showing stages of the diagnostic and therapeutic process and number of patients at each stage.

<p>Flow chart showing stages of the diagnostic and therapeutic process and number of patients at each stage.</p