The tools of an evidence-based culture: implementing clinical-practice guidelines in an Israeli HMO.

Purpose: Although clinical-practice guidelines (CPGs) are implemented on the assumption that they will improve the quality, efficiency, and consistency of health care, they generally have limited effect in changing physicians' behavior. The purpose of this study was to design and implement an effective program for formulating, promulgating, and implementing CPGs to foster the development of an evidence-based culture in an Israeli HMO.

Method: The authors implemented a four-stage program of stepwise collaborative efforts with academic institutions composed of developing quantitative tools to evaluate prescribing patterns, updating CPGs, collecting MDs' input via focus groups and quantitative surveys, and conducting a randomized controlled trial of a two-stage, multipronged intervention.

Pediatricians' satisfaction with their abilities to care for children with developmental, behavioral and psychosocial problems.

Background: Developmental and behavioral pediatrics has emerged as an area of special interest and new responsibility for pediatricians. The aim of this study was to evaluate the impact of training, experience, and other factors on pediatricians' satisfaction with their abilities to care for children with developmental, behavioral and psychosocial problems.

Methods: A questionnaire was sent to 211 pediatricians working in primary care clinics in the community in Israel.

Effect of the characteristics of family physicians on their utilisation of laboratory tests.

Background: The use of laboratory tests by family physicians has increased in recent years.

Aims: To evaluate the relationship between family physicians' characteristics and the number and type of laboratory tests requested, taking into account chronic diseases.

Design Of Study: Retrospective, cross-sectional study.

Ethnic variability in warfarin maintenance in the community setting: a population-based study in a managed care environment in Israel.

Background: Ethnicity has been associated with variance in warfarin treatment regimens in various settings.

Objectives: To determine whether ethnicity is associated with variance in patient management in Israel.

Methods: Data were extracted from the electronic patient records of Clalit Health Services clinics in the Sharon Shomron region.

Empiric treatment of uncomplicated urinary tract infection with fluoroquinolones in older women in Israel: another lost treatment option?

Background: Current guidelines for the treatment of uncomplicated urinary tract infection (UTI) in women recommend empiric therapy with antibiotics for which local resistance rates do not exceed 10-20%. We hypothesized that resistance rates of Escherichia coli to fluoroquinolones may have surpassed this level in older women in the Israeli community setting.

Objectives: To identify age groups of women in which fluoroquinolones may no longer be appropriate for empiric treatment of UTI.

Microbial colonization of nebulizers used by asthmatic children.

Background: The aim of the present study was to determine the microbial colonization of nebulizers used at home by asthmatic children, and to investigate their parents' cleaning and maintenance routines.

Methods: The nebulizer equipment used at home by 39 asthmatic children was examined. Swabs taken from the inner surface of the reservoir cups, face masks and filters were cultured.

[The increase in requests for laboratory tests in the community--are there any effective intervention programs?].

In recent years there is a steady increase in requests for laboratory tests by primary care physicians. This increase does not necessarily have a diagnostic and therapeutic yield. There is a relationship between background characteristics of the family physicians and their utilization of laboratory tests.

Survey of parents, nurses, and school principals on their perceptions of the controversial role of schools in health promotion.

Background: The aim of this paper was to study the perceptions of parents, nurses, and school principals of the role of the health services in elementary schools.

Methods: A questionnaire was distributed to the heads of parents' committees, school nurses, and school principals of 35 randomly selected elementary public schools in Israel. Respondents were asked to qualify the degree of importance of the traditional and contemporary roles of the school health-care team.

When gatekeepers meet the sentinel: the impact of a prior authorization requirement for cefuroxime on the prescribing behaviour of community-based physicians.

Aims: Prior authorization (PA), the requirement of physicians to obtain pre-approval as a prerequisite for coverage, may decrease drug utilization via a 'sentinel effect', a decrease in utilization caused by external review of prescribing. The purpose of this study was to assess the affect a PA restriction had on the utilization patterns of cefuroxime tablets in a managed care organization (MCO) in Israel.

Methods: Physician prescribing patterns were evaluated by conducting a retrospective drug utilization analysis.

Pediatrician attitudes to exclusion of ill children from child-care centers in Israel: pressure on ambulatory practices.

Background: The exclusion of ill children from child-care centers may be associated with high social, economic and medical costs.

Objective: To assess the opinions of pediatricians working in an outpatient setting in Israel on the exclusion/return of children in child-care centers.

Methods: A questionnaire on practices of exclusion/return of children in child-care centers, in general and according to specific signs and symptoms, was administered to a random computer-selected cross-sectional sample of 192 primary care community pediatricians in Israel.

Teaching evidence-based medicine in a managed care setting: from didactic exercise to pharmacopolicy development tool.

Objectives: To implement a residency-based program for the teaching of evidence-based medicine in an Israeli HMO and to incorporate this effort into the HMO's routine drug policy formulation process.

Methods: Residents and preceptors participating in the family practice residency program in The Leumit Health Fund, 1 of the 4 HMOs operating in Israel, were invited to participate in a workshop for the formulation of guidelines for antibiotic treatment of the common infectious diseases encountered in primary care. The participants were allocated to teams consisting of a preceptor (an attending physician) and a resident physician, with each team choosing a different disease to analyze.

Bacterial contamination of spacer devices used by asthmatic children.

Objectives: To investigate bacterial contamination in spacer devices used by asthmatic children and the device maintenance procedures practiced by parents.

Methods: Spacer devices used by 62 asthmatic children were examined. Swabs taken from the inner surface of the reservoirs and face masks were cultured.

Exclusion of ill children from child-care centers in Israel.

The aim of the study was to examine criteria for ill children in child-care centers. A questionnaire on practices of exclusion/return of children according to specific signs and symptoms was mailed to the directors of care centers in central Israel. Thirty-six of the 60 questionnaires (60%) were returned by mail and the reminded were completed in personal visits to the CCCs achieving a response rate of 100%.

Efficacy of postexposure immunization with live attenuated varicella vaccine in the household setting--a pilot study.

The aim of the present study was to examine the efficacy of postexposure vaccination with Varilrix in the household setting. A randomized, double-blind, placebo-controlled design was used. Twenty-two children received the varicella vaccine and 20, a placebo.

Economic evaluation of an updated guideline for the empiric treatment of uncomplicated urinary tract infection in women.

Background: Until recently trimethoprim-sulfamethoxazole was the drug recommended in the Leumit Health Fund for the empiric treatment of uncomplicated urinary tract infection in women. However, due to increased uropathogen resistance to this drug, the fund has designated nitrofurantoin as its new drug of choice.

Objectives: To evaluate the potential economic impact of implementing this new pharmaco-policy.

Physician adherence to recommendations for duration of empiric antibiotic treatment for uncomplicated urinary tract infection in women: a national drug utilization analysis.

Background: Current guidelines for the empiric treatment of uncomplicated urinary tract infection in women recommend that first-line trimethoprim-sulfamethoxazole (TMP-SMX) or ofloxacin be given for 3 days and nitrofurantoin for 5 days. Increasing the duration of treatment raises costs, and perhaps, the incidence of adverse effects, without contributing to effectiveness. The aim of this study was to investigate physician adherence to these recommendations.

Adverse reactions to accidental forearm injection of Bacille Calmette-Guerin vaccine in schoolchildren: 12-month cohort follow-up.

This study examined the natural history of reaction after accidental intradermal administration of bacille Calmette-Guerin (BCG) vaccine instead of purified protein derivative (PPD) in 226 schoolchildren. At 18 days after vaccination, a local reaction with a diameter of 4.5-14 mm was found in 62% of the students, and ulceration with discharge was found in 26.

Assessment of participation in physical activities and relationship to socioeconomic and health factors. The controversial value of self-perception.

Physician counseling on physical activities for sedentary people is usually based on anamneses. The aim of the present study was to investigate the accuracy of self-perception of participation in physical activities, and the correlation of physical activity with background factors. A random sample of 276 individuals aged 20-65 years completed a detailed questionnaire on type and intensity of physical activity and associated socioeconomic and health factors.

Are people who use "natural drugs" aware of their potentially harmful side effects and reporting to family physician?

We studied the extent of patients' utilization of complementary medicine (CM), and their knowledge and attitude regarding it in 740 patients visiting 25 randomly family medicine practices. One-third reported using some kind of CM, usually a natural drug (67.6%), often together with conventional drugs.

Effectiveness of an herbal preparation containing echinacea, propolis, and vitamin C in preventing respiratory tract infections in children: a randomized, double-blind, placebo-controlled, multicenter study.

Objective: To evaluate the effectiveness and safety of a preparation containing echinacea, propolis, and vitamin C in the prevention of respiratory tract infections in children during a 12-week winter period.

Design: Randomized, double-blind, placebo-controlled study.

Subjects: Four hundred thirty children, aged 1 to 5 years, were randomized to an herbal extract preparation (n = 215) or a placebo elixir (n = 215).

Comparison of blood pressure measurements on the bare arm, below a rolled-up sleeve, or over a sleeve.

Background: This study examined the effect of measuring blood pressure below subjects' rolled-up sleeves, over the sleeve, or on the bare arm. This is an important day-to-day issue for the busy GP.

Methods: The sample consisted of 201 subjects in family practice clinics and residents of a senior citizens' home.

Usefulness of electronic databases for the detection of unrecognized diabetic patients.

Background: Even mild hyperglycemia is associated with future acute and chronic complications. Nevertheless, many cases of diabetes in the community go unrecognized. The aim of the study was to determine if national electronic patient records could be used to identify patients with diabetes in a health management organization.

Urinary tract infection in women--physician's preferences for treatment and adherence to guidelines: a national drug utilization study in a managed care setting.

Background: The treatment of urinary tract infection (UTI), the most common bacterial infection in most Western countries, is a global clinical and economic issue. Trimethoprim-sulfamethoxazole (TMP-SMX) and nitrofurantoin are the two drugs currently recommended in clinical guidelines in Israel for uncomplicated UTI in women.

Objectives: This study evaluates physician preferences for treatment and adherence to guidelines.

Prevalence of and change in the prescription of methylphenidate in Israel over a 2-year period.

Introduction: The use of methylphenidate for the treatment of attention deficit-hyperactivity disorder (ADHD) has increased dramatically in the past decade in some countries in Europe and North America. In response to a public debate in Israel, several Knesset members introduced a legislative initiative that aims to limit the prescription of methylphenidate by physicians. The objective of this study was to examine the rate methylphenidate prescriptions dispensed for the treatment of ADHD in children in northern and central Israel in 1999 and 2001.

Impact of a single-session education program on parental knowledge of and approach to childhood fever.

We evaluated knowledge of and approach to childhood fever in parents before and after attending a single reinforced educational session on the subject given by the pediatrician during a visit with their sick child. The study group consisted of 155 consecutive parents of children who visited the pediatrician for treatment of low-grade fever (<38.5 degrees C) once during the period of July 1999-2000, and again, within 6 months later.