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Background: Limited health budgets and continual advancement of health technologies require mechanisms for prioritization. Israel, with a publicly funded health service basket, has implemented and optimized such a health technology assessment process since 1999.We describe the process of evaluating technologies according to the Israeli model, analyze its outputs and benefits over two decades of implementation, and compare its key features with international experience., Methods: Retrospective data were collected between 1998 and 2023, including work processes, committee composition, number of applications submitted and approved by a clinical domain, and yearly cost of the basket. Features were evaluated within the evidence-informed deliberative process (EDP) framework., Results: This national model involves relevant stake holders in a participatory and transparent process, in a timely manner, and is accepted by the public, health professionals, and policy makers, facilitating early adoption of the newest medical technologies. Between 11 and 19 percent of applications are approved for reimbursement annually, mostly pharmaceuticals. On average 26 percent of approved technologies are added to the list without additional budget. Major domains of approved technologies were oncology, cardiology, and neurology., Conclusions: Israel created a unique model for the expansion of the health service basket. Despite an increasing number of applications and rising costs, the mechanism enables a consensus to be reached on which technologies to fund, while remaining within budget constraints and facilitating immediate implementation. The process, which prioritizes transparency and stake holder involvement, allows just a resource allocation while maximizing the adoption of novel technologies, contributing to an outstanding national level of health despite relatively low health spending.

Background: Overuse of healthcare services is a common phenomenon defined as: "a healthcare service that is provided under circumstances in which its potential for harm exceeds the possible benefit." It is expressed in the gap between desired services and available ones and is accompanied by high financial and human life costs. One-fifth to one-third of patients receives unnecessary, ineffective, or potentially harmful treatments or services. One of the greatest challenges to understanding overuse is the lack of definition for appropriate use. Apart from the physical and mental damage caused by overuse or improper use of medical services, this phenomenon has many implications, such as increasing waiting times for services, creating long queues, and incurring considerable financial costs as over 10% of hospital expenses are used to correct medical errors or preventable infections. Government intervention through economic arrangements such as deductibles and pre-authorization of services by the insurer are partially effective in reducing the overuse of health services. Additional solutions include ensuring safety and quality of care as well as shared decision-making.

Background: Hip fractures increase the risks of mortality and major morbidity in the elderly. Hip fractures are associated with chronic pain, reduced mobility, disability and increasing dependence. We evaluated the direct costs incurred to the Israeli healthcare system in 2013 as a result of hip fracture injuries in elderly patients., Methods: Hip fractures costs evaluation consisted of first-year and long-term direct costs. Data on the incidence of hip fractures resulting in hospitalizations were retrieved from the Israeli Ministry of Health's (MOH) Central Database of Hospital Admissions. Hospitalization, rehabilitation and nursing utilization rates and costs were estimated based on the professional literature and according to the MOH's price list., Results: During 2013, 6285 elderly patients were hospitalized in Israel due to hip fractures. Direct costs of hip fracture, comprising hospitalization, rehabilitation and nursing costs incurred during the first year after the injury, were estimated at 454 million New Israeli Shekels (NIS; 83,841 NIS per person). Long-term nursing care costs in 2013 were 265 million NIS, with an average cost of approximately 49,000 NIS for 1600 elderly persons receiving long-term nursing care as a result of a hip fracture. Overall, the total direct costs of hip fracture in the elderly population in Israel in 2013 were 719 million NIS., Conclusions: The direct costs of hip fractures in Israel among the elderly are approximately 719 million NIS per year. The majority of costs are associated with the first year following the injury. To reduce healthcare costs in Israel, changes in the country's healthcare policy on hip fractures are required. For example, there is a need for a program for detecting high- risk populations, and for early intervention following the injury.

Background: All too often, health policy and management decisions are made without making use of or consulting with the best available research evidence, which can lead to ineffective and inefficient health systems. One of the main actors that can ensure the use of evidence to inform policymaking is researchers. The objective of this study is to explore Israeli health systems and policy researchers' views and perceptions regarding the role of health systems and policy research (HSPR) in health policymaking and the barriers and facilitators to the use of evidence in the policymaking process., Methods: A survey of researchers who have conducted HSPR in Israel was developed. The survey consisted of a demographics section and closed questions, which focused on support both within the researchers' organisations and the broader environment for KTE activities, perceptions on the policymaking process, and the potential influencing factors on the process. The survey was sent to all health systems and policy researchers in Israel from academic institutions, hospital settings, government agencies, the four health insurance funds, and research institutes (n = 107). All responses were analyzed using descriptive statistics. For close-ended questions about level of agreement we combined together the two highest categories (agree or strongly agree) for analysis., Results: Thirty-seven respondents participated in the survey. While many respondents felt that the use of HSPR may help raise awareness on policy issues, the majority of respondents felt that the actual use of HSPR was hindered for many reasons. While facilitators do exist to support the use of research evidence in policymaking, numerous barriers hinder the process such as challenges in government/provider relations, policymakers lacking the expertise for acquiring, assessing, and applying HSPR and priorities in the health system drawing attention away from HSPR. Furthermore, it is perceived by a majority of respondents that the health insurance funds and the physician organisations exert a strong influence in the policymaking process., Conclusions: Health system and policy researchers in Israel need to be introduced to the benefits and potential advantages of evidence-informed policy in an organised and systematic way. Future research should examine the perceptions of policymakers in Israel and thus we can gain a broader perspective on where the actual issues lie.

Background: Practical solutions are needed to support the appropriate use of available health system resources as countries are continually pressured to 'do more with less' in health care. Increasingly, health systems and organizations are exploring the reassessment of possibly obsolete, inefficient, or ineffective health system resources and potentially redirecting funds to those that are more effective and efficient. Such processes are often referred to as 'disinvestment'. Our objective is to gain further understanding about: 1) whether how and under what conditions health systems decide to pursue disinvestment; 2) how health systems have chosen to undertake disinvestment; and 3) how health systems have implemented their disinvestment approach., Methods/design: We will use a critical interpretive synthesis (CIS) approach, to develop a theoretical framework based on insights drawn from a range of relevant sources. We will conduct systematic searches of databases as well as purposive searches to identify literature to fill conceptual gaps that may emerge during our inductive process of synthesis and analysis. Two independent reviewers will assess search results for relevance and conceptually map included references. We will include all empirical and non-empirical articles that focus on disinvestment at a system level. We will then extract key findings from a purposive sample of articles using frameworks related to government agendas, policy development and implementation, and health system contextual factors and then synthesize and integrate the findings to develop a framework about our core areas of interest. Lastly, we will convene a stakeholder dialogue with Canadian and international policymakers and other stakeholders to solicit targeted feedback about the framework (e.g., by identifying any gaps in the literature that we may want to revisit before finalizing it) and deliberating about barriers for developing and implementing approaches to disinvestment, strategies to address these barriers and about next steps that could be taken by different constituencies., Discussion: Disinvestment is an emerging field and there is a need for evidence to inform the prioritization, development, and implementation of strategies in different contexts. Our CIS and the framework developed through it will support the actions of those involved in the prioritization, development, and implementation of disinvestment initiatives., Systematic Review Registration: PROSPERO CRD42014013204.

Background: Ensuring the use of research evidence in health system management and policy decisions is an important challenge in this century. Knowledge transfer and exchange (KTE) has emerged as a paradigm to address the challenges and start closing the 'know-do' gap. This area of work is gaining momentum in most developed countries, yet, to date, no work has been performed in Israel within this area. The purpose of this study was to identify which KTE activities health systems and policy researchers in Israel have undertaken., Methods: A cross-sectional web-based survey of researchers who have conducted health systems and policy research in Israel was developed. The survey consisted of a demographics section, quantitative scales, and open-ended questions. The survey was sent to all health systems and policy researchers in Israel (n = 125)., Results: The study response rate (28%) was relatively low as compared to other studies in the same field (range of 42% to 88%). Our survey found that more than a third of the health systems and policy researchers in Israel reported that they were frequently or always involved in the following KTE activities: interactions with target audience through the research process (i.e., during developing a research question or executing the research; 35% to 42%) or through formal or informal meetings during conferences, workshops, or conversations (40%). Less than half of the health systems and policy researchers in Israel are engaged in bridging activities aimed to facilitate target audiences to use research., Conclusions: This is a fairly new area in Israel and therefore the level of engagement of researchers in KTE activities is not very high. The low response rates could be because KTE is a new field in Israel and minimal KTE initiatives have been undertaken. It is preferable to have higher response rates, yet, after several initiatives, this was the outcome. While the findings are relevant, they may not reflect the total population of health system and policy researchers in Israel. Health system and policy researchers in Israel need to be introduced to the benefits and potential advantages of KTE in an organized and systematic way.

Although the beneficial effect of statins in secondary prevention of cardiac events is well established, their effectiveness in primary prevention is questionable when most evidence derives from randomized controlled trials and not "real-life" data. To evaluate the association between persistent use of statins and risk of acute nonfatal cardiovascular events in primary prevention patients in community settings, we retrospectively analyzed a cohort of 171,535 adults 45 to 75 years old with no indication of cardiovascular disease who began statin therapy from 1998 to 2009 in a large health maintenance organization in Israel. Persistence with statins was measured by the proportion of days covered with dispensed prescriptions of statins during the follow-up period. Main outcome measurements were occurrence of myocardial infarction or performance of a cardiac revascularization procedure. Incidence of acute cardiovascular events during the follow-up period (993,519 person-years) was 10.22 per 1,000 person-years. Persistence with statins was associated with a lower risk of incident cardiac events (p for trend <0.01). The most persistent users (covered with statins for ≥80% of their follow-up time) had a hazard ratio of 0.58 (95% confidence interval 0.55 to 0.62) compared to nonpersistent users (proportion of days covered <20%). Similar results were found when analyses were limited to patients with >5 years of follow-up. Treatment with high efficacy statins was associated with a lower risk of cardiac events. In conclusion, our large and unselected community-based study supports the results of randomized controlled trials regarding the beneficial effect of statins in the primary prevention of acute cardiac events., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Medical resonance imaging (MRI) is a technology for imaging and diagnosis of tissues and organs which does not use ionizing radiation. It was developed in the 1960's and 1970's and has been in clinical use since the 1980's. Over the last two decades there has been a substantial increase in utilization of MRI due to: improvements in imaging technology and image processing, the development of new indications for its use, and the increase in availability and accessibility of MRI in several medical fields. However, there is also overutilization of this technology due to: the use of imaging as a substitute for regular physical examinations, repeated examinations for the same medical reason, "defensive" medicine, and due to the public's desire for sophisticated examinations. These issues are all responsible for the increased use of MRI. MRI is an expensive technology and therefore, cost-lowering medical and economic mechanisms are employed to Limit its use. Until recently there were ten MRI scanners in Israel and this review presents their utilization patterns. The number of MRI scanners will double in the coming years. This may improve accessibility in different regions of the country, shorten waiting times, and improve medical diagnosis due to implementation for new indications. An international comparison showed that the number of MRI scanners in Israel is lower than the average number of MRI scanners in OECD countries. However, the utilization of MRI scanners in Israel is high relative to other OECD countries, indicating the high level of efficiency of the Israeli healthcare system.

Background: Clinical evidence points to patient-perceived difficulties and compliance problems in implementing early insulin therapy. Therefore, individual treatment aims are necessary to optimize diabetes therapy, as currently acknowledged by the new ADA/EASD guidelines. Better characterization of patient-perceived difficulties in the implementation of early insulin treatment may contribute to improved compliance and optimal tailoring of treatment regimens for the individual patient., Objectives: To assess differences in quality of life (QoL) and patient-perceived difficulties in health care with every addition of oral hypoglycemic agents (OHAs) and insulin therapy., Methods: The analysis was conducted on a cross-sectional sample of 714 diabetic patients treated with OHAs or with insulin once or twice daily. Differences in diabetes-specific QoL, overall QoL, and perception of difficulties associated with specific diabetes treatment attributes were evaluated using trend analysis and comparisons between groups. The contribution of each diabetes treatment attribute to QoL measures and glycemic control was also assessed., Results: No significant differences were found in QoL measures among patients treated exclusively with OHAs when these patients were assessed by the number of oral agents, irrespective of the degree of glycemic control. Better controlled patients treated with 2 OHAs, compared with poorly controlled patients treated with a single OHA, had a lower perception of difficulties associated with diabetes treatment attributes. Poorly controlled patients treated with 2 OHAs and better controlled patients treated with 3 OHAs had similar QoL and perceived difficulties with care. However, the insulin-based alternative was consistently associated with a significantly higher perception of pain and lower overall QoL when compared with the oral regimens. Multivariate models accounted for 52% and 32% of the variance in QoL measures., Conclusions: From the patients' perspective, oral therapy is the preferred strategy for attaining the treatment goals since the addition of OHAs was not associated with lower QoL or patient-perceived difficulties with care. If early insulin treatment is considered, physicians should address specific diabetes treatment characteristics, mainly the issue of pain, to promote improved QoL and disease control.

Objective: The objective of this study is to describe the design and validation of a newly developed brief, treatment-focused scale for use with type 1 and type 2-diabetes, exploring patient-perceived difficulties that are associated with treatment., Methods: The content of the construct was derived from consultation with experts, from existing instruments and the literature, as well as from diabetic patients. The original draft was comprised of 11 attributes. Based on an interim analysis, an additional 12th attribute was added. The final scale was tested on 988 diabetic patients from 25 practices in Israel. Respondents also completed a diabetes-specific quality of life (QoL) questionnaire and indicated their current perceived overall health status., Results: The patient-perceived difficulty of diabetes treatment (PDDT) scale contains 12 items reflecting diabetes-treatment characteristics: adherence to self-monitoring of glucose schedule, frequency of self-monitoring of glucose, adherence to medication administration schedule, frequency of medication administration, multiple number of medications, synchronization between meals and medications, dependence on the medications, pain associated with treatment, diet restrictions, self-care, multiple healthcare providers, and costs of treatment. Response rate to all attributes was very high. Construct validity was shown by significant correlations between PDDT attributes and diabetes-specific quality of life (r = 0.31-0.46) and self-report adherence to recommended treatment (r = 0.14-0.28), as well as between overall perceived difficulty and diabetes-specific quality of life (r = 0.60). Furthermore, the PDDT items showed discriminant capabilities with respect to known groups of patients., Conclusions: The PDDT scale is a simple and valid instrument that may assist in identifying potential barriers in adherence to recommended treatments and to new treatment options., (Copyright © 2011 John Wiley & Sons, Ltd.)

Optimism has several orientations. One such outlook is a general tendency to regard the world as a positive place, accepting difficulties as mere challenges instead of impassable barriers. Among health care workers, optimism improves their level of functioning, their patients' satisfaction, and their therapeutic results. Optimistic staff members report feeling less pressure, use fewer avoidance strategies, focus on practical problem solutions, seek social support, and have more trust in people and organizations. The aim of this article is to provide a review of the literature concerning the role of optimism, both in daily life and in crisis situations. An attempt was made to find the linkage between optimism among health care workers during disasters and their active response, with special emphasis on the relationship between optimism and knowledge, feelings or behavior. Based on the literature, optimism was found to be helpful both in daily medical work and in cases of medical emergencies. Optimism was also revealed one of the key components of resilience and self-efficacy. Therefore, it is recommended to consider strengthening the optimism through initiative programs. Obtaining optimism can be included in toolkit preparedness for health care workers in order to confront the complications in the aftermath of disaster. These programs, together with appropriate information, social support, professional trust, and leaders modeling behavior, will raise the well-being and enhance coping skills of the health care workers during and aftermath of disaster scenarios.

Introduction: In the last two decades there has been a world wide increase in the number of drugs that are being switched from the prescription-only category to non-prescription categories. In Israel, until recently, non-prescription medicines were only permitted to be sold by a pharmacist in pharmacies. In May 2005, following amendments to the law, several non-prescription medicines which were previously sold under a pharmacist's supervision, were reclassified as general-sales-list (GSL) medicines and permitted to be displayed and sold directly off the shelves in pharmacies and in other places such as grocery stores and petrol stations., Objective: To study the change in the patterns of consumption of non-prescription drugs in Israel two years after the reform began., Methods: A representative sample of the population of Israel was chosen and interviews were conducted at two time points: before the reform commenced and two years after the beginning of the reform. Statistical processing was performed in order to examine the changes in patterns of consumption of non-prescription drugs in Israel between these two time points., Results: In both surveys it was found that: approximately 70% of the Israeli public buys non-prescription medicines; 70% of the people interviewed said that they had been aware of the reform, but of these, about 75% continued buying nonprescription drugs from the pharmacist while 21% bought medicines off the shelves at the pharmacy and 4% purchased medications at grocery stores. The most common reasons for buying medicines off the shelves without a pharmacist were earlier knowLedge about the medication, convenience and availabiLity when the pharmacies were closed. An insignificant difference was observed for the purchase of non-prescription drugs from the different types of pharmacies: the health maintenance organizations (HMO) pharmacies continue to be the leading pharmacies from which the public purchased their non-prescription medicines, white there was a slight increase in the purchases from pharmacy chains. In the two surveys, the purchaser's personal experience was the biggest factor influencing the decision to buy a certain drug, followed by the doctor's and the pharmacist's recommendation. Only 15% thought that non-prescription medicines are not safe., In Conclusion: Two years after the reform began no breakthrough was observed in the pattern of purchase of non-prescription medicines. Despite exposure to the reform, most Israelis continue to buy these medicines from the pharmacists. Therefore, it appears that more time will be needed for this reform to actually start making an impact and changing the habits of Israeli consumers when purchasing non-prescription drugs.

The reformation in the marketing of non-prescription medicinal products has been launched. As of May 10th 2005, the pharmacist regulations 2004 (marketing of over-the-counter (OTC) drugs outside of pharmacies, as well as not by a pharmacist) will be in effect. This change aLlows the marketing of medicines outside of pharmacies, as has been the custom in the U.S.A., England and some of the European Union countries for many years. This reformation is incorporated in a policy that encourages self-medication by the use of non-prescription drugs. The self-medication policy originates from the point of view of the consumers who wish to be responsible for their own health and save precious time wasted on doctor visits; and the government's assumption that self-medication of OTC medicines by citizens wiLL decrease expenses for the HMOs in both doctor's billings as well as medication costs. In order to regulate the marketing terms of these medicinal products, regulations and complimentary guidelines were written and published. These documents encompass the following issues: the list of OTC medicines, marketing reguLations, packaging regulations, Licensed marketing Locations, storage regulations as well as display regulations, advertising regulations, monitoring and control. The medicinal products in this category only included medicines containing "safe" active ingredients with restrictions regarding the strength/concentration and packaging size; this category does not include medicines requiring special storage conditions (such as refrigeration or freezing), medicines containing an active ingredient that is addictive, medicines containing an active ingredient with danger of poisoning if misused, and medicines containing an active ingredient that has the potential to harm. The implementation of the regulations and guidelines will improve the consumer's ability to diagnose and treat oneself when sick with minor ailments, without consulting a doctor.

Background: The European Quality of Life 5-Dimensions questionnaire is one of the most commonly used measures of health-related quality of life., Objectives: To present the feasibility, reliability and validity of the Hebrew version of the EQ-5D., Methods: We conducted face-to-face interviews with a representative sample (n = 1666) of the Israeli Jewish population. The data collected included demographic and medical information, and self-valuation of health using the EQ-5D descriptive system, Visual Analogue Scale and Time Trade-Off. Construct validity was assessed by assuming that older individuals, those with a greater burden of diseases, and those reporting experience with their own severe illness would have lower EQ-5D indexes, VAS and TTO values. Test-retest reliability was assessed in a small sample (n = 50) that was reevaluated after a 3 week interval., Results: Test-retest reliability of the EQ-5D and VAS was very high (r > or = 0.85). Reliability of the TTO was moderate (r = 0.48). There were significant differences in the EQ-5D index, profiles, VAS and TTO between healthy and sick respondents and younger and older respondents, indicating good validity of the instrument., Conclusions: The Hebrew translation of the EQ-5D is a practical, reliable and valid instrument for assessing the health-related quality of life of the general Israeli Jewish population.

Objectives: (1) To improve quality and equity by increasing utilisation of mammography screening among Israeli Arab women. (2) To explore effectiveness of designing interventions with a combined top-down and bottom-up approach., Design: Retrospective study at two periods of time: 2004--intervention's preliminary stages; 2005--intervention's implementation., Setting: Maccabi Healthcare Services (MHS), an Israeli health plan serving 1.7 million members at study period; 7% of them are Arabs by 139 branches, 13 of which serve Arabs exclusively. MACRO-ORGANISATIONAL INTERVENTION (TOP DOWN): Development of a computerised Mammography Promotion System, phone contacts with non-respondents and intraorganisational reporting of screening rates. INTENSIVE INTERVENTION (BOTTOM UP): A local analysis of barriers to care and implementation of tailored solutions. This intervention was initiated and documented in three Arab branches, with spillover to the entire Arab sector. MEASURE DEFINITION: Biennial breast cancer (BC) screening of eligible women. Improvement measures Changes in BC screening rates in Arabs and comparisons with overall MHS BC screening rates for 2004 and 2005., Results: In 2005, average BC screening rates in Arab branches increased from 26.7% to 46.2% (73% improvement), while overall MHS screening rates increased from 49.0% to 63.1% (29% improvement). Analysis of the relative differences between 2004 and 2005 BC screening rates indicated statistically significant differences (p<0.006) in rates between the Arab and other branches. These results did not change after adjustment for branch size, region and branch average age., Conclusions: Combined top-down interventions and bottom-up initiatives are effective for formulating programmes to reduce inequality.

Counterfeit drugs are a major threat to public health and safety around the world. This review describes the various distribution methods and channels of counterfeit drugs, including the growing use of the internet. National, regional and international efforts to confront this problem are presented, as well as a wide range of technologies that may assist in detection and enforcement. Finally, the Israeli perspective and actions are illustrated.

A counterfeit drug is one which is deliberately and fraudulently mislabeled with respect to identity and/or source. Counterfeit drugs can be found worldwide, both in deveLoped and developing countries, and their dissemination is a major threat to public health and safety, and has major economic effects on the consumers, the pharmaceutical industry, and society at Large. One of the first measures in confronting this problem is bringing it to the awareness of medical staff and public. This review aims to describe the extent of the problem, to discuss its negative effect, and to present actual and possible consequences.

Objectives: The aim of this study was to describe the history and present situation with health technology assessment (HTA) in Israel., Methods: The method used in this study was a historical analysis based mainly on the knowledge of the authors, but supplemented by the published literature., Results: HTA originated in Israel as a centralized function conducted under the auspice of research, developing into an active multidisciplinary center. Throughout the expansion of the field, HTA was performed in affiliation with several local and international bodies, while providing direct and indirect support at the national level. Today, mainly as a result of vigorous dissemination of the principles, methodology and tools for HTA by the Israeli Center for Technology Assessment in Health Care (ICTAHC), this discipline is increasingly a decentralized activity conducted by a great variety of institutions. Israeli health policy decisions are increasingly based on the results of HTA., Conclusions: ICTAHC's role and functioning has expanded since its beginnings. HTA has become an important part of health care in Israel.

The Israeli Center for Technology Assessment in Health Care (ICTAHC) was established in 1998 at the Gertner Institute for Epidemiology and Health Policy Research, on foundations set in 1992 by the Medical Technology Assessment Unit. The Center is defined as an independent multidisciplinary research center, whose main aims are to assist in developing processes for the adoption of new technologies, identify and propose health priorities, and serve as an educational center for all stakeholders. Moreover, the Center promotes working relations with overseas counterparts as an essential component for expansion and advancement of the field of health technology assessment. Throughout the years, ICTAHC had contributed significantly to the development of the discipline of health technology assessment in Israel and to actual decision making in the health care system. The Center had outlined the principles, guidelines and overall framework for technology assessment in the country, as well as substantiating the discipline through various research areas, which materialized into a variety of technology-related policy accomplishments. Today, the Center serves as a national focal point in the health care system in Israel, as well as maintaining an active position in the international milieu. It has been a decade since the establishment of ICTAHC. This paper reviews the evolution of the center, describes changes in the HTA field in Israel, identifies areas of focus and main research accomplishments, and illustrates the breadth of potential research scope and projections for the future.

Objectives: In a resource-constrained reality, physicians are facing polar demands-those of healthcare managements to adopt cost-conscious behaviors and those of ethical standards that obligate physicians to consider only their patients' best interests. In our study, we aimed to determine the attitudes, practices, and knowledge of healthcare costs among Israeli physicians., Methods: A questionnaire was developed and mailed to a representative sample of physicians in Israel. The overall response rate was 51 percent. The study reviewed self-reported levels of cost consciousness in practice, attitudes, obstacles related to cost containment, and knowledge of the costs of medical resources., Results: Forty-two percent of the physicians reported high levels of cost consciousness in their daily practice; 70 percent reported greater current cost consciousness in comparison to 5 years ago; 76 percent of the responses legitimized institutional demands for cost containment. Although 83 percent of the physicians that responded expressed the belief that economic thinking was inherently the role of management, only 39 percent thought it was part of the physician's role. It was found that predominant predictors of agreement to cost consciousness concepts were employment by a community health plan, a managerial position, participation in health economics seminars, and male gender., Conclusions: Cost consciousness among physicians is related to a broad array of parameters. Interventions must emphasize the benefits of evidence-based medicine as an anchor for both cost containment and quality care, as well as providing assistance to physicians in accepting economic decision-making as part of their professional role.

Preference Based questionnaires are instrumental in the use of Health Related Quality of Life in economic analyses in medicine. These questionnaires combine the features of Health State Measures with those of direct methods of valuations, and therefore link between a profile, which describes a certain health state, to the utility of living in that state. Using statistical models, which are based on values to a sample of profiles, a complete table of utilities for all profiles may be constructed. These utilities serve to evaluate the effectiveness, and cost-effectiveness, of medical interventions. This article describes the method of creating and valuing preference based questionnaires and discusses the problems inherent in using the utilities they produce. The article also covers four of the most common questionnaires- Health Utility Index (HUI), Quality of Well Being (QWB), EuroQoL 5 Dimensions (EQ-5D) and Short Form 6 Dimensions (SF-6D). Finally, it briefly mentions the subject of specific preference based questionnaires.

Health State Measures (HSMs) are one of the existing methods for assessing Health Related Quality of Life. These measures provide a quantitative description of the quality of life across different aspects of living--physical, emotional and social. They allow us to determine the effects of diseases and medical interventions on each of those aspects. Health state measures may be generic--applicable to all conditions and populations, or focus on the unique features of a specific disease, state or group. This article discusses the differences in scope and responsiveness between generic and specific HSMs, with an emphasis on Minimal Clinically Important Difference, and their significance in regard to the selection and use of these questionnaires. The article also provides a short overview of the most commonly used HSMs--Sickness Impact Profile (SIP), Nottingham Health Profile (NHP) and Medical Outcome Study 36-Item Short Form (SF-36).

Assessment of the impact of medical interventions on patient's quality of life is becoming a major aspect in evaluating the effectiveness of these interventions. Based on the concept of combining life expectancy and quality of life in a single value, many tools for measuring this effect have been developed in the last few decades. Quality-adjusted life years (QALYs) are calculated by multiplying life expectancy by a factor representing the quality of life during that period. Health related quality of life may be measured directly by several methods. The most commonly used are Visual Analogue Scale (VAS), Standard gamble (SG) and Time Trade-Off (TTO). This article reviews these three methods, their applications and their advantages and disadvantages. It also addresses some of the problems characteristic of each measure, their theoretical and practical differences and the implications of those differences on the values obtained from each one. Finally, the article discusses the attempts to map the relationships between the three measures, in order to be able to convert values from one to another.

The technological revolution has characterized the past fifty years of medical care. Innovations in health services have dramatically improved patients' quality of life and longevity while reducing the rate of hospitalization and enhancing productivity. Nevertheless, it is clear that modern technological advances both represent and claim a large portion of current health expenditures. This article presents an historical review of the advances in health services in the USA and Israel, and the unique contribution of medical technology (MT) in determining the supply and demand in the health systems. It will outline the factors that influence the processes of health technology assessment and decision-making in allocating the appropriate utilization of MT in an era of limited resources.

Community medicine around the world is facing constant trends of changes. The need to overcome the huge burden of chronic diseases, the need to prioritize and adapt new technologies, and above all, the fact that all these must be done within a given, restricted budget, calls for advanced medical management. In this review we focused on the development of the role of the physician manager in Maccabi Healthcare Services (MHS) over the last 60 years. From what was once a reactive, utilization control-oriented administrative physician role, there has emerged a proactive, formally educated, health quality leader who is expected to lead his clinical colleagues towards achieving the organization's goals. Every organization should answer 4 basic questions in order to encourage/develop the new generation of physician managers. 1. Who am I?--What is the profile and what are the tasks of the physician manager's role? 2. What is the time allocation allotted to the physician manager by the organization to enable him to do his job? 3. What are the educational and managerial tools provided for the 'new" physician manager? 4. What are the rewards that the organization grants to its best people? By addressing the above questions MHS has successfully developed new generations of young clinical leaders who can help MHS management conduct a real dialogue with its clinical physicians in order to maximize the services that our beneficiaries are receiving from the HMO. Our conclusion is that choosing the right people, providing them with the right tools and positioning the physician manager appropriately in the organization's hierarchy will enable the medical care delivery system in Israel to achieve the level of clinical leadership that can lead us towards a better future.

The subspecialty departments are greatly underutilized for teaching during the first two years of medical school. While second-year students are spending most of their time behind closed doors in the laboratory, lectures, and small groups, the clinical environment is teeming with actual patients whose cases are often directly analogous to the material being learned. Moreover, even in today's environment of increased emphasis on quality of medical care and medical education reform, many U.S. medical students still lack essential exposure to common technologies, tests, and procedures performed within several subspecialties. To remedy this situation, the authors propose that educators develop a system of subspecialty clinical learning for first- and/or second-year students correlated to the classroom study of the pathophysiology of the various organ systems. For example, the second-year cardiology course could be augmented with self-directed, patient-centered learning assignments in the cardiac unit, the pathology lab, the echo lab, and other areas. The authors explain the several advantages of comprehensive subspecialty clinical learning (e.g., it will help prepare physicians to practice distributed care, aid development of competencies within the behavioral and social sciences, foster students' professional development, and encourage creative approaches to issues of health care quality). The authors acknowledge the multiple difficulties of implementing such an approach, and present evidence supporting their argument that with the appropriate vision and leadership, such a living curriculum is important and achievable.