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Purpose: To investigate the influence of various risk factors for age-related macular degeneration (AMD) on the rate of undergoing photodynamic therapy (PDT)., Design: An observational population based cohort study., Settings: A district of the largest health maintenance organization (HMO) in Israel., Study Population: All HMO members in the district, older than 50 years on January 1, 2001, who did not terminate their membership until May 31, 2005 (139,894 members); of those, 283 underwent PDT for AMD during the study period (775 procedures)., Observation Procedures: We extracted information from the chronic disease registry of the HMO as well as demographic information including age, gender, country of birth, place of residency, and social security economic status., Main Outcome Measures: Effect of various risk factors for AMD on the rate of PDT., Results: The age-adjusted proportion of patients requiring PDT was significantly higher in hypertensives (P = .03, chi2 test), in hyperlipidemics (P = .002), in ischemic heart disease patients (P = .002) and among males (P = .03) and Ashkenazi Jews (P = .02). No significant difference in PDT rates was noted in diabetics, congestive heart failure (CHF), and chronic renal failure (CRF) patients. PDT rates were lower in the lower socioeconomic class (P = .002). Logistic regression found a significant effect of age, hyperlipidemia, hypertension, socioeconomic status, and gender on the rate of PDT, while ischemic heart disease (IHD), diabetes, CHF, CRF, place of birth, and place of residence did not contribute significantly to the model., Conclusions: Advanced age, hypertension, hyperlipidemia, male gender, and socioeconomic status are risk factors for undergoing PDT for predominantly classic neovascular AMD.

Over the past few years more than a thousand Israeli civilians were murdered and thousands were wounded in recurrent terrorist attacks. Many others had been exposed to the terrorists' attacks, either directly or indirectly. However, the impact of the terror on physical illness had not yet been explored. Stress may cause diseases like hypertension or ischemic heart diseases and may exaggerate asthma, inflammatory bowel diseases and others; this is in addition to posttraumatic disorders, depression and anxiety. This article reviews the influence of stress, and especially conflicts, on chronic physical illness and aims to encourage further research on this subject in Israel.

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. Various studies have been conducted in order to understand the physician's motives for ordering laboratory tests in attempts to reduce their number. Interventions to reduce laboratory test utilization yield different and sometimes opposing results. We reviewed the literature dealing with laboratory test utilization and interventions to reduce it.

Purpose: To investigate the effect of topical beta-blockers on the prevalence of depression among glaucoma patients., Design: Retrospective observational population-based cohort study., Participants: We reviewed the electronic medical records of all the members in a district of the largest health maintenance organization in Israel (Central District of Clalit Health Services) who were older than 20 years (317,469 members)., Methods: We documented all antiglaucoma prescriptions (n = 274,023) and all antidepressant prescriptions (n = 16,948) filled by glaucoma patients in the district between January 1, 2001 and December 31, 2003. We included only those patients who filled at least 6 consecutive antiglaucoma prescriptions at least once every 2 months (n = 6597; 5846 [88.6%] were treated with topical beta-blockers). Depressed patients were defined as patients that filled at least four prescriptions for antidepressants during the study period (n= 810, 12.3% of all glaucoma patients)., Main Outcome Measure: Relationship of topical beta-blocker use and prevalence of depression among glaucoma patients., Results: No significant demographic differences were noted between glaucoma patients treated and not treated with topical beta-blockers. Of those treated and not treated with beta-blockers, 12.2% (12.7% after age-adjustment) and 12.7%, respectively, were also receiving drug therapy for depression (P = 0.7, chi-square test). With stratification by age, treatment with topical beta-blockers did not influence the prevalence of depression in any age group. Logistic regression analysis revealed a significant effect of age, place of birth, and gender on the prevalence of depression, but the prevalence of use of topical beta-blockers had no significant effect., Conclusions: Use of topical beta-blockers by glaucoma patients does not appear to increase the risk of depression in this population.

Background: Maintaining a death register and holding staff discussions about patients who died can aid the physician in audit and research, which will lead to improved care of the terminally ill and the bereaved and to the development of prevention strategies. These issues are important for students and residents as well., Objectives: To review the value of mortality-case discussions in primary care clinics, particularly teaching clinics., Methods: The clinic death register, instituted in 1998, includes age, gender, cause of death, place of death, relevant illnesses, and support provided to the patient before the death. In the half-yearly sessions, the data are reviewed, and individual cases that had an emotional impact on the staff, or information that can bring about changes in future care are discussed by the clinic staff and trainees., Results: In our clinic 233 deaths occurred during a 6 year period (1998-2003). The crude all-cause mortality rate was 7.1/1000. The median age was 80 years old. Neoplastic causes were slightly more frequent than cardiovascular causes of death. Only 15% died at home; 20% lived alone and 70% lived with a spouse or family members before the death. Topics discussed in the mortality review meetings include identifying pre-suicidal patients, when to hospitalize the sick elderly, dealing with the anger of bereaved families, and ensuring proper home care for terminal patients., Conclusions: We recommend keeping a death register and conducting mortality review sessions in order to improve the quality of care, emotional support of the staff, and training students and residents about the complex issues surrounding the death of patients.

Objectives: Topical beta-blockers are contraindicated in obstructive pulmonary diseases (OPDs). In this study we aimed to evaluate through central or local electronic medical records (EMRs) the prescription patterns for topical ocular beta-blockers for patients with glaucoma and OPD treated by ophthalmologists., Methods: The study was carried out at the Leumit Health Maintenance Organisation (HMO) in Israel. The physicians at the HMO all work with an EMR, either a central EMR incorporating data from primary-care physicians and consultants, or a local one. The study population included all HMO members who filled at least one prescription for antiglaucoma medications in 2004. The patients were divided into two groups: those with a previous diagnosis of OPD (ICD-9 codes 493) and those with no known diagnosis of OPD., Results: 7481 patients consumed topical antiglaucoma medications during the study period, and 14.5% had a diagnosis of OPD. 798 OPD patients were treated by ophthalmologists, and of the 61.8% who were treated with topical beta-blockers, only 38 received betaxolol. In comparison with glaucoma patients without OPD, OPD patients received fewer beta-blockers (p < 0.001), more selective beta-blockers (p < 0.0001) and less timolol (p < 0.001). Of the OPD patients treated by ophthalmologists with a central EMR, 59.5% received beta-blockers in comparison with 66.4% treated by ophthalmologists with a local EMR (p = 0.06). OPD patients treated by ophthalmologists with a central EMR received more non-beta-blockers in comparison with patients treated by ophthalmologists with a local EMR (p = 0.02)., Conclusion: Most patients with OPD and glaucoma continued to receive topical beta-blockers, mostly noncardioselective beta-blockers. A central EMR with a comprehensive and highly available medical history reduced the prescription of beta-blockers to OPD patients, but rates remained unacceptably high.

Background: Use of methylphenidate for the treatment of attention-deficit hyperactivity disorder (ADHD) has increased throughout the world in the past decade. In Israel, as elsewhere, there is much debate regarding the diagnosis of ADHD and methylphenidate use. The aim of this study was to examine methylphenidate use rates for the treatment of ADHD among children in Israel during the years 1998-2004 with a special focus on prescriptions among girls., Study Design and Methods: This was a longitudinal population-based prevalence study wherein we reviewed the computerised database of a major health maintenance organisation (HMO). Subjects studied included all children living in the central district of Clalit HMO in Israel who were prescribed methylphenidate in the 7-year period from 1998-2004., Main Outcome Measures and Results: The overall 1-year prevalence rate of methylphenidate use in children aged 0-18 years increased from 0.7% in 1998 to 2.5% in 2004, an increase by a factor of 3.54 (95% CI 3.31, 3.79). In 1998, the rate of methylphenidate prescription ranged from 0.20% among schoolgirls to 1.2% among boys, a 6-fold difference. In 2004, the rate of methylphenidate prescription ranged from 1.1% among schoolgirls to 3.8% among boys; the sex difference had narrowed to only 3.45. Except for kindergarten girls, methylphenidate utilisation increased for all ages from kindergarten to high school, both among boys and among girls., Conclusion: The continuous increasing rate of methylphenidate use in Israel, especially among girls, represents a significant public health issue. There is a need for future research into the relationship between sex and ADHD diagnosis and treatment.

Purpose: To study the incidence of herpetic eye disease (HED) of the ocular surface in diabetics., Design: Observational historical cohort study., Setting: A district of the largest health maintenance organization in Israel (the Central District of Clalit Health Services)., Participants: We reviewed the electronic medical records of all patients older than 50 years (159634 patients) in the district, and of these, 22382 (14.0%) patients had diabetes mellitus., Methods: All filled prescriptions for acyclovir eye ointment between January 1, 2001 and December 31, 2003 (1483 tubes) and all hemoglobin A1c laboratory tests during 2003 (41910 tests) were documented. An ocular surface HED event was defined when a patient consumed at least 1 tube of topical acyclovir per month, whereas no acyclovir use was documented 3 months before and 3 months after that event., Main Outcome Measures: Incidence of ocular surface HED events in diabetics compared with nondiabetics adjusted for age and gender., Results: After age and gender adjustment, significantly more diabetics had ocular surface HED (5.21 per thousand) compared with nondiabetics (4.27 per thousand; P<0.0001). Stratification by age revealed a significantly higher prevalence of HED in diabetics, aged 60 to 79 years. Recurrent herpetic events occurred during the study period in 25.2% of HED-affected diabetics, and in 16.6% of HED-affected nondiabetics (P = 0.05). Diabetics with poor glycemic control (mean annual hemoglobin A1c > 9%) consumed significantly more ocular acyclovir (P = 0.01). Multivariate analysis revealed this effect to be independent of age, gender, place of birth, or place of residency., Conclusions: Ocular surface HED is significantly more common among patients with diabetes mellitus. Poor glycemic control correlates with increased consumption of ocular acyclovir in diabetic patients.

Background: Good care of the diabetic patient reduces the incidence of long-term complications. Treatment should be interdisciplinary; in the last decade a debate has raged over how to optimize treatment and how to use the various services efficiently., Objectives: To evaluate the quality of care of diabetic patients in primary care and diabetes clinics in the community in central Israel., Methods: We conducted a retrospective cross-sectional study of a random sample of 209 diabetic patients in a district of the largest health management organization in Israel. Patients were divided into two groups - those treated only by their family physician and those who had attended diabetes clinics. Data included social demographics, medications, risk factors, quality of follow-up, laboratory tests, quality of diabetes and blood pressure control, and complications of diabetes., Results: Of the 209 patients 38% were followed by a diabetes clinic and 62% by a family physician. Patients attending the specialist clinic tended to be younger (P= 0.01) and more educated (P= 0.017). The duration of their diabetes was longer (P < 0.01) and they had more diabetic microvascular complications (P= 0.001). The percentage of patients treated with insulin was higher among the diabetes clinic patients (75% vs. 14%, P= 0.0001). More patients with nephropathy received angiotensin-converting enzyme inhibitors in the diabetes clinic (94% vs. 68%, P= 0.02). Follow-up in the specialist clinic as compared to by the family physician was better in the areas of foot examination (P< 0.01), fundus examination (P= 0.0001), and hemoglobin A1c testing (P= 0.01). On a regression model only fundus examination, foot examination and documentation of smoking status were significantly better in the diabetes clinic (P< 0.05)., Conclusion: There is still a large gap between clinical guidelines and clinical practice. Joint treatment of diabetic patients between the family physician and the diabetes specialist may be a proposed model to improve follow-up and diabetes control. This model of treatment should be checked in a prospective study.

Background: Acute respiratory viral infections are minor self-limited diseases. Studies have shown that patients with ARVI can be treated as effectively by non-physician practitioners as by physicians., Objectives: To examine whether a military medic, using a structured questionnaire and an algorithm, can appropriately triage patients to receive over-the-counter medications and refer more complicated cases to a physician., Methods: The study group comprised 190 consecutive soldiers who presented to a military primary care clinic with symptoms of ARVI. Using a questionnaire, a medic recorded the patient's history and measured oral temperature, pulse rate and blood pressure. All patients were referred to a doctor. Physicians were "blind" to the medic's anamnesis and to the algorithm diagnosis. We compared the medic's anamnesis and therapeutic decisions with those of the doctors., Results: Patients were young (21.1 +/- 3.7 years) and generally healthy (93% without background illness). They usually had a minor disease (64% without fever) that was mostly diagnosed as viral ARVI (83% of cases). Ninety-nine percent were also examined by a physician. According to the patients' data, the medics showed high overall agreement with the doctors (83-97.9%). The proposed algorithm could have saved 37% of referrals to physicians, with a sensitivity of 95.2%. Had the medics been allowed to examine the pharynx for an exudate, the sensitivity might have been 97.6%., Conclusions: Medics, equipped with a questionnaire and algorithm but without special training and without performing a physical examination, can appropriately triage patients and thereby reduce the number of referrals to physicians.

Background: Air pollution is a potential cause of asthma and COPD exacerbations. On the evening of Lag Ba-Omer, when there were bonfire parties throughout the country, significant air pollution was reported., Objectives: To evaluate the association of the air pollution caused by Lag Ba-Omer bonfires party (8th May 2004) and asthma and COPD exacerbations in the Rehovot area., Methods: Data on air quality and pollution levels was retrieved from the monitoring system of the Ministry of the Environment for the period of Lag Ba-Omer (May 2004). All visits to the Kaplan Medical Center Emergency Department, local after-hours first aid clinics and hospital admissions in May 2004 were evaluated. The daily rate of visits and admissions with the diagnosis of asthma or COPD exacerbation was recorded., Results: Data from the Rehovot monitoring station revealed worsening in the air pollution indices in the two days after Lag Ba-Omer. On the same days of the week, a week earlier and a week later, the air quality was good. There was no increase in asthma or COPD visits to after-hours first aid clinics and no increase in hospitalizations. An increase in the rate of visits due to asthma and COPD to the emergency department was noted in the days after Lag Ba-Omer in comparison to the control days (15/277 (5.4%) vs. 14/593 (2.4%), p < 0.05)., Conclusion: There was an increase in emergency department visits due to asthma and COPD without an increase in hospital admissions in the days of air pollution after Lag Ba-Omer. Further studies should focus on a possible increase in self medication and family physician visits in the period around Lag Ba-Omer.

Purpose: To describe prescription trends within a managed care setting for glaucoma medications and to examine the effect of introduction of Cosopt--a fixed combination of dorzolamide and timolol., Patients and Methods: All prescriptions dispensed to any of the 470,350 members of an Israeli health maintenance organization were monthly scanned for patients treated for glaucoma, between January 2000 and May 2003. The monthly mean number of glaucoma patients was 3899 +/- 104 (mean +/- SD). All topical glaucoma prescriptions were documented, and the monthly prescription rate of each medication was calculated and plotted. The monitored glaucoma medications were: beta-adrenergic antagonists, dorzolamide, latanoprost, pilocarpine, brimonidine, Cosopt, and others., Results: beta-adrenergic antagonists were the top prescribing drug (>35% of all glaucoma prescriptions). The prescription rates of pilocarpine and beta-adrenergic antagonists were in constant decline, while latanoprost and brimonidine increased steadily. The introduction of Cosopt changed the prescription trends of dorzolamide from increasing to rapidly decreasing, and accelerated the long-term decline of beta-adrenergic antagonists. Concomitant with the introduction of Cosopt the prescription rate of beta-adrenergic antagonists temporarily increased. This was due to a total increase in glaucoma prescriptions. When Cosopt was introduced, 37.5% of patients were prescribed Cosopt together with beta-adrenergic antagonists, and 16.5% also received dorzolamide. Thereafter the co-prescription decreased steadily., Conclusions: Introduction of a combination drug should be accompanied by physicians', pharmacists', and patients' education to prevent its inappropriate usage together with its components.

Background: The health system of the medical corps of the Israel Defense Force is based primarily upon primary healthcare. In recent years, health management organizations have considered the primary care physician responsible for assessing the overall health needs of the patient and, accordingly, introduced the term "gatekeeper.", Objectives: To describe and analyze how PCPs in the IDF view their roles as primary care providers and to characterize how they perceive the quality of the medical care that they provide., Methods: We conducted a survey using a questionnaire that was mailed or faxed to a representative sample of PCPs. The questionnaire included demographic background, professional background, statements on self-perception issues, and ranking of roles as a PCP in the IDF., Results: Statements concerning commitment to the patient were ranked higher than statements concerning commitment to the military organization. Most physicians perceive the quality of the medical care service that they provide as high; they also stated that they do not receive adequate continuous medical education., Conclusions: Our survey shows that PCPs in the IDF, like civilian family physicians, perceive their primary obligation as serving the needs of their patients but are yet to take on the full role of "gatekeepers" in the IDF's healthcare system. We conclude that the Medical Corps should implement appropriate steps to ensure that PCPs are prepared to take on a more prominent role as "gatekeepers" and providers of high quality primary medical care.

Purpose: To compare the prevalence of keratoconjunctivitis sicca (KCS) in a prospective cohort of 22,382 diabetic patients with that in the general population., Design: Prospective, observational, cohort study., Setting: A district of israel's largest health maintenance organization., Study Population: We followed the electronic medical records of all patients in the district older than 50 years (159,634 patients) between January 1 and December 31, 2003. Of those, 22,382 (14.0%) had diabetes., Observation Procedure: The proportion of ocular lubrication consumers was compared among diabetic and nondiabetic patients. All HbA1c laboratory tests performed by the diabetic patients were documented (41,910 tests), and glycemic control was correlated with the consumption of ocular lubrication., Main Outcome Measures: Ocular lubrication use by diabetic patients compared with the general population and the relationship between glycemic control and ocular lubrication use., Results: After age and gender adjustment, a significantly higher percentage of diabetic patients (20.6%) received ocular lubrication, compared with nondiabetic patients (13.8%, P < .001). The difference was significant for all age groups and for both sexes (P < .001). A similar significant difference was prominent between diabetic and nondiabetic patients aged 60 to 89 years who were frequent users of ocular lubrication. Ocular lubrication consumption increased with poorer glycemic control (mean annual HbA1c levels). Multivariate analysis revealed this effect to be independent of age, sex, place of birth, or place of residence., Conclusions: KCS is significantly more common among diabetic patients. Poor glycemic control correlates with increased artificial tear use in diabetic patients.

Background: Hypertension in diabetics is a recognised risk factor for vascular disease, both of large and small vessels. Tight control of blood pressure (BP), aiming at 130/80, reduces both morbidity and mortality from vascular disease., Objective: Tight control of BP in diabetics aiming at 130/80., Target Population: Type 2 diabetics with BP over 130/80, whether undergoing treatment or not, in the Shoham primary care clinic., Methods: Patients meeting the above criteria were identified by scanning their files. Their compliance to treatment and dose adjustment was followed. Preferred first line drugs were ACE inhibitors and diuretics., Results: A total of 91 of the 115 (79%) diabetics were identified as also being hypertensive. The objective of BP 130/80 or less was achieved in 26% of cases at the beginning of the research and in 53% after 6 months (p<0.001). Prior to the intervention, the average BP in the hypertensives was 142.1+/-17.6/80.6+/-8.3 and they were being treated with an average of 1.5+/-1.2 drugs. Twenty-one patients (23%) were receiving no drug treatment. After 6 months the average BP in these patients was 132.2+/-14.2/77.6+/-6.1 and they were being treated with an average of 2.0+/-1.2 drugs. Six (6.5%) patients were without drug treatment. The average diastolic and systolic pressure was significantly lower after the intervention (p<0.001 and p=0.001 respectively) and more anti-hypertensive drugs were being used (p=0.001), Conclusion: Through good clinical team co-operation it is possible to successfully treat hypertension in diabetics. It is important to implement the guidelines of treating hypertensive diabetics.

Background: Physicians' awareness of their important role in defusing the obesity epidemic has increased. However, the number of family practitioners who treat obesity problems continues to be low. Self-efficacy refers to the belief in one's ability to organize and execute the courses of action required to produce given attainments. Thus, practitioners who judge themselves incapable of managing obesity do not even try. We hypothesized that practitioners' self-efficacy and motivation would be enhanced as a result of participating in an interactive course designed to enrich their knowledge of obesity management., Methods: Twenty-nine family practitioners participated in the course, which was accompanied by qualitative interviews. The difference between the physicians' pre-course and post-course appraisals was tested by paired t-test. The interviews were analyzed by qualitative methods., Results: Post-course efficacy appraisals were significantly higher than pre-course appraisals (p < 0.0005). A deeper insight on the practitioners' self-efficacy processes was gained through reflection of the practitioners on their self-efficacy during the interviews., Conclusions: Up-to-date information and workshops where skills, attitudes and social support were addressed were important in making the program effective.

Background: The visit to the emergency department (ED) constitutes a brief, yet an important point in the continuum of medical care. The aim of our study was to evaluate the continuity of care of adult ED visitors., Methods: We retrospectively reviewed all ED discharge summaries for over a month 's period. The ED chart, referral letter and the patient's primary care file were reviewed. Data collected included: age, gender, date and hour of ED visit, documentation of ED referral and ED discharge letter in the primary care file., Results: 359 visits were eligible for the study. 192 (53.5%) of the patients were women, average age 54.1 +/- 18.7 years (mean +/- SD). 214 (59.6%) of the visits were during working hours of primary care clinics ("working hours"), while the rest were "out of hours" visits. Only 196 (54.6%) of patients had a referral letter, usually from their family physician. A third (71/214) of "working hours" visits were self referrals, the rate rose to 63.5% (92/145) of "out of hours" visits (p < 0.0001). The ED discharge letter was found in 50% (179/359) of the primary care files. A follow-up visit was documented in only 31% (111/359). Neither follow up visit nor discharge letter were found in 43% of the files (153/359)., Conclusions: We have found a high rate of ED self referrals throughout the day together with low documentation rates of ED visits in the primary care charts. Our findings point to a poor continuity of care of ED attendees.

Type 2 diabetes is a common chronic illness with many complications, entailing enormous expenditures health services. In the Western world, diabetes is the most common cause of amputations of the lower limb, end stage renal failure and blindness amongst 18-65 year olds. The care of the diabetic patient is multi-faceted and the long term compliance of the patient is essential. In the last decade there is an ongoing heated debate regarding how treatment and care should be provided to diabetics and by whom. "Shared care" between the family physician and the specialist diabetes clinic is becoming more popular in an attempt to raise standards of care while reducing costs. The aim of the current review is to evaluate management modalities of the diabetic patient and its' applications to the Israeli health system.

Background: Annual screening for diabetic retinopathy is highly recommended. The early detection of background retinopathy and laser treatment can prevent most of the diabetes related blindness. However patient compliance is relatively low., Aim: We aimed to raise the performance of annual fundus examination among diabetic patients, and to evaluate the rate of undetected severe diabetic retinopathy., Methods: The study took place in an urban primary care clinic located in an average socio-economic neighborhood. The intervention program was based on implementation by the clinic staff with no additional external resources. The program included: locating the diabetic population, extending telephone invitation, and establishing cooperation with ophthalmologists., Results: In 2000, the year prior to the intervention, 42% (177/420) of our diabetic patients had a fundus examination. In 2001 the rate increased to 76% (318/420), an increase of 80%. In 17% (55/318) of the patients the ophthalmologic examination was positive, including 33 cases of background retinopathy. Patients with retinopathy had a significantly higher HbA1c levels and hypertension was more common. Twenty cases had an early diabetic retinopathy, while the other 13 were immediately sent for laser treatment. In the laser treatment group, the male to female ratio was almost double (69% vs. 35%, p = 0.06). Diabetes duration was longer (15.6 + 4.9 years vs. 8.4 + 5.6, p < 0.001) and they had a significantly higher rate of diabetic foot and peripheral vascular disease., Conclusion: An intervention that involved primary care clinic staff without external resources increased compliance with annual fundus examination and detected diabetic retinopathy in a preventable stage.

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., Methods: The central district databases of Israel's largest health management organization were reviewed for all patients over 20 years old with a documented diagnosis of diabetes mellitus (DM) in the chronic disease register or patient file (identified diabetic patients) or a fasting serum glucose level of >126 mg/100 ml according to the central laboratory records (suspected diabetic patients). The family physicians of the patients with suspected diabetes were asked for a report on their current diabetic status., Results: The searches yielded 1,694 suspected diabetic patients; replies from the family physicians were received for 1,486. Of these, 575 (38.7%) were confirmed to have diabetes mellitus. Their addition to the identified patient group raised the relative rate of diabetic patients in the district by 3.2%., Conclusion: Cross-referencing existing databases is an efficient, low-cost method for identifying hyperglycemic patients with unrecognized diabetes who require preventive treatment and follow-up. This model can be used to advantage in other clinical sites in Israel and elsewhere with fully computerized databases.

Background: There are many patient dependent factors that determine health care costs. However, it is not clear if the family physicians' background and training affects health care costs., Aim: To investigate if the family physicians background and training affect their costs., Methods: Included in the study were all the family physicians of Clalit Health Services, Central District according to the following criteria: at least two years work on the same patient list of at least 450 patients, doctors either with specialization in family medicine or with no specialization. The annual costs for treating 1,000 normalized patients (NP) were calculated for each doctor. The doctors' socio-demographic backgrounds were recorded including the country in which they graduated from medical studies, seniority, place of work and managerial position., Results: A total of 137 doctors treating 268,453 NP were investigated. The average age of the doctors was 47.4 +/- 8.0 years and on average they had 22.7 +/- 8.2 years of work experience as doctors. Most had graduated in the former USSR (57%), or Israel (20%). Forty percent were specialists in family medicine. We found an 8.7% reduction in health care costs for 1,000 NP over a year when comparing specialists in family medicine to non-specialists (p < 0.01). In multiple regression, the following factors were associated with lower costs: a country practice and specialization in family medicine., Conclusion: The health care costs are reduced by specialists in family medicine when compared to non-specialists. It also appears that costs are lower in non-urban practices. These findings should affect decision makers in the health system in encouraging specialization in family medicine.

Background: The threat of bioterrorism consequent to the September 11, 2001 attack in the USA generated suggestions for improved medical response mainly through hospital preparedness., Objectives: The aim of the present study was to investigate the impact of this period of tension on patients' first choice for care and for receiving relevant information, and on primary care doctors' feelings of responsibility in the eventuality of an anthrax attack., Methods: During October 11-31, 2001, 500 patients from 30 clinics throughout Israel were asked to complete a questionnaire on their awareness of the anthrax threat, measures taken to prepare for it, and preferred sources of care and information. Their 30 physicians, and an additional 20, completed a questionnaire on knowledge about anthrax and anthrax-related patient behaviours and clinic visits., Results: The outstanding finding was the low rate (30%) of patients who chose the hospital emergency department as their first choice for care or information if they were worried about an anthrax attack or the media communicated that an attack was in progress. The other two-thirds preferred their family doctor or the health authorities. Most of the physicians (89%) felt it was their responsibility to treat anthrax-infected patients and that they should therefore be supplied with appropriate guidelines., Conclusion: This study suggests that in Israel, a country with a high degree of awareness of civil defence aspects, both patients and primary care doctors believe that family physicians should have a major role in the case of bioterrorist attacks. This must be seriously considered during formulation of relevant health services programmes.

Background: Sleepiness at the wheel is the main cause of approximately a fifth of road traffic accidents. The driver will often feel drowsy before the accident, therefore preventive measures can be taken in order to stay alert., Aim: To estimate sleepiness among sleep deprived drivers and to explore methods they use to stay alert., Methods: We choose three professions at increased risk of sleepiness: physicians working night shifts, night shift nurses and hi-tech workers who work 12 hours or more a day at least twice a week. The subjects answered an anonymous questionnaire concerning past involvement in road accidents or "near misses", known risk factors for road accidents and methods used to fight sleepiness, as well as some demographic data., Results: A total of 115 drivers (38 physicians, 37 nurses and 40 hi-tech workers) participated in this study. The average age was 36.0 + 7.9 years and 53% males. Thirteen percent had been involved in road accidents as drivers in the last year, 53% of them remember that the accident was due to sleepiness or fatigue. Thirty-seven percent remember at least one occasion of "near accident" due to sleepiness. Driving in the "dangerous" hours was positively associated with "near accidents" (69% vs. 29%, p < 0.001) and in accidents (17% vs. 11% P = NS). Physicians were involved in "near accidents" (p < 0.005) more often. The most frequent methods used to overcome sleepiness were: listening to the radio (86.1%), opening the window (65.2%) and turning on the air conditioning in the car (57.4%)., Conclusion: Driving whilst sleepy is an important contributor to road accidents. It seems that sleep deprived workers and especially physicians working in shifts, are at an increased risk. This issue should receive a higher priority as part of preventive medicine among physicians themselves and their patients.

Background: Menopause affects women's health and well-being, but their knowledge of proper care and maintenance is uncertain., Objective: To assess the attitude and approach of the healthy, low risk, postmenopausal population in Israel to personal healthcare and menopause., Methods: The study population comprised 500 menopausal women attending community outpatient primary care clinics. All women completed a 20-item questionnaire covering personal healthcare habits, lifestyle, knowledge about menopause, and attitude and approach to menopause and use of hormone replacement therapy., Results: The patients' mean body mass index was 25.8 +/- 4.1 kg/m2; more than half the women were overweight, 28% engaged in regular sports activity, and 11.2% smoked; 74% had a positive attitude towards their age; 60% underwent yearly screening mammography; 74% had had Pap smear, and 86% had lipid profile measurements during the last year; self-examination of the breast was regularly performed by only 49%. HRT is currently being used by 27% and had been used in the past by another 16%. The primary reasons for stopping therapy were irregular bleeding in 38% and apparent ineffectiveness in 35%. There was a positive significant correlation between level of education and both undergoing regular medical screening and engaging in regular sports activity. HRT current utilization was negatively associated with age and being a housewife., Conclusions: A relatively high percentage of the study population safeguards its health and regularly uses HRT. We believe that stronger efforts are needed in Israel to promote good healthcare habits and positive attitudes toward menopause and HRT use.

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., Patients and Study Design: The population included all children aged 0-18 years living in central or northern Israel and insured by the largest national health management organisation who were prescribed methylphenidate at least once in 1999 or 2001. This was a population-based prevalence study comparing the two timepoints using data from the health management organisation and descriptive statistics., Results: The overall 1-year prevalence of methylphenidate prescriptions dispensed to children was 1.01% in 1999 and 1.22% in 2001 (relative risk [RR] 1.21, 95% CI 1.15-1.26), an increase of 21%. Seventy-seven percent of those prescribed methylphenidate were boys. The prescription rate ranged from 0.2% (RR 1.24, 95% CI 0.76-2.05) in Arabic cities to 5.99% (RR 1.19, 95% CI 1.09-1.30) in kibbutzim; this wide variation by type of residence apparently involved cultural, racial and economic factors., Conclusion: Israel shows no unusual or unexpected patterns in methylphenidate prescriptions dispensed to children and a lesser increase over time than other developed countries. This suggests that limiting physician freedom to prescribe methylphenidate to children may not be justified.

Background: The common feature of the different varieties of non-conventional medicine (NCM) is the lack of recognition, complete or partial, given to them by the institutions of conventional medicine. Treating all varieties in the same way can cause confusion., Aim: To investigate the knowledge and attitudes of family practitioners (FP) in the methods of NCM that are most commonly practiced in Israel., Methods: Anonymous questionnaires were used that tested knowledge and probed attitudes about FP about acupuncture, homeopathy, shiatsu and reflexology., Results: 130 FP participated in the study (response rate 91%). In-depth training of any one of the NCM methods was rare (3-7%). Overall, a very minimal level of knowledge of all four methods was found--58% did not manage to answer even one knowledge question correctly, and the best result was five correct answers out of eight. Most of the doctors recognized NCM as legitimate, and thought that conventional and non-conventional medicine should co-exist side by side. Over 30% saw the possibility of integrating all four NCM methods within the institutions of conventional medicine. No significant difference was found in the doctors' attitudes towards the different methods. Better knowledge was associated with more positive attitudes towards NCM (p < 0.05), and a greater likelihood of referring patients (p < 0.1)., Conclusion: Since attitudes towards NCM seem to be shaped by knowledge to a certain extent, educators should consider teaching more about these treatments both in medical schools and as part of CME.

Background: Erectile dysfunction (ED) is a common problem among male adults that generally has been ignored by family practitioners., Objective: Our aim was to assess the effect of a mailed questionnaire about ED on the readiness of patients to raise the subject with their family doctor., Methods: The study population included all men aged 40 years and over on the patient list of a family practitioner. A control group made up of males of similar ages was chosen in another family practice. The patient files were reviewed for ED. Anonymous questionnaires including questions about sexual dysfunction and satisfaction with sex life, as well as demographic and medical details, were sent to the study population. Patients who suffered from ED were invited to visit their family doctor. In the following 2 months, the study and control group populations' visits to the family practitioner were monitored for complaints of sexual dysfunction., Results: In the 2 years prior to the study, 14/205 (6.8%) of the study population had complained to their family practitioner of ED in comparison with 6/205 (2.9%) in the control group (P = NS). In the 2 months following the sending of the questionnaire, 23 patients consulted their family practitioner with ED, 19 of whom had not discussed their problem with the family practitioner previously; only a further two patients went to discuss ED in the same period in the control group (P < 0.001). A total of 85/205 (41.5%) patients returned the questionnaire and 35/85 (42.5%) said they suffered from ED. Of 35 patients who reported ED, 15 had been for a consultation; only six of them consulted their family doctor., Conclusion: ED is reported infrequently to family doctors. Sending an anonymous questionnaire on the subject increases awareness of the problem and in turn increases the number of cases that can be treated.

Background: Colorectal cancer is the second leading cause of cancer mortality in israel. Unfortunately, compliance with annual fecal occult blood testing is very low., Objective: To assess the effectiveness of interventions to increase FOBT screening in primary care clinics in Israel., Methods: A prospective, randomized study included all 50-75 year old enrollees of six family physicians in two primary care clinics. The register of two physicians, one from each clinic, was allocated to one of three groups. Two FOBT reminder strategies were tested: a physician reminder (753 patients), and a patient reminder that was either a phone call (312 patients) or a letter (337 patients). The control group (913 patients) of physicians continued administering their regular level of care. The main outcome measure was the percentage of patients undergoing FOBT screening in each study arm at the conclusion of the one year study period., Results: In the intervention groups 14.3% (201/1,402) were screened using the FOBT over the course of the study year. Using an intent-to-screen analysis, the screening rate in the physician and patient reminder groups was significantly higher than in the control group (16.5 and 11.9%, vs. 1.2% respectively, P < 0.0001). Phone reminders were significantly more effective than letters (14.7 vs. 9.2%, P = 0.01)., Conclusions: Various reminder systems for FOBT are beneficial, especially those centered around the family physician. Further research should focus on this area, in conjunction with other novel approaches.

Background: Migration leads to changes in almost all areas of life including health. But how far are health beliefs also preserved, and how far are they affected by the process of acculturation to the host society?, Objectives: To examine the difference between behavior and attitudes towards conventional and traditional medicine among elderly Yemenite immigrants., Methods: A community-based study was conducted in the Yemenite neighborhoods in the city of Rehovot. All inhabitants of Yemenite origin over the age of 70 were identified from the population register, excluding those who were institutionalized or demented. Social work students interviewed them at home. The questionnaire inquired after health problems in the preceding month. For each of these problems, the respondent was asked whether any mode of treatment had been employed--Yemenite folk remedies, conventional medical care, or other. Their attitudes towards Yemenite folk medicine and conventional medicine were recorded. Socioeconomic data included their current age, age at immigration, year of immigration, marital status, gender, religiosity, and education., Results: A total of 326 elderly people were identified who fulfilled the selection criteria, of whom 304 (93%) agreed to be interviewed. Of these, 276 (91%) reported at least one health problem in the preceding month, providing 515 problems of which 349 (68%) were reported to a conventional medical doctor while 144 (28%) were treated by popular folk remedies. Fifty-nine problems (11.5%) were treated by specifically Yemenite traditional remedies, mostly by the respondents themselves (38/59) rather than by a traditional healer. Immigrants who arrived in Israel over the age of 30 years, as compared to respondents who immigrated at an earlier age and grew up in Israel, were more likely to use traditional Yemenite remedies (24.4% vs. 8.2%, P < 0.005)., Conclusion: Aged Yemenite Jews in Israel prefer modern medicine. The earlier the immigrant arrived in Israel, the more positive the attitude towards modern medicine and the less use made of traditional Yemenite healing.

Background: Patients' consent to being part of medical education is often taken for granted, both in primary and secondary care. Formal consent procedures are not used routinely during teaching and patients are not always aware of teaching activities., Objective: To investigate patients' attitudes and expectations on issues of consent regarding participation in teaching in general practice, and the influence of a student's presence on the consultation., Methods: The study took place in 46 teaching practices during the sixth year clinical internship in family medicine. Patients completed questionnaires at the end of 10 consecutive eligible consultations. The questionnaire contained data on the willingness to participate in teaching, the preferred consent procedure and the effects of the student's presence. The doctors were asked to estimate the sociodemographic level in their clinic area., Results: A total of 375 questionnaires were returned; the response rate was not affected by the clinic's sociodemographic level. Overall, 67% of the patients had come into contact with students in the past; 3.2% of the participants objected to the presence of a student during the consultation; 15% would insist on advance notification of the presence of a student, and another 13.9% would request it; 4% stated that the presence of students had a detrimental influence on the physical examination and history; and 33.6% would refuse to be examined by a student without the doctor's presence., Conclusion: Most patients agreed to have a student present during the consultation; some would like prior notification; a minority refused the student's presence. A large minority would refuse to be examined without the tutor's presence. Our findings need to be taken into account when planning clinical clerkships.

Background: Urinary incontinence in older women is common. Its characteristics and impact on quality of life is not well established since these women are usually reluctant to tell their healthcare providers about the problem., Objective: To determine the characteristics of urinary incontinence in women and the manner in which it affects patients' quality of life., Methods: Twenty family physicians were requested to distribute a questionnaire to the first 25 consecutive women aged 30 to 75 years who visited their clinic for any reason. The questionnaire covered general health issues, symptoms of urinary incontinence, and quality of life., Results: A total of 418 women, mean age 50.0 +/- 11.8 years, completed the questionnaire (84% response rate). Of these, 148 (36%) reported having episodes of urinary incontinence. Urinary incontinence was found to be associated with older age, menopause, obesity and coexisting chronic disorders. Sixty percent of the women with urinary incontinence found it to be a disturbing symptom, and 44% reported that it had a detrimental effect on their quality of life. Only 32% of the affected women had sought medical advice, half of them from their family physician. Treatment was recommended to 66% of those who sought help, and in about two-thirds of these it brought some measure of relief., Conclusions: Urinary incontinence is a common complaint among women attending primary care clinics, but it does not receive appropriate attention. Though it often adversely affects quality of life, only a small proportion of women seek medical advice. Family physicians should raise the issue as a part of the routine general health check-up.

Background: The consultation is the pivot of clinical teaching in ambulatory care. It is therefore essential that students observe the consultation. The students' presence itself influences the consultation and also requires the patients' consent. Moreover the introduction in Israel of the "Patients' Rights Act" in 1996 has made us more acutely aware of the place of the patient in teaching especially with regard to the consent to be part of the teaching process., Aim: This study was undertaken in order to investigate how tutors in family medicine perceive changes in the consultation caused by the presence of students., Methods: An anonymous physician questionnaire was distributed on the first day of the 6th year clinical clerkship in family medicine. The questions pertained to perceived influence on length and content of the consultation. In addition physician and patient background information was gathered; and the physicians were asked to estimate the patients' willingness to be part of the teaching process., Results: 46 tutors in family medicine participated, 70% of whom were female. Sixty four percent of the doctors thought that the student's presence had an influence on the consultation. Ninety one percent thought that it increased consultation length, especially of the physical part (93%). More than half thought that the student's presence might interfere with asking intimate questions. The majority held the opinion that the patient's gender and socioeconomic background were inconsequential. Ninety two percent of physicians estimated that 5% or less of the patients would refuse the presence of a student., In Conclusion: Tutors in family medicine think that the presence of a student affects the consultation. Those involved in and responsible for teaching should take this into account. Further research of these changes with objective measurements is needed.

Screening for the early detection of colorectal cancer using the fecal occult blood test has been shown to be effective in reducing mortality. In Israel family physicians recommend that their patients, aged 50-75, have the test performed annually. But compliance with testing in the general population has been poor. We therefore studied this issue in 3 primary care facilities, in 384 patients, average age 62.7 +/- 6.9 years; 81 (21.1%) performed the fecal occult blood test. Performance rates were significantly lower (13.9%) in those aged 50-59 (p = 0.0003), as compared with those aged 60-69 and 70-75 (24.3% and 24.7%, respectively). Compliance rates of the patients of different physicians varied as well. Recommendation of family physicians led to overall compliance of 21.1%. Additional efforts are needed to increase compliance in order to decrease colorectal cancer morbidity and mortality in Israel.

Background and Objectives: During February 1998, there was heightened tension in the Persian Gulf area. Iraq's ruler, Saddam Hussein, threatened Israeli citizens with the use of biological weapons. This study observed the use of health care services by patients visiting our clinics during this period., Methods: During the period of February 17, 1998, through March 1, 1998, 12 family physicians classified all clinic visits as "related" or "unrelated" to the crisis. The participating clinics were situated in (A) high-risk and (B) low-risk areas, according to their location as related to missile hits during the 1991 Gulf War., Results: A total of 1,841 visits were recorded during the crisis period (February 17-23). There were 934 visits in Area A and 907 in Area B. Overall, 194 visits related to the crisis were recorded, of which 155 were in Area A. The rate of crisis-related visits was higher in Area A (16.6% versus 3.4%). There were more visits for authorizations for special masks (8.2% versus .8%), requests for information (3.9% versus 1.3%), and tranquilizers (2.1% versus .5%). In the period subsequent to the agreement reached on February 24, crisis-related visits declined sharply in both areas., Conclusions: During the crisis, there was an increase in visits related to the threat of biological warfare. The phenomenon was more pronounced in areas that had sustained missile hits during the 1991 Gulf War.

Clinical guidelines are systematically developed statements designed to help practitioners and patients make decisions about appropriate health care for specific clinical states. Attitudes of family physicians to clinical guidelines for treating diabetes and guidelines in general were evaluated from anonymous questionnaires answered by physicians participating in continuous medical education throughout the country (May-June 1998). The questionnaire dealt with attitudes to the recently published specific guidelines for treating the diabetic patient and overall perception of the efficacy of clinical guidelines. 293 family physicians, aged 40.2 +/- 7.0 responded (83%). 93.5% appreciated the guidelines and thought them applicable. Most (83.7%) reported the guidelines to be of help in their daily work; 31.4% said they were oversimplified; a quarter said they aimed mainly at containing costs. Most respondents preferred written guidelines of up to 5 pages. In view of our results, attention can now be turned to developing ways to implement the guidelines. To improve adherence, they need to be short and the rate of publication of new clinical guidelines should be slowed.

Background: Most countries today are experiencing an accelerated pace of population aging. The management of the elderly housebound patient presents a special challenge to the family physician., Objectives: To investigate a series of home visits to housebound patients, the therapeutic procedures used, the equipment needed, and the diagnostic conclusions reached., Methods: The details of 379 consecutive home visits to housebound patients were recorded by 91 family doctors serving 125,000 patients in Israel., Results: The average age of the patients was 76.1 years. The vast majority of the visits were during office hours (94%). In 24.1% it was the doctor who decided to make the home visit on his/her own initiative. The most common initial reason for a home visit was undefined general symptoms, but the doctor was usually able to arrive at a more specific diagnosis after the visit. Medications were prescribed in 59.1% of the visits, and in 23.5% the medication was administered directly by the physician. The commonest drugs used were analgesics and antibiotics. In 19.3% of visits no action at all, other than examination and counseling, was undertaken. The equipment needed included prescription pads (73%), a stethoscope (81%), sphygmomanometer (74.9%), and otoscope/torch (30.6%). Only 15% of visits resulted in referral to hospital., Conclusions: Home visits to housebound patients serve as a support to caregivers, provide diagnostic information, and help the family with the decision as to when hospitalization is appropriate. The specific medical cause for the patient being housebound had little effect on the process of home visiting.

The Israeli health system has been undergoing major changes in recent years. Considerations of cost containment have led sick funds to open new out-of-hours services in the community to reduce visits to hospital emergency departments. Referred and self-referred visits to our emergency department during a 1-month period were studied. Patients after trauma or whose visits resulted in hospitalization were excluded. Of the 505 encounters 56.3% were of women; the average age was 52.5 +/- 19.3 years (range 18-96). 57.4% visits were during working hours of primary care clinics ("working hours"), while the others were "out-of-hours" visits. Only 52.7% had a referral letter, 75% of them from the family physician. The quality of the handwriting in 46% was good, in 44% fair and the remaining 10% were illegible. A specific clinical question was asked in only 16% of the letters. A third of "working-hours" visits were self-referrals, rising to 64% in "out-of-hours" visits (p < 0.001). The most common diagnoses in discharge letters were: chest or abdominal pain, asthma, back pain, headache, nephrolithiasis and upper respiratory tract infection. The rate of self-referrals was relatively high throughout the day. Cost-containment efforts did not seem to eliminate self-referrals with "primary care" problems. The quality of referral letters should be improved both with regard to format and content.

The content of all consultations of a family physician during the first 2 months in a new practice and again in the same 2 months, 2 years later were analyzed. The workload did not change between the 2 periods, but in the first period there were relatively more men over the age of 60 years, and a more marked predominance of women in the 45-59 year age-group. There were more follow-ups of pre-existing conditions during the first period, but in both periods the main reason for visits was an acute condition; a quarter of visits required only simple counseling without further investigation or prescribing of medication. During the first period 9% of visits were for the explicit purpose of getting to know the new physician, usually by women. Thus the initial period in a new practice is not excessively burdensome, but involves seeing a number of patients who come either simply to get to know the new doctor, or to present non-chronic problems without expectation of further investigation.

Background and Objectives: The past 20 years have seen a large immigration of Ethiopian Jews to Israel, primarily in 2 airlifts, one in 1984-1985 and one in 1991. Infectious and parasitic diseases were the dominant health problems in the early years. Recently, we noticed changing health patterns in this population, particularly an increase in clinic visits for asthma, which contrasted with asthma rates of 2.5% reported among Ethiopian Jews at the time of immigration to Israel. This study evaluated the prevalence and characteristics of asthma in a population of Jews of Ethiopian origin who had been in Israel for 8-17 years., Methods: We audited 302 files of adult patients of Ethiopian origin and 604 files of age- and gender-matched patients of non-Ethiopian origin. Each file was reviewed by 2 physicians. Asthma was defined by published clinical criteria as found in the patient file. Data on allergies and eosinophilia were collected as well., Results: The average age of the 2 groups of asthmatics was 44.1 +/- 16.2 and 42.4 +/- 20.7 years, respectively. The prevalence of asthma in the patients of Ethiopian origin was 51/302 (17%), compared with 35/604 (5.8%) in the control group. Thirty-three percent of the Ethiopian asthmatics and 37% of the control group suffered from various allergic diseases. Among the patients of Ethiopian origin, the prevalence of eosinophilia was 44%, with no significant difference between asthmatics and non-asthmatic patients (49% versus 43%). Eosinophilia was found in 8.4% of the control group. Asthma was more prevalent among patients with eosinophilia (22%) than without eosinophilia (6.4%)., Conclusions: Asthma is 3 times as prevalent in adults of Ethiopian origin, compared with the general population in our clinics, and markedly increased above the rate reported for newly immigrated Ethiopian Jews. We conclude that the move from the rural hills of Ethiopia to the more urban and industrialized setting of Israel has resulted in an increased prevalence of asthma in this population, but the specific cause is uncertain.

Few reports have suggested that nulliparous young patients with endometrial cancer may be treated conservatively to preserve fertility. We present a young nulliparous woman with a well differentiated adenocarcinoma of the endometrium treated with progestins. Since she did not respond, a definite operation was performed revealing involvement of the uterine isthmus, thus necessitating adjuvant radiotherapy.

Direct self-referral to a consultant is common in the Israeli health system. Yet patients' reasons for their urgent, unscheduled self-referrals for ambulatory consultations (UUSR) have not been explored. We studied such consultations in an urban multi-disciplinary consultation center serving a population of approximately 100,000. Over a 3-month period such consultations in ophthalmology, ear-nose-and-throat and dermatology clinics were treated by a duty family physician (FP). The FP was instructed to focus on the urgent complaint and either to give definitive treatment and schedule a consultation when needed, or refer the patient for immediate specialist consultation. Patients treated by the FP were asked to fill an anonymous questionnaire, which 347/645 (55.4%) did. Among the reasons for UUSR were that the patient thought that his/her complaints should be treated by a consultant (29%), the patient was sent by the FP without a consultation note (13.9%), the FP was not available (10.4%), or the patient wished to see the consultant for a second opinion (8.2%). In only 7.8% had the patient noted that his complaint needed urgent consultation. Duration of complaints, but not prior efforts to schedule a consultation, were associated with different reasons for asking for an UUSR. For various reasons patients preferred an UUSR rather than seeing their own FP. Patients' opinions regarding self-referrals are important in planning primary care facilities and FP training.

Music is a universal language, and its effects on pain relief and stress reduction are well known. We evaluated patients' opinions of the effects of background music in their family doctors' surgery. Low volume, background, classical music was played in the doctors' surgery on 5 consecutive clinic days. All patients were asked to fill a short anonymous questionnaire on leaving. Among the 135 consecutive patients offered the questionnaire, there was 87.4% compliance. Among the 118 who completed the questionnaire, 95% said that the background music did not disturb them, 89% thought it made them feel better and 80% thought that it aided the doctor's performance. We conclude that low volume, background music in the doctors's surgery may contribute to better doctor-patient interaction, although larger studies are needed to confirm our findings.

Results of laboratory tests ordered during a primary care encounter may reveal findings of abnormal liver function tests, including elevated liver enzymes, hyperbilirubinemia, hypoalbuminemia or abnormal coagulation tests. The object of this study was to describe the spectrum of these liver function test (LFT) abnormalities in primary care. Results of all laboratory tests ordered during 10 months in an urban primary care clinic were retrospectively reviewed and the medical charts of patients with abnormal LFTs were studied. In 217/1088 (20%) of the tests at least 1 LFT abnormality was found in 156 patients. New diagnoses were made in 104 patients. The main diagnostic groups were: non-alcoholic fatty liver changes, Gilbert's disease, acute infectious hepatitis, alcoholic liver disease and cirrhosis and hepatotoxic drug injury. In 60 patients the physician classified the abnormality as negligible and not associated with significant disease. However, an abnormal test that had been ordered for evaluation of a specific complaint, was indeed likely to represent significant disease (X2 = 29.5, p < 0.001). We conclude that finding abnormalities in liver function tests is common in the primary care clinic but does not often indicate significant liver disease.

Direct self-referrals to a consultant, especially on an urgent basis, has not been widely explored before. The health insurance system in Israel permits elective direct self-referrals to various specialists, but the range and reasons of urgent self-referrals has not yet been evaluated. Our aim was to evaluate urgent self-referrals to ambulatory consultants and to see to what extent a qualified family physician can triage and treat those patients. The setting was an urban ambulatory multi-disciplinary consultation center in the city of Ashdod in central Israel, serving a population of approximately 150,000. Over a three-month period, all patients who made urgent self-referrals for an ambulatory consultant in Ophthalmology, Ear, Nose and Throat (ENT) and Dermatology were triaged by an on-duty qualified family physician. The physician was instructed to take care of the patient in one of three ways: 1) immediate referral to a specialist; 2) begin treatment and schedule the patient for a specialist consultation; 3) administration of definitive treatment. Eight hundred and ninety-eight patients aged 46 +/- 22 years were treated by the triaging family physician. Forty-six percent had ophthalmological symptoms, 26% had dermatological symptoms and 20% had ENT-related symptoms. A symptom duration of less than 24 hours was reported by 36% of the patients. Eye problems were more commonly of short duration (p < 0.001). Sixty percent of the patients were given a definitive treatment, another 19% were given immediate treatment and scheduled for elective consultation with a specialist and 21% were referred for an immediate specialist consultation. Of the immediate consultations, 73% were ophthalmological and 27% came from a range of other complaints (p < 0.001). Our conclusion was that a family physician can treat most of the urgent self-referrals to ambulatory consultations in the three domains that were evaluated. A triage system is particularly suitable for urgent self-referrals to ENT as well as dermatological problems.

The use of oral anticoagulant therapy (OAT) to prevent thromboembolism has been widespread in recent years. The concept of high- and low-intensity regimens has facilitated treatment for many, and has lowered the hazards of overly intense anticoagulation. However, a significant proportion of patients suited to the low intensity regimen are not being treated. It is not clear whether its wider use is limited by continued debate, lack of resources, lack of expertise, or other causes. We retrospectively reviewed the medical records of 32 patients treated with OAT administered in the primary care setting. The average age was 66 +/- 11 years (range 34-84). 9 were treated with high-intensity OAT: 8 due to artificial heart valves, and 1 due to a hypercoagulable syndrome with recurrent thromboembolism. 23 were treated with low-intensity OAT, 17 of whom had atrial fibrillation. 11 were also being treated continuously with other medication which interacted with OAT or interfered with other coagulation pathways. Such medication included: aspirin, dipyridamole, amiodarone, bezafibrate and allopurinol. Of 414 coagulation tests, 57% and 65% were in the therapeutic range in the high- and low-intensity OAT groups, respectively. There was no major bleeding event, but in 2 of 8 who bled, gastrointestinal bleeding led to hospitalization. Treatment was discontinued in 1 patient because of difficulties in achieving target INR, and in the 2 hospitalized for bleeding. The percentages of test results in, above and below the therapeutic range were similar to those in other large series, for both intensity regimens. We found that a significant proportion of patients were under chronic treatment with other medication which interacted with OAT. To estimate the rate of complications in primary care OAT, larger series are needed. We conclude that OAT can be given and monitored by the family physician, and that awareness of long and short term drug interactions with OAT is mandatory.

The primary care clinics of the Israeli Defense Forces are similar to those of the civilian health system, yet some characteristics are unique: Soldiers are a young, healthy population; their physicians are either serving in the reserves for short periods, or are primary care physicians of the regular army; and during military service the soldier is usually treated in several different primary care clinics. A detailed medical record facilitates communication between the various primary care physicians. As part of a 2-year quality assurance project all naval clinics in Israel were surveyed at 6-month intervals. From the clinic records, 685 encounters involving the 7 most common problems were randomly chosen. We evaluated the quality of the medical records of these encounters scoring them according to subjective, objective assessment and therapeutic and evaluative plan (SOAP) Each record was evaluated by 2 physicians and scored from 0 to 100, using fixed criteria. The score for the therapeutic and evaluative plan was significantly higher than that of the other parts of the medical record (80% vs. 55-59%, p < 0.001). The score of the primary care physicians was significantly higher than that of physicians of the reserves (73% vs. 63%, p < 0.001). Encounters involving upper respiratory tract infections and abdominal pain scored higher than those involving other common problems. The medical recording process has a fundamental role in medical care. Our findings suggest that the subjective, objective and assessment parts of naval medical records need improvement. Further studies might help improve the quality of primary medical care.

The intrauterine contraceptive device (IUCD) is the most popular, reversible contraceptive method, worldwide. Leaving an IUCD in-utero even beyond the time recommended by the manufacturer has been found both safe, and effective in terms of contraceptive ability. In 1995 we screened the medical records of the gynecologic infirmaries of 4 agricultural settlements (kibbutzim) and found 78 women who had worn an IUCD continuously for more than 5 years. All had been regularly examined every 6 months. Most of the IUCDs (63, 80.7%) were copper-containing. Mean IUCD wear was 7.9+/- 2.6 years (range, 5-17 years). At the time of the study, 38 (48.7%) of the IUCDs were still in utero. Related complications were 3 cases of dysmenorrhea (3.8%) and 20 of metrorrhagia. No pregnancies or pelvic infections were recorded. This study also shows that wearing an IUCD beyond the time recommended by the manufacturer is not associated with loss of contraceptive effectiveness. Furthermore, the rate of IUCD-related complications after 5 years of wear was not higher than during the first 5 years. To support these findings further studies with larger samples are needed.

Palmar fasciitis and polyarthritis (PFPA) is an uncommon syndrome characterized by progressive and extensive rheumatic disease. It has usually been associated with neoplasms, most commonly in elderly patients, preceding or accompanying the diagnosis of malignancy. We report a case of a 25-year-old patient with severe deforming PFPA preceding the diagnosis of carcinoma of the ovary. The histopathological findings of diffuse fibrosis, connective tissue proliferation and vasculitis with C3 and IgM deposits in subcutaneous tissue and synovia may further clarify the possible pathogenesis of this unique syndrome.