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BACKGROUND: Mortality rates used to evaluate and improve the quality of hospital care are adjusted for comorbidity and disease severity. Comorbidity, measured by International Classification of Diseases codes, do not reflect the severity of the medical condition, that requires clinical assessments not available in electronic databases, and/or laboratory data with clinically relevant ranges to permit extrapolation from one setting to the next. AIM: To propose a simple index predicting mortality in acutely hospitalized patients. DESIGN: Retrospective cohort study with internal and external validation. METHODS: The study populations were all acutely admitted patients in 2015-16, and in January 2019-November 2019 to internal medicine, cardiology and intensive care departments at the Laniado Hospital in Israel, and in 2002-19, at St. James Hospital, Ireland. Predictor variables were age and admission laboratory tests. The outcome variable was in-hospital mortality. Using logistic regression of the data in the 2015-16 Israeli cohort, we derived an index that included age groups and significant laboratory data. RESULTS: In the Israeli 2015-16 cohort, the index predicted mortality rates from 0.2% to 32.0% with a c-statistic (area under the receiver operator characteristic curve) of 0.86. In the Israeli 2019 validation cohort, the index predicted mortality rates from 0.3% to 38.9% with a c-statistic of 0.87. An abbreviated index performed similarly in the Irish 2002-19 cohort. CONCLUSIONS: Hospital mortality can be predicted by age and selected admission laboratory data without acquiring information from the patient's medical records. This permits an inexpensive comparison of performance of hospital departments.

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Closure of patent foramen ovale (PFO) is expected to prevent paradoxical emboli. In the absence of randomized trials, its efficacy has been assessed by comparing uncontrolled cohort studies of medically treated patients with those treated by PFO closure. The objective of this study was to highlight a confounder of such studies, namely, the variability in the duration of follow-up. We searched the literature for cohort studies of patients with ischaemic strokes, including those with PFO. During the first year of follow-up, recurrence hazards in patients younger than 55 years were 1-4% in those with any ischaemic stroke, 1-6% in medically treated patients with PFO and 0-5% in those after PFO closure. In most studies, the recurrence hazards were highest immediately after the index stroke and declined thereafter. Still, hazards were commonly reported in terms of annual averages over a wide range of follow-up periods for the various cohort studies, thereby ignoring the possibility that the duration of the follow-up may in and of itself affect the derived average recurrence hazards. A disregard of the time variance of stroke recurrence may confound the conclusions from comparisons between uncontrolled studies of patients with stroke and PFO.

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Clinical decision analyses use time horizons that vary from hours to the patient's entire life. Analyses of decisions with a lifetime horizon commonly use Markov models, which simulate the patient's lifespan by dividing it into equal periods (cycles). At each cycle, the model exposes a hypothetical cohort to the competing hazards of normal aging and of the disease in question (disease-specific hazards), and the results are presented as years of life expectancy. This paper highlights two limitations of lifetime Markov models that have been ignored in recent publications. First, since there are no readily available data on changes in disease-specific hazards over time, these hazards are often derived from short-term follow-up studies, and assumed to be constant over the patient's entire life. Second, results may be better presented in terms of health states (i.e. proportions of patients expected to recover completely, recover with a disability or die) rather than life expectancy. Although well-known, these two limitations require re-emphasis. They may be avoided by restricting the time horizon of decision analyses and presenting results as health states as well as life expectancies. When a lifetime horizon is necessary, the performance of Markov models may be improved by the using of time-variant disease-specific hazards derived from long-term follow-up studies, or from theoretical models that simulate more closely the disease progression over time, rather than assuming constant disease-specific hazards.

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BACKGROUND: Patients who feel involved in their treatment have better outcomes than those who do not. OBJECTIVE: To identify determinants of perceived patient involvement in obstetric care. METHODS: A retrospective study was undertaken in 1,452 (83%) of 1,750 women sampled in November 1995 from maternity wards of 14 general hospitals in Israel. A postal and telephone survey using a self-administered questionnaire included the following variables: hospital (identity number), patients' age, self-reported complications, previous deliveries, education, ethnicity, and number of obstetric interventions performed and/or considered. The main outcome measured was the reported involvement in decisions for obstetric interventions. RESULTS: Reported full involvement varied from 72% for epidural analgesia to 13% for forceps/vacuum extraction. Factor analysis identified two dimensions of perceived involvement: one for "routine" interventions (enema, monitoring, IV line and episiotomy), which are performed in Israel mostly by midwives, and another for "special" interventions (forceps/vacuum extraction, epidural or other analgesia, and cesarian section) performed by physicians. Logistic regression identified hospitals, younger age, number of interventions, and Arab ethnicity as correlates of a perceived non-involvement in decisions for "special" interventions. CONCLUSIONS: Clinical setting, age and ethnicity affected patient perception of involvement in decisions for obstetric interventions.

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The authors' threefold purpose in this article was to (a) propose a model of the relationship between the emotional aspects of physicians' attitudes to medical errors (e.g., fear of litigation) and their functional consequences (e.g., tendency to defensive practice); (b) develop a measure of some of these attitudes; and (c) provide empirical support for some of the relationships in the model. Medical students and physicians responded to a questionnaire concerning their attitudes toward uncertainty and medical error. The dependent variables were two dimensions of attitudes to uncertainty ("reluctance to disclose uncertainty" and "stress from uncertainty") and four dimensions of attitudes to medical error ("fear of litigation," "support for self-regulation," "tendency to defensive practice," and "self-disclosure of errors"). Stress from uncertainty correlated with fear of malpractice litigation and defensive practice. They concluded that interventions that aim to increase physicians' tolerance of uncertainty may also reduce their fear of malpractice litigation and their tendency to defensive practice.

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BACKGROUND AND OBJECTIVE: We describe an approach for the resolution of difficulties that some preclinical medical students appeared to have when acquiring patient interviewing skills. SETTING: Two medical schools in Israel. TYPE OF STUDY: Descriptive. OBSERVATIONS: Students' difficulties were related to the inconsistency between the patient-centered approach that was emphasized in the preclinical teaching programs and the disease-centered (biomedical) approach that was practiced on the wards. Others were confused by ambiguous vocabulary and by the multiplicity of rules that they had to remember. Still others appeared to resent attempts to teach them what they thought was elementary courtesy, to reject counterintuitive interviewing rules, and to be bored by the repetitive nature of the practice sessions. TEACHING INTERVENTION: We used an integrated learner- and teacher-centered approach, which is based on the premise that students learn more effectively when autonomous and self-motivated than when responding to instructions from others. Rather than the students being lectured, they were asked to identify the problems in doctor-patient communication and to propose solutions. We conducted live demonstrations of patient- and disease-centered interviews and encouraged students to discuss the advantages and disadvantages of each of them. Lastly, we supervised students as they interviewed patients with increasingly difficult communication problems. CONCLUSIONS: The described approach is consistent with current theories of adult learning. It permits the instructor's input and also supports students' autonomy in identifying and resolving problems in patient interviewing and in choosing the balance between patient- and disease-centered interviewing styles according to the patient's needs. The feasibility of our approach is conditional on the availability of instructors who feel comfortable conducting group discussions, are familiar with the literature on doctor-patient relations, and are experienced enough to demonstrate different interviewing techniques using live patients.

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BACKGROUND: The degree to which serum total cholesterol predicts cardiovascular disease is uncertain. While most authors have placed TC among the most powerful risk indicators of CVD, some have claimed that it predicted CVD in women only, or even not at all. OBJECTIVE: To determine the predictive value of serum total cholesterol relative to diabetes, smoking, systolic blood pressure and body mass index (kg/m2), for cardiovascular disease mortality in 3,461 occupationally active Israeli males. METHODS: A prospective follow-up was carried out for the years 1987-1998 to determine the effect of age, smoking habits, a history of diabetes, SBP, BMI and TC, at entry, on CVD mortality. RESULTS: There were 84 CVD deaths during a total of 37,174 person-years follow up. The hazard ratios (95% confidence intervals) for CVD mortality with respect to variables at entry were: diabetes 5.2 (2.1-13.2), age 2.2 (1.7-2.9), smoking 1.3 (1.0-1.8), SBP 1.4 (1.1-2.0), TC 1.5 (1.0-2.1) and BMI 1.2 (0.7-2.2). Among non-obese, non-diabetic, normotensive subjects the hazard ratio of TC adjusted for age and smoking was 1.16 (1.09-1.22) per 10 mg/dl. In the remaining subjects it was 1.04 (0.98-1.12) only. There was a significant interaction between TC and diabetes, hypertension or obesity (P = 0.003). CONCLUSIONS: In this population of Israeli males we found an interaction between TC and other risk indicators for CVD. Confirmation is required for the unexpected finding that the predictive value of TC for CVD mortality among non-diabetic, non-obese and normotensive subjects exceeded that among subjects with either of these risk factors.

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BACKGROUND AND OBJECTIVE: Preventive measures are commonly classified into primary (prevention of a disease from occurring), secondary (screening of asymptomatic persons with a view of early detection and treatment of disease), and tertiary (treatment of patients with a view of palliation, cure, rehabilitation, prevention of relapse, or prevention of complications). The objective of the present survey was to assess the adherence to this classification in a sample of abstracts of scientific publications. METHOD: We searched the literature (key terms prevention and primary, secondary, or tertiary) and identified 317 abstracts describing various preventive interventions. We tabulated the level of prevention as defined in the abstract, by what was done, to whom, and why. MAIN FINDINGS: There was a considerable variability in the way the various levels of prevention were defined in the reviewed abstracts. CONCLUSIONS: The definitions of the levels of prevention are not specific enough to be appropriately used by all. We suggest, therefore, to define clinical interventions by their objective, target population, and type ("reduction of mortality of patients with symptomatic ventricular ectopy by beta-blockers"), rather than in terms of level of prevention ("tertiary prevention of ventricular ectopy").

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BACKGROUND: The increasing utilization of general internal medicine hospital wards in Israel during the last decade is a source of concern for health policy makers. OBJECTIVES: To report on the distribution of selected main and secondary diagnoses among GIM inpatients, and to estimate the proportion of disorders for which appropriate care in the community will reduce the need for hospital admissions and re-admissions. METHODS: Data from the Health Information and Computer Services of the Israel Ministry of Health (national hospitalization database) for a one year period were analyzed by distribution of diagnostic entities (ICD-9-CM) in GIM and in medical subspecialty wards. RESULTS: Of the 313,824 discharges from hospital divisions of medicine in 1995, 256,956 (81.9%) were from GIM and 56,868 (18.1%) from specialty wards. Main and secondary discharge diagnoses were available for 188,807 GIM and 35,992 specialty patients. Of all main diagnoses in GIM wards, 27% were coded as "general or systemic symptoms and signs" or as "abnormal laboratory or ill defined manifestations" (ICD-9-CM codes 780-799, 276,277), and heart diseases comprised another 27%. The remaining main diagnoses covered almost all medical conditions. The combined proportion of "ambulatory care sensitive hospital admissions" (bronchial asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, diabetes) constituted 12% of all main diagnoses in GIM, and respiratory symptoms or signs comprised another 11%. A by-product of this analysis was an insight into the experience of undergraduate medical students in GIM. CONCLUSIONS: Assuming that 12-75% of admissions for "ambulatory care sensitive disorders" are preventable, an improved review before hospital discharge and a closer outpatient follow-up may reduce the load on GIM wards by 1-17%. This wide range justifies controlled trials to determine the effect of improved community care on hospital utilization. GIM wards offer valuable learning opportunities, but they cannot be a substitute for primary care clinics. The unexplained high proportion of GIM inpatients who were discharged with an unspecified main diagnosis could be detrimental for the accuracy of hospitalization statistics, and justifies investigation by chart audits into physicians' habits of documentation.

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We reviewed the recent literature on hospital readmissions and found that most of them are believed to be caused by patient frailty and progression of chronic disease. However, from 9% to 48% of all readmissions have been judged to be preventable because they were associated with indicators of substandard care during the index hospitalization, such as poor resolution of the main problem, unstable therapy at discharge, and inadequate postdischarge care. Furthermore, randomized prospective trials have shown that 12% to 75% of all readmissions can be prevented by patient education, predischarge assessment, and domiciliary aftercare. We conclude that most readmissions seem to be caused by unmodifiable causes, and that, pending an agreed-on method to adjust for confounders, global readmission rates are not a useful indicator of quality of care. However, high readmission rates of patients with defined conditions, such as diabetes and bronchial asthma, may identify quality-of-care problems. A focus on the specific needs of such patients may lead to the creation of more responsive health care systems for the chronically ill.

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BACKGROUND: Tolerance of uncertainty is believed to be an important attribute of practicing physicians. This study attempts to (1) estimate how medical students perceive physicians' tolerance of uncertainty and (2) measure the tolerance of uncertainty of practicing physicians. RESEARCH DESIGN: Cross-sectional. SETTING AND SUBJECTS: Medical students (n = 113) and practicing physicians (n = 151) at the Faculty of Health Sciences, Ben-Gurion University, Israel. MEASURES: A self-administered, Hebrew version of an instrument developed in the United States. INDEPENDENT VARIABLES: Age, gender, seniority (year of study for students or years in practice for physicians), country of birth for students or of graduation for physicians, and physicians' specialty. DEPENDENT VARIABLES: Two dimensions, which were identified by factor analysis: reluctance to disclose uncertainty and stress from uncertainty. RESULTS: The estimates of physicians' stress from uncertainty by first-year students aged <22 years were higher than those by first-year students aged > or =22 years. There were no significant differences in the way junior and senior medical students perceived physicians' tolerance of uncertainty. Stress from uncertainty was higher in female physicians (P = 0.028) and in graduates of the former Soviet Union (P = 0.044) than among male physicians and Israeli graduates, respectively. Reluctance to disclose uncertainty was higher among graduates of the former Soviet Union (P = 0.003) and among psychiatrists (P = 0.021) than among Israeli graduates and other specialties, respectively. CONCLUSIONS: The reliability and factor structure of the instrument were replicated. The previously reported differences in tolerance of uncertainty between women and men and between local and foreign graduates were confirmed. Physicians' tolerance of uncertainty appeared to be higher than that attributed to them by students. The expected age-related differences in perception of clinical uncertainty were not detected between junior and senior medical students.

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BACKGROUND: In 1995 hospital costs constituted about 42% of the health expenditures in Israel. Although this proportion remained stable over the last decade, hospital discharge rates per 1,000 population increased, while hospitalization days per 1,000 population and average length of stay declined. OBJECTIVE: To gain an insight into the forces behind these changes, we compared the trends in hospital utilization in Israel with those in 21 developed countries with available data. MATERIALS AND METHODS: Our data were derived from The "Hospitals and Day Care Units, 1995" report by the Health Information and Computer Services of the Israel Ministry of Health, and the Organization for Economic Cooperation and Development Health Data, 98. We examined the numbers of acute care hospital beds, of patients on dialysis and of doctors' consultations, health expenditures and age structure of the population in 1995 or closest year with available data, as well as changes in DRs, HDs and ALOS between 1976 and 1995. RESULTS: In Israel the DRs increased from 130 in 1976 to 177 in 1995 (36%), HDs declined from 992 to 818 (18%), and ALOS declined from 7.60 to 4.51 days (41%). Relative to other countries, in 1995 Israel had the lowest ALOS; low HDs similar to those in the UK, Portugal, Spain, the USA and Sweden; and intermediate DRs similar to those in Belgium, Germany, Sweden and Australia. The number of acute care beds per 1,000 population was directly related to HDs (r = 0.954, P = 0.000) and to DRs (r = 0.419, P = 0.052). Health expenditures (% of the gross national product) correlated with the number of patients on dialysis per 1,000,000 population (r = 0.743, P = 0.000). Between 1976 and 1995, HDs and ALOS declined in most countries, however the trends in DRs varied from an increase by 119% in the UK to a decline by 29% in Canada. CONCLUSIONS AND HYPOTHESES: The increase in DRs in Israel from 1976 to 1995 was shared by many but not all countries. This variability may be related to differences in trends in local practice norms and in available hospital beds. If the number of patients on dialysis is a valid index for use of expensive treatment modalities, the correlation of health expenditures with the number of patients on dialysis suggests that the use of expensive technology is a more important determinant of health care costs than the age of the population or hospital utilization. Since the use of expensive technology is highest during the first few days in hospital, decisions about health care policy should consider the possibility that the savings incurred by a further decline in HDs and ALOS may be offset by a possible increase in per diem hospital costs and in health care expenditures after discharge from hospital.

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Rehabilitation after acute myocardial infarction (AMI) consists of education, exercise, and an encouragement to return to work (RTW). This study attempts to (1) determine whether the time interval between AMI and the visit at occupational medicine (OM) clinics predicts resumption of full employment, and (2) estimate the incidence of work-related recurrent AMI after RTW. We followed 216 consecutive AMI patients at a single OM clinic. The independent variables were clinical and personal data, physical workload and time between AMI, and first visit to the OM clinic. The outcome variables were full employment 24 months after the acute event and recurrent AMI during this period. Of all patients, 168 attempted RTW. Of these, 18 stopped working subsequently. Of the remaining 150 patients, 54 returned to part-time work and 96 were employed full-time after 2 years. Logistic regression indicated that a failure to resume full employment was independently associated with diabetes, older age, Q wave AMI, angina before AMI, heavy work, and a late visit to the OM clinic. For each month's delay in referral to the OM clinic, there was a 30% decrease in the chance for full employment 24 months after AMI. Six (4%) of the 150 patients who resumed employment sustained a recurrent AMI, two of them while at work. A delayed referral to the OM clinic was associated with work disability after AMI. Late referrals to OM clinics should receive a more intensive and sustained rehabilitation than early referrals. Whether an earlier referral to OM clinics will result in increased RTW rates is unknown. Patients who attempted to resume employment had a 1.2% risk of a recurrent ischemic event at their workplace.

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HYPOTHESIS: Periodic complete blood counts are not recommended for disease prevention in low-risk, non-pregnant adults. Consequently, there are few follow-up studies of the prevalence of incidentally detected anemia in asymptomatic subjects and its significance for their well-being. The objective of this survey is to determine the frequency of anemia and its predictive value for disease over a 15-yr annual follow-up of a cohort of asymptomatic young males, selected for physical fitness and intelligence. METHODS: One thousand Israeli airmen aged 18-30 yr at entry into this historical-prospective study in 1968 were used as subjects. Hematocrit (Hct) levels were examined annually. On the average each subject had 13.2 tests in the course of the 15 yr follow-up. We arbitrarily defined anemia as a Hct of 40% or less on two or more tests, and compared the prevalence of diagnosed disorders in subjects with and without anemia. RESULTS: During follow-up, anemia was found in 125 (12.5%) of the subjects. On successive annual examinations of the same individual Hct levels varied by 3% or more in 3.5% of those without anemia, and in 10.5% of those with anemia. The frequency of diagnosed disorders, excluding inter-current infections and trauma, was 25.6%, and 10.9% among those with and without anemia, respectively (OR = 2.8, 95% CI 1.8-4.6). Anemia was associated with inflammatory bowel disease (OR = 12.1, 95% CI 2.3 78.6) and malignancy (OR = 3.6, 95% CI 1.1-10.7). It preceded diagnosis only in one case with Waldenstr 246 m's macroglobulinemia, in one case of inflammatory bowel disease and two cases of myocardial infarction. CONCLUSIONS: A finding of anemia doubled the likelihood of chronic disease. However, it had a limited predictive value for subsequent morbidity and did not lead to detection of treatable disorders or to disorders that might otherwise have endangered flight safety. Fluctuations of up to 3% in Hct over time may be viewed as normal in young males.

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Volunteers for epidemiological research, have lower mortality rates than non-volunteers, thereby producing a bias referred to as the "healthy volunteer effect" (HVE). Occupationally active persons have been similarly shown to have a reduced mortality relatively to the general population (the "healthy worker effect"). To determine whether a HVE exists in occupationally active persons, we followed for 8 years a cohort of Israeli male industrial employees, of whom 71.6% agreed to participate in 1985 in screening examinations for cardiovascular disease. We calculated standardized mortality ratios (SMRs) of the entire cohort relative to the general population, and compared the mortality among participants with that of the non-participants. Over 8 years follow up, SMRs were 78% for the entire cohort, 71% for participants and 99% for non-participants. Participants were older than non-participants and worked more commonly in smaller factories. A proportional hazard model indicated that after adjusting for these variables, the all cause mortality hazard ratio among participants and non-participants was 0.69 (95% CI = 0.51-0.94). During the first and last two years of the 8-year follow-up there were 39.6 and 30.0 age-adjusted deaths per 10,000 person-years among participants, and 58.6 and 51.5 respectively among non-participants. We conclude that the HVE occurs in occupationally active persons, and that it may persist for up to 8 years follow-up.

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OBJECTIVES: This study estimated weight gain after smoking cessation and identified factors attenuating this gain. METHODS: We conducted a prospective follow-up of 1209 male factory workers for 2 to 4 years. The independent variables were smoking habits. age, sports activity, education, alcohol consumption, ethnicity, duration of follow-up, and body mass index (BMI, kg/m2) at entry. The dependent variable was increase in BMI during follow-up. RESULTS: The mean age-adjusted BMI at entry into the study was 26.6 kg/m2 among past smokers and 25.4 kg/m2 among current smokers. There were no differences in BMI between those who quit less than 3 years before entry and those who quit more than 6 years before entry. During follow-up, the average increase in BMI was 0.07 kg/m2 among never smokers, 0.19 kg/m2 among smokers who had stopped smoking before entry, 0.24 kg/m2 among current smokers, and 0.99 kg/m2 among those who stopped smoking after entry. Cessation of smoking after entry predicted an increased gain in BMI; older age, a higher BMI at entry, sports activity, and alcohol consumption attenuated this gain. CONCLUSIONS: The increased rate of weight gain after smoking cessation is transient. However, the weight gained is retained for at least 6 years.

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For more than 70 years, physicians in the Israeli health care system have been employed on a fixed salary rather than on a fee-for-service basis. The present report is a brief review of the origin and development of this unique salaried physician model and its effect on the terms of physicians' employment. Archival documents were reviewed. The salaried physician model was introduced to ensure egalitarian health care for patients rather than equal payment for physicians. It was accepted by physicians because it guaranteed their employment and income. However, over the years, the salaried physician model has evolved into a complex wage scale, with multiple fringe benefits that bypass formal agreements in order to reward individual physicians. In addition, the salaried physician model has encouraged illegal private practice, which is viewed today as one of the major problems of the Israeli Public Health Services.

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