Cost-effectiveness analysis of extended conservative therapy versus surgical intervention in the management of herniated lumbar intervertebral disc.

The management of herniated lumbar intervertebral disc for patients not responding to an initial trial of conservative therapy is generally surgical. Little is known about the effect of continued conservative therapy on patients who have not improved or have deteriorated within the first 3 months. This study assessed which form of treatment, surgical or continued conservative therapy, is more cost-effective once an adequate trial of conservative therapy has failed. The study is a retrospective chart review of 55 white male truck drivers who presented with acutely herniated nucleus pulposus between 1985 and 1989. Twenty-five patients underwent surgery, and 30 underwent continued conservative therapy after initial rehabilitation. No significant difference was found in outcome (80% good or fair in both the surgical and conservative groups) or costs ($55,000 +/- $1,000/case during a 5-year period), hence no difference in the cost-effectiveness between the two treatment modalities (each $63,000 +/- $2,000/adjusted outcome). Conservatively treated patients, however, missed significantly more work. It was concluded that, for a patient not responding to the initial trial of conservative therapy, the option to undergo continued conservative treatment should be made available.     

Taking care of terminally-ill patients at home - the economic perspective revisited

End-of-life care can be delivered in a variety of settings, whereby the majority of terminally-ill cancer patients prefer to die at home. The aim of our study is to evaluate health services utilisation during the last year of life, and to compare terminally ill patients who have received home-specialised palliative care services (HSPCS) with patients who died receiving home non-specialised palliative care services. The study included 120 and 515 patients, respectively, who died between 1999-2000. Age and gender distribution were similar in both groups. During the last year of life, mean health services cost per person among the HSPCS group was lower by more then 30% (P < 0.005). The median cost per patient was as low as one-fifth in the last month. Men and the older age group of 65 and above, cost significantly less compared with women and younger patients, respectively, regardless of provider setting. The main differences in health services utilisation were in hospitalisations and oncology treatments (P < 0.01 and P < 0.05, respectively).     

Effects of guided written disclosure of stressful experiences on clinic visits and symptoms in frequent clinic attenders

BACKGROUND: Psychosocial variables such as major stressful life events/daily stressful events have been associated with health care utilization. OBJECTIVE: Our aim was to examine the effects of a guided disclosure protocol (GDP) of past traumas on symptoms and clinic visits among frequent clinic attenders. METHODS: Forty-one frequent clinic attenders (> or =2 visits/3 months) took part. Patients were randomly assigned individually to either a casual content writing control group (n = 19) or a trauma content writing experimental GDP group (n = 22). GDP patients wrote about an upsetting event chronologically (day 1), verbally described their thoughts and feelings and described the event's impact on life (day 2), and finally wrote about their current perspective on and future coping with the event (day 3). Three months later, patients were reassessed blindly for symptoms and clinic visits, and an average of 15 months later they were assessed blindly for clinic visits again. RESULTS: Compared with controls, GDP patients reported lower symptom levels at 3 months (2.3 versus 5.2), and made fewer clinic visits during the 3 (1.3 versus 3.0) and 15 month (5.1 versus 9.7) follow-ups. The percentage of GDP patients making > or =10 visits during the 15 month follow-up was smaller (10%) than among controls (33%). CONCLUSIONS: The findings extend previous findings to frequent clinic users, using a new form of written disclosure aimed at shifting trauma from implicit to explicit memory. The GDP may be an inexpensive additional intervention in primary care for reducing symptoms and clinic visits among frequent clinic users.     

The Impact of Structured Laboratory Routines in Computerized Medical Records in a Primary Care Service Setting

Inappropriate laboratory ordering is a problem affecting medical systems worldwide. An intervention was called for as a result of increasing laboratory costs. Thus, we aimed to assess the impact of introducing computerized laboratory routines to a computerized primary care setting. The study included 380 primary care physician practices of Clalit Health Service (HMO) southern district (CHS-SD) in Israel, caring for 470,000 members. Consensus laboratory routines order sets were electronically introduced into all physicians’ computerized medical record (CMR) software, after consensus and internal marketing process. The primary findings were that a previously observed annual increase in laboratory test utilization was stopped, a 2% reduction in total number of tests and a 4% reduction in the total number of tests per age adjusted person was observed. In conclusion the wide use of CMRs and communication technology combined with an appropriate organizational process can be used to increase appropriate utilization of laboratory tests.     

Aetiology of respiratory tract infections: clinical assessment versus serological tests.

Two hundred and fifty ambulatory patients with febrile respiratory tract infections were included in a prospective study, aimed at determining the reliability of physicians judgements relating to the aetiology of the infection. Compared with advanced serological testing, physicians' judgements for a bacterial/atypical, rather than viral, aetiology had a negative predictive value of 60% and a positive predictive value of only 50%. We conclude that physicians' ability to assess whether the infectious aetiology of RTI is viral or bacterial/atypical is low and no more reliable than tossing a coin.     

Hypodermoclysis: an alternative infusion technique.

Hypodermoclysis, the subcutaneous infusion of fluids, is a useful and easy hydration technique suitable for mildly to moderately dehydrated adult patients, especially the elderly. The method is considered safe and does not pose any serious complications. The most frequent adverse effect is mild subcutaneous edema that can be treated by local massage or systemic diuretics. Approximately 3 L can be given in a 24-hour period at two separate sites. Common infusion sites are the chest, abdomen, thighs and upper arms. The preferred solution is normal saline, but other solutions, such as half-normal saline, glucose with saline or 5 percent glucose, can also be used. Potassium chloride can be added to the solution bag if needed. Hyaluronidase can also be added to enhance fluid absorption. Hypodermoclysis can be administered at home by family members or a nurse; the technique should be familiar to every family physician.     

Is our appearance important to our patients?

OBJECTIVES: We aimed to explore patients' attitudes towards family physicians' and nurses' appearance. METHODS: One hundred and sixty- eight patients from three teaching Family Medicine clinics in Beer- Sheva, Israel, were interviewed in the clinics regarding the medical staff's dress code. They were also asked to choose one picture for either a male or female physician which, in their opinion, was the most suited for their own family physician, from a selection of pictures of the same male and female doctors dressed in different attires. RESULTS: One hundred and twenty-six patients (75%) replied that the attire of the physician had no influence on their decision in choosing their own family doctor. Fifty-two per cent of the patients preferred the doctor in a white coat and 71 % had the same preference for the nurse. Older age was associated with increased preference for a white coat. The dressing items which scored high for male doctor were a name tag, a formal suit or a shirt with a tie and sports shoes. For a female doctor a name tag, short haircut, trousers and sports shoes ranked highly. Long hair, earrings, and sandals scored low for a male physician, while mini-dress, shorts and tight clothes scored low for a female physician. CONCLUSION: About half of patients still prefer the doctor to be dressed in a white coat. Patients prefer a more formal dressing for male and female physicians in family medicine clinics. Most of the patients claimed that the attire of the physician had no influence on their choice of family physician.      

Health services utilization by depressive patients identified by the MINI questionnaire in a primary care setting

OBJECTIVES: To identify patients with depression, in primary care clinics in Israel, using the MINI (Mini-International Neuropsychiatric Interview) as a screening tool and to evaluate the health services utilization and costs of the patients identified. DESIGN: Phone interviews (between 1997 and 2000) and health services utilization data extracted from computerized databases. SETTING: Three primary care clinics belonging to Clalit Health Services (HMO). PARTICIPANTS: A random sample of 2755 patients, aged 21-65. MAIN OUTCOME MEASURES: MINI score results, utilization data. RESULTS:The study included interviews with 2507 patients. The screening questionnaire identified 5.9% with major depression, 1.6% with minor depression and 14.3% with depressive symptoms. Higher rates of depression were found among women, immigrants, secular or traditional religious Jews, and the unemployed. Those identified with major depression had higher health services utilization and costs. Logistic regression analysis showed that depression was related to older age, female gender, fewer years of education and among seculars. Depressed patients had significantly more somatic comorbidity. CONCLUSIONS: Health services utilization and costs of people identified as depressed by the screening tool were higher. Depressive patients had higher comorbidity, which might be partially responsible for the higher cost.     

Health services utilization by depressive patients identified by the MINI questionnaire in a primary care setting

Objectives To identify patients with depression, in primary care clinics in Israel, using the MINI (Mini-International Neuropsychiatric Interview) as a screening tool and to evaluate the health services utilization and costs of the patients identified. Design Phone interviews (between 1997 and 2000) and health services utilization data extracted from computerized databases. Setting Three primary care clinics belonging to Clalit Health Services (HMO). Participants A random sample of 2755 patients, aged 21–65. Main outcome measures MINI score results, utilization data. Results The study included interviews with 2507 patients. The screening questionnaire identified 5.9% with major depression, 1.6% with minor depression and 14.3% with depressive symptoms. Higher rates of depression were found among women, immigrants, secular or traditional religious Jews, and the unemployed. Those identified with major depression had higher health services utilization and costs. Logistic regression analysis showed that depression was related to older age, female gender, fewer years of education and among seculars. Depressed patients had significantly more somatic comorbidity. Conclusions Health services utilization and costs of people identified as depressed by the screening tool were higher. Depressive patients had higher comorbidity, which might be partially responsible for the higher cost.