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Biomedical subjects

S Nakar

Publications and source records attributed to S Nakar.

16 recordsLinked to original sources
PubMed2000

[Israeli family physicians' attitudes to clinical guidelines for treatment of diabetes].

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.

Adult↗
PubMed2000

Home visits to the housebound patient in family practice: a multicenter study. Israeli General Practice Research Network.

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.

Aged↗
PubMed1999

[Referrals to an emergency department--are there differences between self-referrals and referrals from general practitioners?].

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.

Adult↗
PubMed1999

Outreach clinics in Israel: a common but unregulated phenomenon.

BACKGROUND: Specialist outreach consultations in the primary care setting have long been controversial with regard to both their effectiveness in treating patients and their potential in improving the interaction between family physicians and specialists. OBJECTIVE: The aim of this study was to establish the prevalence and nature of outreach consultations in primary care clinics in Israel. METHODS: Questionnaires were sent to the heads of all public family practices of the General Sick Fund in our district (38 practices with about 180,000 patients). All 38 practice managers returned completed questionnaires. RESULTS: Twenty-eight of the 38 practices (74%) have some type of specialist consultation available within their clinics. The most common specialties providing outreach clinics are cardiology (47%), nephrology (45%) and internal medicine (39%), where the consultation was performed with the family physician and the patient present. Psychiatry consultations (42%), however, were generally performed without the patient being present. Most of the practice heads felt that in essence outreach clinics could be a positive way of treating their patients. CONCLUSIONS: Head physicians of primary care clinics tend to see outreach clinics as being a very positive tool with which to treat patients. Although many family physicians have some form of specialist consultation available, it is provided and performed mainly on an ad hoc basis. At present no data are available on how best to structure these consultations, or on which specialties outreach clinics are most suitable.

Family Practice↗
PubMed1999

An unusually high prevalence of asthma in Ethiopian immigrants to Israel.

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.

Adult↗
PubMed1998

[Abnormal liver function tests in the primary care setting].

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.

Adolescent↗
PubMed1998

[Urgent, unscheduled self-referrals by ambulatory patients].

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.

Consultants↗
PubMed1997

[Oral anticoagulation therapy in the primary care setting].

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.

Administration, Oral↗
PubMed1997

Urgent self-referrals to ambulatory consultant--a prospective evaluation of triage by a qualified family physician.

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.

Adolescent↗
PubMed1995

What family physicians need in their doctor's bag.

Our objective was to determine what family physicians need in their doctor's bag for urgent and non-urgent house calls. In a prospective survey, family physicians completed a structured report form after consecutive house calls, recording what equipment they needed for each. Thirteen doctors from two urban practices, making a total of 111 house calls, took part. Frequency of reported need of diagnostic equipment, therapeutic agents and administrative supplies was measured. Items required more than 70% of the time were: stethoscope; sphygmomanometer; patient's medical chart; and prescription pad. All other items were required in less than 30% of house calls. We conclude that doctors should carry a stethoscope, sphygmomanometer and prescription pad with them at all times; the patient's medical chart is also essential. Additional equipment should be accessible as prepared kits and taken as needed, depending on the particular patient's problem.

Adolescent↗
PubMedDate not supplied

Attitudes of Israeli family physicians toward clinical guidelines.

BACKGROUND: Many clinical guidelines (CGs) have been written during the past few years. Although family physicians (FPs) stand to benefit from many of these CGs, incorporating new CGs into daily practice seems to present a challenge. OBJECTIVE: To evaluate Israeli FPs' attitudes toward CGs. METHODS: We administered an anonymous questionnaire to general practitioners, residents, and board-certified FPs who participated in continuing medical education programs throughout Israel during May and June 1998. Our survey focused on physician attitudes and behaviors regarding CGs in general, and to CGs for treating the patient with diabetes mellitus (DM) in particular. The CGs for patients with DM have recently been promoted in the context of primary care quality improvement programs. Respondents also provided demographic and professional data. RESULTS: Of the 404 questionnaires distributed, 293 questionnaires were returned for a response rate of 83%. The average (+/-SD) age of respondents was 40.2 +/- 7.0 years, with a mean (+/-SD) of 13.3 +/- 8.0 years in practice. Overall, opinion regarding CGs was positive. About half of the respondents thought CGs improved patient compliance. Comparisons between the various physician groups highlighted several notable differences. Two thirds of the general practitioners believed CGs improved patient compliance, while this was true of only one third of the FPs (P<.001). Most FPs (62%) and senior residents (69%) felt CGs did not constrain their clinical freedom, while less than half of the general practitioners and junior residents felt this way (P =.045). Eighty-three percent of all respondents agreed that the CGs for the treatment of DM were able to be implemented, and 75% believed the CGs assisted them in the management of patients with DM. Whereas 39% expressed concern about being able to adapt generic CGs to individual patient needs, only 27% (P =.002) felt this way about the DM CGs. The vast majority (92%) were interested in understanding the scientific evidence supporting CGs as a prerequisite to adopting them. Most respondents preferred limiting CG length to a maximum of 5 pages. CONCLUSIONS: We found support among Israeli FPs for the use of CGs. Clinical guidelines seem to be used in the field, in particular those developed for treating DM. In light of our findings, attention should be focused on optimally tailoring new CGs to meet scientific standards and crafting them to suit the preferences of local FPs.

Adult↗
PubMedDate not supplied

The influence of SCUD missile attacks on the utilization of ambulatory services in a family practice.

The consulting load in a family practice exposed to SCUD missile attacks during the 1991 Gulf War was compared with the equivalent period in 1990. The rate of visits was cut by half, with a relative and absolute increase in psychological consultations, and a decrease in consultations for infectious and respiratory conditions. There were more urgent consultations and fewer planned appointments. It is suggested that the stress of the SCUD missile attacks led to a reduction in consultations for trivial disorders, but an increase in the anxiety level of the population.

Ambulatory Care↗
PubMedDate not supplied

Assessment of cognitive function in elderly patients treated with naproxen. A prospective study.

Cognitive functions were assessed in 12 elderly patients prior to and following a three-week therapeutic course of Naproxen, 750 mg/day. Four of the patients deteriorated in one of the four cognitive tests, one of these patients in two tests. However, none of these changes reached statistical significance. Although non-steroidal anti-inflammatory drugs can cause some cognitive alteration in the elderly, this change is mild, and its clinical meaning questioned.

Aged↗