Eliezer Kitai

Women's attitudes towards menopause and hormone replacement therapy

Objectives: To determine how women aged 50 years or more feel about menopause, and their knowledge, use of and attitude toward hormone replacement therapy (HRT). Methods: All study participants resided in a single urban community in central Israel and were selected at random from the computerized government registry. Responses were collected by either telephone interview (n = 171) or mailed questionnaire (n = 41) and were analyzed for the group as a whole and by different demographic and attitudinal factors. Results: Most (80%) of the women had a positive or neutral attitude to menopause. More than 80% had heard of HRT, 55% of whom from a physician. Of these, 12% were currently using HRT and 9.5% had done so in the past. Varied reasons were offered for starting or stopping treatment. Conclusions: Although the great majority of the participants had heard of HRT, and most of these had spoken about it with a doctor, only a small percentage were currently under therapy or had been in the past. We believe gynecologists should devote more effort to public education, in that those women who had discussed HRT with their physician were more likely to use it.

Factors associated with family physicians' involvement in research in Israel.

OBJECTIVES: To identify the factors that encourage or deter family medicine physicians and residents in Israel from participating in research. METHOD: In October 1995, a questionnaire containing items on demographic variables, research attitudes, and academic and research activities in primary care settings was mailed to a random sample of 200 family medicine physicians and residents (out of approximately 600) employed by the General Sick Fund, the largest health maintenance organization in Israel. The questionnaire also contained items regarding difficulties in participating in research and asked for opinions about several general statements about research in family practice. RESULTS: In all, 190 physicians responded, for a response rate of 95%. Based on their responses, the respondents were divided into four groups by amount of research involvement. Univariate analysis using the chi-square test was used for the comparison of variables among the four groups. The respondents reporting greater knowledge of and involvement in research were, by and large, men (p = .01) who were qualified specialists with academic status (p < .00001). They also taught students (p = .0005) and residents (p < .0005), participated in more conferences (p < .0005), and while in residency training had had a mentor who encouraged involvement in research (p = .0001). CONCLUSION: Research is essential to family medicine with regard to both primary care practice and academic activities, its development, however, has been inhibited. Given the results of this preliminary study, family medicine residency programs would be well advised to assign a research mentor to every resident; also, time and resources should be devoted to research in postgraduate training programs. Perhaps more important, women physicians in Israel should be encouraged to participate more actively in research, and support for them in their special needs should be made available.

Prescription of Ocular β-Blockers in Patients with Obstructive Pulmonary Disease

AbstractObjectives: Topical β-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 β-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 β-blockers, only 38 received betaxolol. In comparison with glaucoma patients without OPD, OPD patients received fewer β-blockers (p < 0.001), more selective β-blockers (p < 0.0001) and less timolol (p < 0.001). Of the OPD patients treated by ophthalmologists with a central EMR, 59.5% received β-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-β-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 β-blockers, mostly noncardioselective β-blockers. A central EMR with a comprehensive and highly available medical history reduced the prescription of β-blockers to OPD patients, but rates remained unacceptably high.

Developing a Mediterranean family medicine group

On 9 September 2000, a meeting on General Practice/Family Medicine (GP/FM) in the Mediterranean was held at the 6th Mediterranean Congress in Malta. The creation of a Mediterranean GP/FM group was discussed among delegates from seven Mediterranean countries. Historical, cultural and epidemiological concepts supporting this initiative are presented. The main aims of this group and the key issues of the Malta consensus are clarified.

Clozapine Treatment And Risk Of Unplanned Pregnancy

With recent advances in the medical treatment of chronic psychiatric patients who are capable of living productive lives in their communities, follow-up of these patients is often carried out by their family physicians. These family physicians are also generally responsible for family planning. Many schizophrenic patients have preserved sex drives, but their judgments and responsibilities with respect to contraception are impaired. Often the family physician has to deal with lack of cooperation from these patients when they are asked to use common forms of contraception. Some family physicians rely on the infertility secondary to hyperprolactinemia caused by traditional antipsychotic agents. Clozapine is a new antipsychotic medication, the use of which is increasing rapidly, but not all physicians realize that it does not cause hyperprolactinemia-induced infertility. We present a case of a schizophrenic patient who became pregnant shortly after her antipsychotic treatment was changed to clozapine. The purpose of our report is to increase the awareness of physicians treating patients with clozapine of the possibility of undesired pregnancy when no contraceptive is used.

Help-seeking preferences in the area of mild cognitive impairment: comparing family physicians and the lay public

Background Mild cognitive impairment (MCI) or mild neurocognitive disorder is a well-established clinical entity included in current diagnostic guidelines for Alzheimer’s disease and in major psychiatric classifications. In all, a loosely defined concern obtained from conceptually different sources (the individual, a knowledgeable informant, or a clinician) regarding a decline in cognition and change in functioning constitutes a sine qua non for initiating diagnostics and providing therapy and support. This concern in practice may translate into complex proactive help-seeking behavior. A better understanding of help-seeking preferences is required in order to promote early detection and management. Objectives To compare help-seeking preferences of family physicians and the lay public in the area of MCI. Methods A structured questionnaire was used to collect data from 197 family physicians (self-administered) and 517 persons aged 45 and over from the lay public (face to face). Information regarding familiarity with MCI and help-seeking preferences was assessed. Results The vast majority in both samples reported that family physician, spouse, and children are the most highly recommended sources of help-seeking. In regard to professional sources of help-seeking, a higher percentage of the physicians than the lay public sample consistently recommended seeking help from nurses and social workers and psychiatrists, but a higher percentage of the lay public recommended turning to a neurologist for help. Discussion There were both similarities and differences between family physicians and the lay public in their preferences regarding help-seeking for a person with MCI. Most prominent is the physicians’ greater tendency to recommend professional sources of help-seeking. Conclusion Understanding of help-seeking preferences of both physicians and lay persons might help overcome barriers for establishing diagnosis, receiving care, and improving communication between doctors and patients.

Non-specific symptoms as clues to changes in emotional well-being

Background -Somatic symptoms are a common reason for visits to the family physician. The aim of this study was to examine the relation between non-specific symptoms and changes in emotional well-being and the degree to which the physician considers the possibility of mental distress when faced with such patients.Methods -Patients who complained of two or more symptoms including headache, dizziness, fatigue or weakness, palpitations and sleep disorders over one year were identified from the medical records of a random sample of 45 primary care physicians. A control group matched for gender and age was selected from the same population. Emotional well-being was assessed using the MOS-SF 36 in both groups.Results -The study group and the control group each contained 110 patients. Completed MOS questionnaires were obtained from 92 patients, 48 patients with somatic symptoms and 44 controls. Sixty percent of the patients with somatic symptoms experienced decreased emotional well being compared to 25% in the control group (p = 0.00005). Symptoms of dizziness, fatigue and sleep disturbances were significantly linked with mental health impairments. Primary care physicians identified only 6 of 29 patients (21%) whose responses revealed functional limitations due to emotional problems as suffering from an emotional disorder and only 6 of 23 patients (26%) with a lack of emotional well being were diagnosed with an emotional disorder.Conclusions -Non-specific somatic symptoms may be clues to changes in emotional well-being. Improved recognition and recording of mental distress among patients who complain of these symptoms may enable better follow up and treatment.

Smoking prevention and primary physician's and patient's characteristics.

OBJECTIVE To describe relationships between primary physician and patient characteristics and the approach to prevention and quitting of smoking. METHODS A questionnaire composed of descriptions of cases and clinic activities was given to primary physicians. RESULTS Fewer smoking physicians use written materials, yet former smokers more often recommend smoking cessation groups. Greatest efforts are invested in high-risk patients. However, former smokers invest greater efforts among youth and pregnant women. Workload and patients main complaint exert great influence on raising the subject. CONCLUSIONS The various attitudes of physicians emphasize the importance of physician education that should be according to their smoking habits.

The tools of an evidence-based culture: implementing clinical-practice guidelines in an Israeli HMO.

Purpose Although clinical-practice guidelines (CPGs) are implemented on the assumption that they will improve the quality, efficiency, and consistency of health care, they generally have limited effect in changing physicians’ behavior. The purpose of this study was to design and implement an effective program for formulating, promulgating, and implementing CPGs to foster the development of an evidence-based culture in an Israeli HMO. Method The authors implemented a four-stage program of stepwise collaborative efforts with academic institutions composed of developing quantitative tools to evaluate prescribing patterns, updating CPGs, collecting MDs’ input via focus groups and quantitative surveys, and conducting a randomized controlled trial of a two-stage, multipronged intervention. The test case for this study was the development, dissemination, and implementation of CPG for the treatment of acute uncomplicated cystitis in adult women. Interventions in the form of a lecture at a conference and a letter with personalized feedback were implemented, both individually and combined, to improve physicians’ rates of prescribing the first-line drug, nitrofurantoin, and, in the absence of nitrofurantoin, adhering to the recommended duration of three days of treatment with ofloxacin. Results The tools and data-generating capabilities designed and constructed in Stage I of the project were integral components of all subsequent stages of the program. Personalized feedback alone was sufficient to improve the rate of adherence to the guidelines by 19.4% (95% CI = 16.7, 22.1). Conclusions This study provides a template for introducing the component of experimentation essential for cultivating an evidence-based culture. This process, composed of collaborative efforts between academic institutions and a managed care organization, may be beneficial to other health care systems.

Web-based question-answering service of a family physician -- the characteristics of queries in a non-commercial open forum.

The use of the Internet is growing rapidly. Up to 70% of American Internet surfers use the Web for some kind of medical purpose. Only a few studies characterized the consulting population and their inquiries. The objective of this study was to define the content of queries and the characteristics of the consulting population in an open access ‘Ask the family physician’ non-commercial open forum. Data had been collected from the family medicine forum in www.doctors.co.il. This site has 10 – 15 new queries daily, and a physician reply is given on most occasions within 24 h. We analysed demographic characteristics and the content of the queries. In addition, we sent detailed questionnaires to 200 randomly selected consulters. We analysed 1,002 consecutive queries. The average age of the consulters was 31.8 years, 63.4% women. Women applied more often for someone else, compared to men (13.7 versus 8%p = 0.01). 82.2% applied to the forum for a first opinion on the subject matter. The most frequent subjects were: infectious diseases (7.3%), deciphering blood chemical analysis results (3.2%), vitamin B12 (3.2%), deciphering blood count analysis results (2.9%), Epstein – Barr virus and Cytomegalovirus (2.8%), and hypertension (2.4%). Only 10% (20/200) replied to our e-mail questionnaire. We described the characteristics of inquiries to a Web-based question answering service. Its consumers are mainly younger females who consult the virtual physician prior to consulting their own family physician. They mainly seek medical knowledge especially in interpreting laboratory tests and information about various medical conditions.