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The Face of the Israeli 21st Century Primary Care Physician. The Department of Family Medicine, Hebrew University, Jerusalem, Israel Dr Amnon Lahad Dr Brendon Stewart-Freedman. Background. The Israeli primary care physician (PCP) faces extraordinary pressures:
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The Face of the Israeli 21st Century Primary Care Physician The Department of Family Medicine, Hebrew University, Jerusalem, Israel Dr Amnon Lahad Dr Brendon Stewart-Freedman
Background The Israeli primary care physician (PCP) faces extraordinary pressures: • Increased chronic illness burden. • Aging population. • Increasing patient expectation. • Shifting care from hospitals community. • Limited physician supply. • Rising pressure to contain costs.
Background • Shifting aspects of care from PCP to nurses, pharmacists and other para-medical staff is one possible solution. • The expectation is that these substitutions will reduce physician workload and thus cost, while maintaining quality of care.
In Israel: Y-net 14/12/05 • A severe shortage of MDs In the IDF. • Waiting weeks for a physician’s visit. A physician may check up to 200 soldiers per day. Any change will take at least six years. • איתי גל פורסם: 14.12.05, 13:34
Pazi committee: • In 2002 Israel had surplus of MDs (3.4-3.7 / 1000). • Over the coming years this surplus will decrease due to reduction in the number of physicians immigrating from CIS, aging of the physician population and increased demand. The rate of MDs will be 2.7 / 1000 in 2021.
Starting in 2010 we will need to double the number of medical students in Israel. • Currently some of the medical schools will not be able to increase these numbers. The Hebrew University will increase the student’s numbers by only 20%
ובשטח... • בהתמחות שלנו כ-80 משרות מתמחה פנויות. • בפנימית, ילדים וכירורגיה כללית, כמעט בכל המחולקות בארץ יש מקומות פנויים להתמחות. • 61% מהרופאים הראשוניים בקהילה אינם מומחים (ענת שמש – משרד הבריאות) ורק חלק מהמומחים רופאי משפחה.
State Comptroller 56ב 2006 • The average visit time in PC (primary care) was 5-8.5 minutes (2004)p 412. Inadequate for providing a meaningful interface, preventive care and addressing psychosocial issues.
Substitution of doctors by nurses in primary careLaurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B
25 articles, relating to 16 studies, met inclusion criteria. • In 7 studies the nurse assumed responsibility for first contact and ongoing care for all presenting patients. • No differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilization or cost.
In 5 studies the nurse assumed responsibility for first contact care for patients wanting urgent consultations. • Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care.
In 4 studies the nurse took responsibility for the ongoing management of patients with particular chronic conditions. • No differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilization or cost.
Abstracts of quality assessed systematic reviewsA meta-analysis of nurse practitioners (NP) and nurse midwives in primary care:Brown S A, Grimes D E.
Nurse practitioners … in PC Controlling for patient severity: • Nurse practitioners ordered more laboratory tests (ES 0.20, 95% CI: 0.10, 0.29, p<0.0001), • Their patients pathological conditions such as BP improved (ES 0.28, 95 % CI: 0.04, 0.51, p=0.01)
Nurse practitioners … in PC • They received higher patient satisfaction (ES 0.30, 95% CI: 0.20, 0.40, p<0.0001). • There were no differences in quality of care, prescribing of drugs, functional status, number of visits per patient and use of the emergency room.
Main results • 6 trials including 1382 participants followed for 6 -12 months. • HbA1c in the intervention groups was not different from the control groups over a 12 month follow up.
Rural nurses in Israel • For at least 40 year, the Clalit Health Services has allowed its rural nurses to provide care, when there is no MD in clinic, including the distribution of a limited list of medications.
Expanding the roles of outpatient pharmacists: effects on health services utilization, costs, and patient outcomes(Beney J, Bero LA, Bond C)
Pharmacists • 25 studies, > 40 pharmacists and 16,000 patients. Compared to other health professionals: • Scheduled service utilization was slightly increased, whereas hospital admissions and emergency room admissions were decreased.
Pharmacists Comparison to usual care: • Pharmacist services decreased the use of non-scheduled health services, the number of physician visits or the number and costs of drugs, compared to control patients (6 studies).
Pharmacists • Improvements in the targeted patient condition were reported in 10 /13 studies that measured patient outcomes, whereas patients’ quality of life did not seem to change.
סיכום • מחקרים הראו, במגוון מצבים שאחיות מיומנות (NP) הגיעו לתוצאות דומות ובעלות ישירה נמוכה יותר • גם לגבי רוקחים נמצא שבמצבים כרוניים, התאמת הטיפול הניתנת על ידם מלווה באיכות רפואת גבוה ובעלות נמוכה יותר. רוקחים יכולים להפחית את מספר הביקורים אצל רופא ראשוני.
המלצות • יצירת צוות טיפולי עם חלוקת אחריות. • הרופא/ים יצור קווים מנחים לטיפול ומניעה. • הרופא יטפל במצבים יותר מורכבים • האחות תטפל במצבי תחלואה שגרתיים • הרוקח יהיה שותף בהתאמת טיפול במצבים כרוניים
המלצות • הדבר יצריך גם אחריות אישית של המקצועות הפרה-רפואיים. • אפשרות של אחיות נבחרות ורוקחים לרישום תרופות מסוימות
המלצות • המטופלים יקבלו יותר שעות טיפול, אם כי חלקן לא מרופא • הרופאים יתרכזו במתן טיפול הדורש את ההכשרה שלהם. הדבר יוסף גם לשביעות הרצון שלנו מהמקצוע.
And we need • יותר רופאים ראשונים – רצוי רופאי משפחה • תגמול גבוה יותר לרופאי משפחה • מניעת אשפוז • 24/7 • פחותבירוקרטיה
