To quantify the effect of hand-hygiene interventions on rates of gastrointestinal and respiratory illnesses and to identify interventions that provide the greatest efficacy, we searched 4 electronic databases for hand-hygiene trials published from January 1960 through May 2007 and conducted meta-analyses to generate pooled rate ratios across interventions (N=30 studies). Improvements in hand hygiene resulted in reductions in gastrointestinal illness of 31% (95% confidence intervals [CI]=19%, 42%) and reductions in respiratory illness of 21% (95% CI = 5%, 34%). The most beneficial intervention was hand-hygiene education with use of nonantibacterial soap. Use of antibacterial soap showed little added benefit compared with use of nonantibacterial soap. Hand hygiene is clearly effective against gastrointestinal and, to a lesser extent, respiratory infections. Studies examining hygiene practices during respiratory illness and interventions targeting aerosol transmission are needed. (Am J Public Health. 2008;98:1372‐1381. doi:10.2105/AJPH.2007.124610)

https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2007.124610

Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis

Background
Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a global threat. Antiviral drugs and vaccinations may be insufficient to prevent their spread.

Objectives
To review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.

Search methods
We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2010, Issue 3), which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to October 2010), OLDMEDLINE (1950 to 1965), EMBASE (1990 to October 2010), CINAHL (1982 to October 2010), LILACS (2008 to October 2010), Indian MEDLARS (2008 to October 2010) and IMSEAR (2008 to October 2010).

Selection criteria
In this update, two review authors independently applied the inclusion criteria to all identified and retrieved articles and extracted data. We scanned 3775 titles, excluded 3560 and retrieved full papers of 215 studies, to include 66 papers of 67 studies. We included physical interventions (screening at entry ports, isolation, quarantine, social distancing, barriers, personal protection, hand hygiene) to prevent respiratory virus transmission. We included randomised controlled trials (RCTs), cohorts, case-controls, before-after and time series studies.

Data collection and analysis
We used a standardised form to assess trial eligibility. We assessed RCTs by randomisation method, allocation generation, concealment, blinding and follow up. We assessed non-RCTs for potential confounders and classified them as low, medium and high risk of bias.

Main results
We included 67 studies including randomised controlled trials and observational studies with a mixed risk of bias. A total number of participants is not included as the total would be made up of a heterogenous set of observations (participant people, observations on participants and countries (object of some studies)). The risk of bias for five RCTs and most cluster-RCTs was high. Observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis. The highest quality cluster-RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Benefit from reduced transmission from children to household members is broadly supported also in other study designs where the potential for confounding is greater. Nine case-control studies suggested implementing transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. Surgical masks or N95 respirators were the most consistent and comprehensive supportive measures. N95 respirators were non-inferior to simple surgical masks but more expensive, uncomfortable and irritating to skin. Adding virucidals or antiseptics to normal handwashing to decrease respiratory disease transmission remains uncertain. Global measures, such as screening at entry ports, led to a non-significant marginal delay in spread. There was limited evidence that social distancing was effective, especially if related to the risk of exposure.

Authors' conclusions
Simple and low-cost interventions would be useful for reducing transmission of epidemic respiratory viruses. Routine long-term implementation of some measures assessed might be difficult without the threat of an epidemic.

/pdf/physical-interventions-to-interrupt-or-reduce-the-spread-of-3z31bk17se.pdf

Physical interventions to interrupt or reduce the spread of respiratory viruses.

The WHO European Office for Integrated Health Care Services in Barcelona is an integral part of the World Health Organizations' Regional Office for Europe. The main purpose of the Barcelona office is within the integration of services to encourage and facilitate changes in health care services in order to promote health and improve management and patient satisfaction by working for quality, accessibility, cost-effectiveness and participation. This position paper outlines the need for Integrated Care from a European perspective, provides a theoretical framework for the meaning of Integrated Care and its strategies and summarizes the programmes of the office that will support countries in the WHO European Region to improve health services.

Integrated care: a position paper of the WHO European Office for Integrated Health Care Services.

Background
It is widely believed that the method of payment of physicians may affect their clinical behaviour. Although payment systems may be used to achieve policy objectives (e.g. cost containment or improved quality of care), little is known about the effects of different payment systems in achieving these objectives.

Objectives
To evaluate the impact of different methods of payment (capitation, salary, fee for service and mixed systems of payment) on the clinical behaviour of primary care physicians (PCPs).

Search methods
We searched the Cochrane Effective Practice and Organisation of Care Group specialised register; the Cochrane Controlled Trials Register; MEDLINE (1966 to October 1997); BIDS EMBASE (1980 to October 1997); BIDS ISI (1981 to October 1997); EconLit (1969 to October 1997); HealthStar (1975 to October 1997) Helmis (1984 to October 1997); health economics discussion paper series of the Universities of York, Aberdeen, Sheffield, Bristol, Brunel, and McMaster; Swedish Institute of Health Economics; RAND corporation; and reference lists of articles.

Selection criteria
Randomised trials, controlled before and after studies and interrupted time series analyses of interventions comparing the impact of capitation, salary, fee for service (FFS) and mixed systems of payment on primary care physician satisfaction with working environment; cost and quantity of care; type and pattern of care; equity of care; and patient health status and satisfaction.

Data collection and analysis
Two reviewers independently extracted data and assessed study quality.

Main results
Four studies were included involving 640 primary care physicians and more than 6400 patients. There was considerable variation in study setting and the range of outcomes measured. FFS resulted in more primary care visits/contacts, visits to specialists and diagnostic and curative services but fewer hospital referrals and repeat prescriptions compared with capitation. Compliance with a recommended number of visits was higher under FFS compared with capitation payment. FFS resulted in more patient visits, greater continuity of care, higher compliance with a recommended number of visits, but patients were less satisfied with access to their physician compared with salaried payment.

Authors' conclusions
It is noteworthy that so few studies met the inclusion criteria. There is some evidence to suggest that the method of payment of primary care physicians affects their behaviour, but the findings' generalisability is unknown. More evaluations of the effect of payment systems on PCP behaviour are needed, especially in terms of the relative impact of salary versus capitation payments.

Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians.

Objective: To review the impact of payment systems on the behaviour of primary care physicians.Methods: All randomised trials, controlled before and after studies, and interrupted time series studies that compared capitation, salary, fee-for-service or target payments (mixed or separately) that were identified by computerised searches of the literature. Methodological quality assessment and data extraction were undertaken independently by two reviewers using a data checklist. Study results were qualitatively analysed.Results: Six studies met the inclusion criteria. There was considerable variation in the quality of reporting, study setting and the range of outcomes measured. Fee-for-service resulted in a higher quantity of primary care services provided compared with capitation but the evidence of the impact on the quantity of secondary care services was mixed. Fee-for-service resulted in more patient visits, greater continuity of care, higher compliance with a recommended number of visits, but lower pati...

Impact of payment method on behaviour of primary care physicians: a systematic review.

Israel is a small country, with just over 8 million citizens and a modern market-based economy with a comparable level of gross domestic product per capita to the average in the European Union. It has had universal health coverage since the introduction of a progressively financed statutory health insurance system in 1995. All citizens can choose from among four competing, non-profit-making health plans, which are charged with providing a broad package of benefits stipulated by the government. Overall, the Israeli health care system is quite efficient. Health status levels are comparable to those of other developed countries, even though Israel spends a relatively low proportion of its gross domestic product on health care (less than 8%) and nearly 40% of that is privately financed. Factors contributing to system efficiency include regulated competition among the health plans, tight regulatory controls on the supply of hospital beds, accessible and professional primary care and a well-developed system of electronic health records. Israeli health care has also demonstrated a remarkable capacity to innovate, improve, establish goals, be tenacious and prioritize. Israel is in the midst of numerous health reform efforts. The health insurance benefits package has been extended to include mental health care and dental care for children. A multipronged effort is underway to reduce health inequalities. National projects have been launched to measure and improve the quality of hospital care and reduce surgical waiting times, along with greater public dissemination of comparative performance data. Major steps are also being taken to address projected shortages of physicians and nurses. One of the major challenges currently facing Israeli health care is the growing reliance on private financing, with potentially deleterious effects for equity and efficiency. Efforts are currently underway to expand public financing, improve the efficiency of the public system and constrain the growth of the private sector.

Bruce Rosen

Papers

Israel: Health System Review.

Can a handwashing intervention make a difference? Results from a randomized controlled trial in Jerusalem preschools

Reforming the Israeli health system: findings of a 3-year evaluation.

Evaluating the Israeli health care reform: strategy, challenges and lessons.

Professional reimbursement and professional behavior: emerging issues and research challenges.