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An Israeli Experience

Hava Tabenkin, MD, MS; Revital Gross, MA; Shuli Brammli, BA; Pesach Shvartzman, MD

JAMA. 1998;279:1943-1948.

Context.— Surveys carried out among users of medical services can be a useful tool for health care organizations in designing proper services. Specifically, patients' views of direct access to specialists can be useful to health organizations considering the gatekeeper model.

Objective.— To assess patients' opinions about direct access to specialists and referral to specialists through their primary care physician.

Design.— An intercept survey, in which patients were interviewed at the randomly selected service provision sites, was carried out in 3 districts in Israel during 1995. A total of 1445 and 1289 patients were interviewed in primary care and specialty clinics, respectively.

Setting.— Primary care and specialty clinics in 3 regions in Israel serving 750000 members of Kupat Holim Clalit, Israel's largest sick fund.

Participants.— Hebrew-speaking members of Kupat Holim Clalit who visited the primary care or specialty clinics in the 3 regions during the study period.

Main Outcome Measures.— Rate of preferences for direct access to specialists and preferences for referral through primary care physician.

Results.— Fifty-two percent of the respondents preferred direct access to specialists, while 48% preferred a referral from their primary care physician. Multivariate logistic regression analysis indicated that the preference for direct access was significantly lower among patients older than 45 years (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.62-0.91); patients whose primary care physician was a specialist in family medicine (OR, 0.80; 95% CI, 0.67-0.97); and patients who were satisfied with their primary care physician (OR, 0.34; 95% CI, 0.27-0.44). Preference for direct access was significantly higher among more highly educated patients (OR, 1.38; 95% CI, 1.16-1.65) and patients residing in Jerusalem (OR, 2.46; 95% CI, 2.05-2.95) and those younger than 45 years who were dissatisfied with their family physician or a primary care physician who was not board certified. If direct access was not available, 33% of respondents would leave the sick fund and 48% would remain; 19% did not know.

Conclusions.— Informing sick fund members, particularly the younger and more educated among them, about the advantages of consulting with the primary care physician, as well as providing specialty training in family medicine to primary care physicians, may reduce patients' preference for direct access to specialists.

From the Department of Family Medicine, Ha'emek Hospital, Kupat Holim Clalit Northern District, Afula (Drs Tabenkin and Shvartzman); the Department of Family Medicine, Ben-Gurion University, Beersheva (Drs Tabenkin and Shvartzman); and the JDC-Brookdale Institute, Jerusalem (Mss Gross and Brammli).

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