title: Establishing an integrated gastroenterology service between a medical center and the community.
abstract: OBJECTIVE
  To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established.
  
  
  METHODS
  Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians' knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators.
  
  
  RESULTS
  An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient's visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett's esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer.
  
  
  CONCLUSIONS
  Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.
authors.affiliation: Yaron Niv, Ram Dickman, Zohar Levi, Gadi Neumann, Eyran Halpern, Rabin Medical Center, Clalit Health Services, Tel Aviv University, Petach Tikva 49100, Israel.
authors.forename: Yaron
authors.initials: Y
authors.lastname: Niv
authors.affiliation: Yaron Niv, Ram Dickman, Zohar Levi, Gadi Neumann, Eyran Halpern, Rabin Medical Center, Clalit Health Services, Tel Aviv University, Petach Tikva 49100, Israel.
authors.forename: Ram
authors.initials: R
authors.lastname: Dickman
authors.affiliation: Yaron Niv, Ram Dickman, Zohar Levi, Gadi Neumann, Eyran Halpern, Rabin Medical Center, Clalit Health Services, Tel Aviv University, Petach Tikva 49100, Israel.
authors.forename: Zohar
authors.initials: Z
authors.lastname: Levi
authors.affiliation: Yaron Niv, Ram Dickman, Zohar Levi, Gadi Neumann, Eyran Halpern, Rabin Medical Center, Clalit Health Services, Tel Aviv University, Petach Tikva 49100, Israel.
authors.forename: Gadi
authors.initials: G
authors.lastname: Neumann
authors.affiliation: Yaron Niv, Ram Dickman, Zohar Levi, Gadi Neumann, Eyran Halpern, Rabin Medical Center, Clalit Health Services, Tel Aviv University, Petach Tikva 49100, Israel.
authors.forename: Dorit
authors.initials: D
authors.lastname: Ehrlich
authors.affiliation: Yaron Niv, Ram Dickman, Zohar Levi, Gadi Neumann, Eyran Halpern, Rabin Medical Center, Clalit Health Services, Tel Aviv University, Petach Tikva 49100, Israel.
authors.forename: Haim
authors.initials: H
authors.lastname: Bitterman
authors.affiliation: Yaron Niv, Ram Dickman, Zohar Levi, Gadi Neumann, Eyran Halpern, Rabin Medical Center, Clalit Health Services, Tel Aviv University, Petach Tikva 49100, Israel.
authors.forename: Jacob
authors.initials: J
authors.lastname: Dreiher
authors.affiliation: Yaron Niv, Ram Dickman, Zohar Levi, Gadi Neumann, Eyran Halpern, Rabin Medical Center, Clalit Health Services, Tel Aviv University, Petach Tikva 49100, Israel.
authors.forename: Arnon
authors.initials: A
authors.lastname: Cohen
authors.affiliation: Yaron Niv, Ram Dickman, Zohar Levi, Gadi Neumann, Eyran Halpern, Rabin Medical Center, Clalit Health Services, Tel Aviv University, Petach Tikva 49100, Israel.
authors.forename: Doron
authors.initials: D
authors.lastname: Comaneshter
authors.affiliation: Yaron Niv, Ram Dickman, Zohar Levi, Gadi Neumann, Eyran Halpern, Rabin Medical Center, Clalit Health Services, Tel Aviv University, Petach Tikva 49100, Israel.
authors.forename: Eyran
authors.initials: E
authors.lastname: Halpern
mesh_terms: D000046:Academic Medical Centers / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D003142:Communication; D003153:Community Health Services / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D003159:Community-Institutional Relations / Q000191:economics / Q000592:standards; D003299:Cooperative Behavior; D003362:Cost-Benefit Analysis; D019033:Delivery of Health Care, Integrated / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D003697:Delphi Technique; D005762:Gastroenterology / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D019983:Guideline Adherence; D017048:Health Care Costs; D006801:Humans; D033183:Interdisciplinary Communication; D017146:Models, Organizational; D058007:Physicians, Primary Care / Q000458:organization & administration; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000458:organization & administration; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D015397:Program Evaluation; D058996:Quality Improvement; D019984:Quality Indicators, Health Care / Q000458:organization & administration; D012017:Referral and Consultation / Q000458:organization & administration; D013997:Time Factors
keywords: Community medicine; Direct referral; Endoscopy; Gastroenterology; Open access endoscopy