Israeli Health Care Research Articles

Advancing Health Care Through Collaboration Between India and Israel

India and Israel officially established diplomatic relations in 1992. Since then they have collaborated on a host of development issues like agriculture, space research, information Technology etc. There has also been a large component of people-to-people interaction. Both nations have a large pool of technically sound man power in health care. Yet, the strengths of their respective health care human resources are not the same. India has a certain niche in the health care field, Israel has another. The concept is to leverage the strengths of both nations and synergize them. This paper proposes institutionalizing Indo-Israeli collaboration in health care areas by opening an AIIMS (All India Institute of Medical Sciences) in Israel and a Tel Aviv University (TAU) Faculty of Medicine campus in India. Both Indian and Israeli doctors and health care professionals will graduate together from both these Institutions leading to value addition for health care human resources. This paper discusses the various aspects of such collaboration.

Reflections of the quality of primary care in Canada and Israel

Rachel Podell and her colleagues at the National Program for Quality Indicators in Community Healthcare in Israel have provided a clear and engaging description of thequality of primary care provided to the elderly in Israel. They examine changes overtime, variation across sub-groups, and comparisons with other countries. Over a 13year timeframe, most of the included process measures improved substantially, withfairly minor differences between demographic groups and largely favourablecomparisons with other countries.In the Podell et al article, there are few direct comparisons of primary care available between Canada and Israel, but we know from other studies that Canadian primary care compares relatively unfavourably with ten other developed countries in a number of measures. These include timely access to care, after-hours care, electronic medical record use and audit and feedback for quality improvement. More concerning is that few of these measures have improved in Canada over a number of years, despite a major policy focus on primary care, investments in payment reforms and the formation of groups and inter-professional teams.Differences in performance trajectories could relate to the major structural differences in primary care between Canada and Israel. While Canada has universal health insurance coverage for necessary physician and hospital services, most physicians practice privately, are paid mainly through fee-for-service and have few accountabilities to the health care system. Many Canadians lack a regular source of primary care and there is little or no competition between primary care practices or groups, as most of them have full practices, and are not accepting new patients. No Canadian province has completely implemented electronic medical records in primary care. Canada also lacks the organizational, administrative and support structures of Israel's health maintenance organizations.Canada and other countries can learn from the advances in data, measurement, feedback, and organization of care that are now applied routinely to ongoing quality improvement in Israel, with impressive results. The Israeli experience suggests that future developments designed to improve care and outcomes should include measurement infrastructure, formal reporting, accountability mechanisms, and management systems to address gaps and inequities in care.

The epidemiology and economic burden of hip fractures in Israel

BackgroundHip fractures increase the risks of mortality and major morbidity in the elderly. Hip fractures are associated with chronic pain, reduced mobility, disability and increasing dependence. We evaluated the direct costs incurred to the Israeli healthcare system in 2013 as a result of hip fracture injuries in elderly patients.MethodsHip fractures costs evaluation consisted of first-year and long-term direct costs. Data on the incidence of hip fractures resulting in hospitalizations were retrieved from the Israeli Ministry of Health’s (MOH) Central Database of Hospital Admissions. Hospitalization, rehabilitation and nursing utilization rates and costs were estimated based on the professional literature and according to the MOH’s price list.ResultsDuring 2013, 6285 elderly patients were hospitalized in Israel due to hip fractures. Direct costs of hip fracture, comprising hospitalization, rehabilitation and nursing costs incurred during the first year after the injury, were estimated at 454 million New Israeli Shekels (NIS; 83,841 NIS per person). Long-term nursing care costs in 2013 were 265 million NIS, with an average cost of approximately 49,000 NIS for 1600 elderly persons receiving long-term nursing care as a result of a hip fracture. Overall, the total direct costs of hip fracture in the elderly population in Israel in 2013 were 719 million NIS.ConclusionsThe direct costs of hip fractures in Israel among the elderly are approximately 719 million NIS per year. The majority of costs are associated with the first year following the injury. To reduce healthcare costs in Israel, changes in the country’s healthcare policy on hip fractures are required. For example, there is a need for a program for detecting high- risk populations, and for early intervention following the injury.

Texture-modified foods and thickened fluids used in dysphagia: Israeli standardised terminology and definitions.

Texture-modified foods and thickened fluids are used as a strategy that aims to compensate for dysphagia and improve the safety and efficiency of swallowing. Currently, in Israel, there are no standardised terminologies and definitions for texture-modified diets. The inconsistent terminology adversely affects patient safety and the efficiency of communication between staff members both within and between health institutions. This present study describes a project of the Israeli Ministry of Health in which the labels and definitions of prevalent foods and fluids used in health institutions are mapped to develop a consensus on national standards. A multidisciplinary committee of speech-language pathologists (SLPs) and registered dietitians (RDs) was appointed. A questionnaire was developed to identify the labels of texture-modified foods and fluids used in the Israeli healthcare system. The questionnaire included questions on knowledge, attitudes and barriers related to the need for a consistent national terminology for texture-modified diets. Questionnaires were sent to 120 institutions. The project was conducted between September 2016 and December 2017. Twenty-six SLPs and 42 RDs responded. The answers revealed that there were 50 labels in use for texture-modified foods. When asked to describe the texture of a particular food item, up to 17 different labels were used. There was broad support for a standardised terminology. The results of the present study confirm the lack of national standards in clinical practice and the need for a consistent terminology. A consensus was achieved between the committee members and the committee adopted the International Dysphagia Diet Standardization Initiative (IDDSI) recommendations and adapted the terminology to Hebrew.

Economic Evaluation of Dapagliflozin as Add-On to Metformin in T2DM in the Israeli Health Care Setting

Background: Dapagliflozin is a potential for combination therapy with metformin in T2DM. However, its cost-effectiveness relative to other alternatives in the Israeli healthcare setup remains unknown. Objective: To evaluate the cost-effectiveness of dapagliflozin 10mg as add-on to metformin, compared to common alternatives (sitagliptin 100mg, glimepiride 2mg, liraglutide 1.2mg) based on Meuhedet health services database. Methods: A cost-effectiveness evaluation was performed using the Cardiff diabetes model. A cohort of 1000 T2DM patients (ages 21 and older) who had received additional medication to metformin was randomly chosen from Meuhedet’s database. Baseline values for demographic and clinical variables prior to the add-on therapy, along with data from clinical trials served as inputs to the model. Simulation was performed for each drug, calculating its total costs and benefits (QALYs). The model’s time horizon was set to 40 years, annual discount rate for both costs and benefits was 3.5% and incremental cost effectiveness ratio (iCER) threshold was £20,000/QALY. Finally, single-variable and multivariable sensitivity analyses were performed. Results: In the base-case scenario, dapagliflozin was found cost-effective compared to sitagliptin, liraglutide and glimepiride (iCER values of £1,232, £-16,517 and £13,476, respectively). For all comparisons, iCER was driven by differences in costs, while differences in QALYs were minimal. Dapagliflozin remained cost-effective even after performing sensitivity analyses. However, when performing the simulation under comparators’ generic competition scenario, dapagliflozin was no longer cost-effective compared to liraglutide (iCER =£24,900/QALY). Conclusion: Dapagliflozin as add-on treatment to metformin was cost-effective compared to several alternatives in T2DM patients in Israel’s healthcare system. Additional research is needed in order to evaluate the effects of evolving new clinical data. Disclosure S. Moshel: Research Support; Self; AstraZeneca. M. Hirsch Vexberg: None. O. Shavit: None. Y. Toledano: None.

Challenges to the Israeli healthcare system: attracting medical students to primary care and to the periphery

BackgroundThe greatest challenges facing healthcare systems include ensuring a sufficient supply of primary care physicians and physicians willing to work in rural or peripheral areas. Especially challenging is enticing young physicians to practice primary care in rural/peripheral areas. Identifying medical students interested in primary care and in residencies in Israel’s periphery should aid the healthcare leadership. It may be particularly important to do so during the clinical years, as this is the stage at which many future physicians begin to crystallize their specialty and location preferences.MethodsQuestionnaires, distributed to 6 consecutive 5th-year classes of the Hebrew University – Hadassah School of Medicine, from 2010 to 2016, elicited information on criteria for choosing a career specialty, criteria for choosing a residency program and whether one-time monetary grants authorized in the 2011 physicians’ union contract would attract students to residencies in the periphery.ResultsCompleted questionnaires were returned by 511 of 740 (69%) students. Ninety-eight (19%) were interested in a primary care residency, 184 (36%) were unsure and 229 (45%) were not interested. Students interested in primary care were significantly less interested in specialties that perform procedures/surgeries and in joining a medical school faculty, while being more inclined towards specialties dealing with social problems, controllable lifestyles and working limited hours. The percentage of students interested in primary care was stable during the study period.Forty-eight of the students indicated interest in residencies in the country’s periphery, and 42% of them were also interested in primary care residencies. Overall, only 3.7% of students were interested in both a primary care residency and a residency in the periphery.Thirty percent of the students indicated that the monetary incentives tempted them to consider a residency in the periphery. Fifty-three percent of these students reported that they did not yet know the geographic area where they wished to do their residency, as compared to only 22% among those not interested in incentives.ConclusionsThis study provides the healthcare leadership with information on the characteristics of the students at a centrally-located medical school who tend to be more interested in primary care and in working in the periphery. Specifically, the study found that students interested in primary care desire a positive life/work balance, something that Israeli non-hospital primary care practice provides. Students considering residencies in the periphery were similarly inclined. Moreover, about a third of students had positive thoughts about monetary incentives for residencies in peripheral hospitals. These students should be identified early during their clinical experience so that attempts to recruit them to the periphery can commence before their specialty and location preferences have fully crystallized. Parallel studies should be performed at additional Israeli medical schools.

Healthcare disparities amongst vulnerable populations of Arabs and Jews in Israel

The complex nature of studying health and healthcare disparities in general, and in the context of the Israeli healthcare system in particular, is depicted in two recent IJHPR articles. The first examines Emergency Department (ED) waiting times in a tertiary children’s hospital and the second examines disparities in the health care for people with schizophrenia of an ethnic-national minority. Contrary to other Israeli studies on wide disparities in health and healthcare, these studies show no disparities - ED waiting times did not differ among Arab and Jewish children and report no differences in performance of Hemoglobin A1C tests or in surgical interventions in patients with cardiovascular disease between Arabs and Jews with schizophrenia. Thus, the studies reflect areas of equitable health care delivery within the Israeli healthcare system.Future studies should account for the fact that the phenomena of health and healthcare disparities is complex and should utilize rigorous methodologies to take into consideration the various factors that may affect the manifestation of differences amongst population groups. As a result, they may help detect disparities which may otherwise be missed.

Perspectives of health professionals on the best care settings for pediatric trauma casualties: a qualitative study

BackgroundCritically-injured children are frequently treated by providers who lack specialty pediatric training in facilities that have not been modified for the care of children. We set out to understand the attitudes and perspectives of policy makers, and senior nursing and medical managers in the Israeli healthcare system, concerning the provision of medical care to pediatric trauma casualties in emergency departments.MethodsWe conducted semi-structured interviews with 17 health professionals from medical centers across Israel and the Ministry of Health. The interviews were analyzed by qualitative methods.ResultsThere was lack of clarity and uniformity concerning the definition of a pediatric trauma casualty. All of the participants attributed extreme importance to the professional level of the care team manager, and most suggested that this should be a pediatric emergency medicine specialist. They emphasized the importance of around-the-clock availability of pediatric medical teams to care for young trauma casualties, and the crucial need for caregivers to be equipped with a wide variety of professional skills for the adequate treatment of a broad spectrum of injuries. All participants described significant variability in pediatric-care training and experience among physicians and nurses working in emergency departments. Most participants believe that pediatric trauma casualties should be treated in designated pediatric emergency departments, in a limited number of medical centers across the country.ConclusionsOur findings indicate that specialized pediatric EDs would constitute the best location for intake of children with major traumatic injuries. Pediatric emergency medicine specialists should manage trauma cases using pediatric surgeons as ad-hoc consultants. The term ‘pediatric patient’ should be defined to allow trauma patients to be referred to the most appropriate ED. Teams working at these EDs should undergo specialized pediatric emergency medicine training. Finally, to regulate the key aspects of trauma care, clear statutory guidelines should be formulated at national and local levels.

The Secret Drama at the Patient's Bedside-Refusal of Treatment Because of the Practitioner's Ethnic Identity: The Medical Staff 's Point of View.

Patients' refusal of treatment based on the practitioner's ethnic identity reveals a clash of values: neutrality in medicine versus patient-centered care. Taking the Israeli-Palestinian conflict into account, this article aims at examining Israeli health care professionals' points of view concerning patients' refusal of treatment because of a practitioner's ethnic identity. Fifty in-depth interviews were conducted with 10 managers and 40 health care professionals, Jewish and Arab, employed at 11 public hospitals. Most refusal incidents recorded are unidirectional: Jewish patients refusing to be treated by Arab practitioners. Refusals are usually directed toward nurses and junior medical staff members, especially if recognizable as religious Muslims. Refusals are often initiated by the patients' relatives and occur more frequently during periods of escalation in the conflict. The structural competency approach can be applied to increase awareness of the role of social determinants in shaping patients' ethnic-based treatment refusals and to improve the handling of such incidents.

Referral Pattern of Nighttime Visits to the Ocular Emergency Department at a Tertiary Referral Center in Israel

Objective: The structure of the Israeli healthcare system is such that it is frequently more convenient for the patient to present to an ophthalmologic emergency department (OED) at night instead of waiting for a scheduled appointment in an outpatient setting. The main objective of this study is to evaluate the diagnoses of patients who attended an OED of a tertiary referral center at night during a one-year period. Methods: A prospective study. All patients who presented to our medical center’s OED between 22:00-06:00 were enrolled. On presentation, all patients filled in a demographic and medical questionnaire, and the attending ophthalmologists filled in another questionnaire on the diagnosis and the treatment that had been provided. Data from electronic/paper medical records were collected and analyzed, and cases were categorized post-factum as urgent or non-urgent. Results: A total of 1,290 patients (50% females, mean age 38 years) comprised the study group. Of them, 364 (29.7%) were self - referred, 208 (17%) were referred by a general practitioner or an ophthalmologist, and 404 (32.9%) were referred for consultation from within the general ED. Trauma was the most frequent diagnosis (47%), followed by infectious/inflammatory conditions (16%), and 365 (29.3%) cases were categorized as non-urgent. Conclusion: Patients who pay nighttime OED visits require ophthalmic care in a range of urgency. We believe it is justified to have in-house on call ophthalmologist during night shift in the ED. However, a significant proportion of the nighttime visits constitute non-urgent cases that could have been treated in ophthalmic primary care facilities. Implying flaws in the structure of the country’s healthcare system by overloading the tertiary care facilities where costs are considerably higher than in the community. Allocation of appropriate resources to such facilities may lead to improved patient management and alleviation of the heavy burden on the public healthcare system.

Cultural Concordance and Health Accessibility Differentials in Israel: Field Survey in Tel Aviv

Inequity occupies an important place in the ongoing global debate on health care accessibility. Israel, with its culturally diverse population and global reputation for an advanced health system, stands to be an ideal case to examine this subject. Economic disparity and geographical barriers are well-documented themes in the extant literature on accessibility gaps. However, the centrality of cultural factors in health care accessibility gaps remains understudied, especially in case of Israel. This study attempts to bridge the gap by examining cultural barriers to health care in Israel, within the conceptual framework of concordance using four communication variables, namely, language, gender, religion, and ethnicity. Based on the analysis of secondary information and primary data collected from field study in the city of Tel Aviv during February 2016, the article discusses how language and gender are main cultural barriers to health care in the study area, while religion and ethnicity do not influence health access significantly.

The role of the physician in Israel\u2019s maternal child health clinics: surveys of professional and parental perceptions

BackgroundPreventative health services are a pediatric health care cornerstone, which strives to promote health and prevent illness and injury. In Israel, Maternal Child Health Clinics (MCHC) provide these well child services for ages 0–6 years. MCHC care includes physician visits; however, the physician’s role is not well defined. The study purpose was to provide a basis for setting policies that determine the role of physicians in the provision of MCHC services. To get broad input we included MCHC stakeholders - parents, MCHC physicians, non-MCHC physicians and MCHC nurses, specifically to obtain insights regarding the MCHC physician role and to characterize the stakeholder demographics, service utilization, and practice patterns.MethodsProfessional groups completed self-administered written questionnaires (n = 398). Parents were interviewed during MCHC visits using a structured questionnaire (n = 1052). All provided demographic data, service characteristics and agreement with ten potential MCHC physician roles - Physical Examination, Abnormal Health Condition Detection, Developmental Screening, Anticipatory Guidance, Parent-Child Interaction Counseling, MCHC Staff Advice, Children-at-Risk Detection, Growth Surveillance, Vaccination Counseling, and Inter-physician Communication.ResultsThe study findings seem to indicate a true shortage of MCHC physicians. The median age of MCHC physicians was significantly higher than both non-MCHC physicians and MCHC nurses. There was agreement among stakeholders regarding some roles (Physical Examination, Developmental Screening and Detection of Abnormal Health Conditions) but not others. Most parents reported having at least one MCHC physician encounter. Parents who did not visit the physician were younger and had fewer children.ConclusionsStakeholders view MCHC physicians as integral to MCHC care. Roles traditionally regarded as part of primary prevention were less likely to be attributed to physicians than screening roles considered secondary prevention.Updating and standardization of the MCHC physician role is needed along with a national strategy to recruit and train MCHC physicians.to ensure optimal pediatric preventive health care in Israel.

Workplace violence in a tertiary care Israeli hospital - a systematic analysis of the types of violence, the perpetrators and hospital departments

BackgroundWorldwide, there is a widespread and disturbing pattern of violence towards healthcare workers. However, violent occurrences in Israeli hospitals have often been unrecognized and underreported. Moreover, most studies have not sufficiently differentiated among the different types of violence.To examine the different types of violence experienced by nurses and physicians, the types of perpetrators and the specialty fields involved.MethodsA quantitative questionnaire was used to assess the incidence of a “basket” of violent behaviors, divided into eight types of violent manifestations. The study population consisted of 729 physicians and nurses in a variety of hospital divisions and departments (surgery, oncology, intensive care, ambulatory services including day care, and emergency room) in a large general hospital. Six hundred seventy-eight of them responded to the survey for a response rate of 93%; about two thirds of respondents (446) were nurses and about one third (232) were physicians. The questionnaires were completed during staff meetings and through subsequent follow-up efforts.ResultsIn the 6 months preceding the survey, the respondents experienced about 700 incidents of passive aggressive behavior, 680 of verbal violence and 81 of sexual harassment. Types of violence differed between patients and companions; for example, the latter exhibited more verbal, threatening and passive aggressive behaviors. Violence was reported in all departments (ranging from 52–96%), with the departments most exposed to violence being the emergency room and outpatient clinics. Nurses in the emergency room were 5.5 times at a higher risk of being exposed to violence than nurses in the internal medicine department. Nurses were exposed to violence almost twice as much as physicians. There was a positive association between the physician’s rank and his/her exposure to violence. A multiple regression model found that being older reduced the risk of being exposed to violence, for both physicians and nurses.ConclusionsThese findings suggest that uniform definitions of a range of different violent behaviors and assessments of their prevalence are important to creating an improved discourse about hospital violence in both research and operational settings. The study findings could assist policy makers in the Israeli healthcare system in implementing interventions on a national level and can promote leaders’ commitment to violence prevention and management. This is an important contribution, as executive commitment is necessary and critical for the necessary organizational changes to occur.

The Impact of a Carbapenem-Resistant Enterobacteriaceae Outbreak on Facilitating Development of a National Infrastructure for Infection Control in Israel.

In 2006 the Israeli healthcare system faced an unprecedented outbreak of carbapenem-resistant Enterobacteriaceae, primarily involving KPC-producing Klebsiella pneumoniae clonal complex CC258. This public health crisis exposed major gaps in infection control. In response, Israel established a national infection control infrastructure. The steps taken to build this infrastructure and benefits realized from its creation are described here.

Policy entrepreneurship in the reform of pediatric dentistry

In a recently published IJHPR article, Cohen and Horev ask whether an individual who holds rightful governmental power is able to effectively “challenge the equilibrium” in ways that might “clash with the goals” of an influential group”. This question is raised within the context of a shift in governmental policy that imposed the potential for cost management by HMOs acting as financial intermediaries for pediatric dental care in an effort to provide Israeli children better access to affordable dental care. The influential group referred to consists of Israel’s private dentists and the individual seeking to challenge the equilibrium was an Israeli Minister of Health whom the authors consider to be a policy entrepreneur.The Israeli health care system is similar to that of the United States in that private benefit plans and self-pay financing dominate in dental care. This is in contrast to the substantial role of government in the financing and regulation of medical care in both countries (with Israel having universal coverage financed by government and the US having government financing the care of the elderly and the poor as well as providing subsidies through the tax system for the care of most other Americans).Efforts to expand governmental involvement in dental care in both countries have either been opposed by organized dentistry or have suffered from ineffective advocacy for increased public investment in dental care.In the U.S., philanthropic foundations have acted as or have supported health policy entrepreneurs. The recent movement to introduce the dental therapist, a type of allied dental professional trained to provide a narrow set of commonly-needed procedures, to the U.S. is discussed as an example of a successful challenge to the equilibrium by groups supported by these foundations. This is a somewhat different, and complementary, model of policy entrepreneurship from the individual policy entrepreneur highlighted in the Cohen-Horev paper.The political traction gained to change the equilibrium favored by organized dentistry – in both Israel and the U.S. - may reflect aspirations for care that is more accessible, patient-centered, accountable and equitable. Evolving aspirations may lead to policy changes to systematize the disparate, disaggregated dental care delivery system in both counties. A change in payment incentives to provide more value is being explored for medical care, and its expansion to dental care can be anticipated to be among the policies considered in the future.

Is there a doctor in the house? Availability of Israeli physicians to the workforce

BackgroundIsraeli policymakers have expressed serious concerns about being able to meet the growing demand for physician services. For this reason, the Israel Ministry of Health (MoH) undertook studies based on 2008 and then 2012 data to obtain an accurate assessment of the size, specialty mix, demographic and geographic composition of the physician workforce. This paper highlights the findings from these studies about the number and percentage of licensed physicians in Israel who were not available, were only partially available, or were about to leave the Israeli healthcare workforce.MethodsThe two studies cross-linked administrative files of the entire physician population in Israel. The two sources were the MoH registry of licensed physicians, which contains demographic, medical education and specialty information, and the Israel Tax Authority income file on employment data. A third source, used only for the study of 2008 data, was the CBS Population Census Data 2008 which was based on a large representative sample of the population (14%), along with the updated Population Registry, which provided data on physicians whose occupation was in medical care as well as the number of work-hours. By linking the files we could also assess the population of licensed Israeli physicians living abroad.ResultsOnly 74% of licensed physicians of all ages in 2012 were active in the Israeli workforce. Of physicians under the age of 70, 87% were living and working in Israel. Female physicians tended to retire from the workforce earlier than males and were more likely to work fewer hours during their working years. The rate of physicians who worked longer hours declined in both genders as age rose. About 10% of licensees had been living abroad for at least a year and the majority of these were older. Approximately 7% of licensed physicians, ages 30–44, were abroad and most are presumed to be doing additional clinical training or gaining research experience.In some specialty fields young physicians were not replacing retirees at a compensatory rate; anesthesiologists, a specialty in short supply in Israel were more likely to be living abroad than other specialists.ConclusionsAssessment of the medical workforce pool and personnel planning require not just the number of licensed physicians but also information about the employment mix of license holders and their level of professional activity in Israel.For planning future workforce needs, it is important to keep in mind that the average female vs. male physician has lower clinical productivity due to shorter hours and earlier retirement and that a group of young physicians will predictably be abroad at any point in time; however major “brain drain” is not evident. Furthermore, extrapolating from the findings in the current studies, we believe that a potential shortage of physicians within Israel can be mitigated by better administrative support of physicians, use of physician extenders, and careful attention to improving physician satisfaction in certain specialties.

On the verge of shared decision making in Israel: Overview and future directions

Israel has a universal-national healthcare system and a progressive health policy legislation which, together, provide its residents with high-level healthcare services and either free or highly subsidized coverage without any pre-existing conditions. However, it is surprising that shared decision making (SDM) practices and policy are not an integral part of Israel's healthcare system. The purpose of this overview is to describe the gap between the organizational-infrastructure compatibility of Israel's universal healthcare policy and the efforts needed to advance SDM as part of routine healthcare practice. Review of recent research and education initiatives will be described as well as recommendations for policy and clinical practice.

Statin adherence and the risk of Parkinson's disease: A population-based cohort study.

BackgroundWhile experimental data provided some compelling evidence on the benefits of statins on dopaminergic neurons, observational studies reported conflicting results regarding the potential of statins to effect the risk of Parkinson’s disease (PD).ObjectivesTo evaluate the association between changes in statin adherence over time and PD risk.MethodsA population-based cohort of new statin users (ages 40-79, years 1999-2012) was derived from a large Israeli healthcare services organization. Data included history of statin purchases and low density lipoprotein cholesterol (LDL-C) levels. Personal statin adherence was measured annually by the proportion of days covered (PDC). PD was detected employing a drug-tracer approach. Stratified (by sex, LDL-C levels at baseline and age) Cox proportional hazards models with time-dependent covariates were used to compute adjusted Hazard Ratio (HR) with 95%CI.ResultsThe cohort included 232,877 individuals, 49.3% men. Mean age at first statin purchase was 56.5 (±9.8) years for men and 58.7 (±9.2) years for women. PDC distribution for the whole follow up period differed between men and women: medians 58.3% and 54.1% respectively. During a mean follow up of 7.6 (±3.4) years, 2,550 (1.1%) PD cases were identified. In a 1-year lagged analysis, we found no association between annual statin adherence and PD risk in all age-groups regardless of statin type and potency. Age-pooled HR (95%CI) for men and women with LDL-C levels at baseline ≤160mg/dL were: 0.99 (0.99-1.01), 1.01 (1.00-1.02); and for men and women with LDL-C >160mg/dL levels: 0.99 (0.98-1.01), 0.97 (0.98-1.01).ConclusionsOur findings suggest that statin adherence over time does not affect PD risk. Future studies should use large-scale cohorts and refining assessments of long-term profiles in statin adherence.

Facility maintenance and management: a health care case study

ABSTRACTContemporary trends in healthcare services provision tend toward the increased use of community based healthcare centers. This study on the concepts of healthcare provision hypothesizes that in the future, the main source of healthcare services will be a network of community based clinics which will be responsible for the majority of primary and ambulatory care. This concept implies that a network of community clinics equipped with state of the art telemedicine will be established with a wide geographical dispersion. The implications for healthcare facilities in terms of the resources and performance of the built environment are investigated by reference to the Israeli healthcare system. This paper reflects the results of research on healthcare facility management over the past 10 years. Comparison of the performance and maintenance of hospital facilities and community clinics reveals that the maintenance and performance of clinic facilities have the potential to combine improved healthcare facili...

Race-based experiences of ethnic minority health professionals: Arab physicians and nurses in Israeli public healthcare organizations

ABSTRACTIncreasing workforce diversity was found to contribute to the narrowing of disparities in health. However, racism toward ethnic minority health professionals has not been adequately researched. In Israel, public healthcare organizations that serve a mixed Jewish-Arab population employ Arab minority healthcare professionals. Instances of prejudice and manifestations of racism toward them, which frequently surface in public discussion and the media, have unfortunately gained little scholarly attention. We used the intergroup contact approach and the theory of the social process of everyday racism as a theoretical framework. The objective of the research was to study race-based experiences of Israeli Arab healthcare professionals.Methodology: We used a qualitative research method that allows respondents to describe their views, experiences, beliefs and behavior in the way they think about them. During 2013 and 2014 we conducted in-depth interviews with a snowball sample of 10 Arab physicians and 13 Arab nurses who work in Israeli public hospitals. The study protocol was ethically approved.Findings: Interviewees noted institutional efforts to maintain egalitarianism and equality. However, at the micro-level, interviewees, mostly nurses, reported instances that ranged from refusal to accept treatment from an Arab nurse, through verbal abuse, to the use of physical violence against them. At the meso-level, interviewees, mostly physicians, reported experiences of institutional discrimination. At the macro-level, one physician reported policy-related discrimination in the context of the immigration of Russian Jewish physicians to Israel.Conclusions: We recommend combining the intergroup contact approach with the social process theory of racism to examine minorities’ subjective perceptions, especially in conflictual and violent contexts; conducting broad-based quantitative research in Israeli healthcare organizations, which may have important implications for the specific strategies to be used; and emphasizing the importance of institutional support. By reconstructing race-based experiences of ethnic minority health professionals, health organizations can better manage racial situations and reduce their frequency.