Health Maintenance Organization In Israel Research Articles

Seasonality in Birth Weight in Israel: New Evidence Suggests Several Global Patterns and Different Etiologies

To investigate the effect of season on birth weight and whether it is expressed also in fluctuations of proportions of extreme birth weights. Information about 225,545 singletons born during 1998 to 2004 was obtained from a large health maintenance organization in Israel. We conducted a linear regression analysis of the weight with month and year of birth, sex, maternal age, diabetes, and several meteorological factors as independent variables, which were also incorporated into multivariate logistic regression models to examine the effect of season of birth on the frequency of low birth weight (LBW, <2500 g) or macrosomia (>4000 g). A significant (P < .001) seasonal pattern in birth weights was observed, with a peak in July and a trough in January. Babies born in summer had an OR of 1.12 (95% CI; 1.07 to 1.18) for macrosomia compared with those born in the winter. No such pattern was found for LBW. While in regions of mid-latitude, summer is associated with relatively lower birth weight, possibly because of exposure to cold temperature during early or mid-pregnancy, our data suggest that in Israel, the peak birth weight is in summer, possibly because of increased exposure to sunlight in the last weeks of the pregnancy.

Association between antidepressant prescribing and suicide in Israel

The effects of antidepressants on suicide are controversial; on the one hand they decrease the incidence of death by suicide, as reflected in epidemiological studies, and on the other hand, there are claims that they increase the risk of impulsivity and suicide. In 1998, primary care physicians in Israel were not allowed to prescribe selective serotonin reuptake inhibitors and in 1999 this prohibition was lifted. We thus evaluated the association between patterns of antidepressant prescribing and the rate of death by suicide in Israel in 1998 compared with that in 2002. Data regarding deaths by suicide were obtained from the Central Bureau of Statistics. Annual rates of antidepressant prescribing were computed from the Intercontinental Marketing Services database. The Intercontinental Marketing Services data covers three out of the four Health Maintenance Organizations in Israel, encompassing 46% of all citizens. Prescribing of all antidepressants increased 2.6-fold between 1998 and 2002. This increase was significantly more pronounced for the selective serotonin reuptake inhibitors. A shift in prescription practices was noted, with a 1.37-fold increase in prescribing by primary care physicians. While the concomitant decrease in overall national rates of completed suicide did not reach significance (17-14 per 100,000), the incidence decreased significantly in men aged 55-74 years (33-22 per 100,000; P=0.029). An overall reduction in suicides, which was significant only in elderly men, was noted in association with increased rates of antidepressant prescription. This study is limited in scope but adds a unique viewpoint related to the possible positive effect of increased antidepressant prescribing in primary care on suicide.

Topical β-Blockers Are Not Associated with an Increased Risk of Treatment for Depression

To investigate the effect of topical beta-blockers on the prevalence of depression among glaucoma patients. Retrospective observational population-based cohort study. We reviewed the electronic medical records of all the members in a district of the largest health maintenance organization in Israel (Central District of Clalit Health Services) who were older than 20 years (317,469 members). We documented all antiglaucoma prescriptions (n = 274,023) and all antidepressant prescriptions (n = 16,948) filled by glaucoma patients in the district between January 1, 2001 and December 31, 2003. We included only those patients who filled at least 6 consecutive antiglaucoma prescriptions at least once every 2 months (n = 6597; 5846 [88.6%] were treated with topical beta-blockers). Depressed patients were defined as patients that filled at least four prescriptions for antidepressants during the study period (n= 810, 12.3% of all glaucoma patients). Relationship of topical beta-blocker use and prevalence of depression among glaucoma patients. No significant demographic differences were noted between glaucoma patients treated and not treated with topical beta-blockers. Of those treated and not treated with beta-blockers, 12.2% (12.7% after age-adjustment) and 12.7%, respectively, were also receiving drug therapy for depression (P = 0.7, chi-square test). With stratification by age, treatment with topical beta-blockers did not influence the prevalence of depression in any age group. Logistic regression analysis revealed a significant effect of age, place of birth, and gender on the prevalence of depression, but the prevalence of use of topical beta-blockers had no significant effect. Use of topical beta-blockers by glaucoma patients does not appear to increase the risk of depression in this population.

The utilization of pediatric computed tomography in a large Israeli Health Maintenance Organization

Concern has been raised about the potential risks related to radiation exposure from CT scans, particularly among children. However, to date, there are few data available describing the magnitude of pediatric CT utilization. The aim of the study was to explore patterns of CT use in pediatric patients, with respect to time, use of multiple scans, body regions imaged, and medical diagnoses. Records of 22,223 scans performed on 18,075 people aged < or =18 years over the period 1999-2003, including diagnoses recorded within 21 days after the examination, were obtained from a large Israeli Health Maintenance Organization (1,600,000 members). The highest annual CT examination rate (per 1,000) was recorded in 2001 (10.1) compared to 7.0 and 6.3 in 1999 and 2003, respectively. The lowest rate (three scans per 1,000) was found for 3-year-old children, with increasing rates with age. The head was the most frequently scanned region, both in young children (78%) and adolescents (39%). Symptoms of ill-defined conditions and injuries were documented in 22% and 10% of all scans, respectively. Although the results suggest that children comprise only 3% of all patients undergoing CT, this important modality must be carefully used because of their increased radiosensitivity, higher effective radiation doses, and longer life expectancy.

Prevalence of Methylphenidate Use among Israeli Children

Use of methylphenidate for the treatment of attention-deficit hyperactivity disorder (ADHD) has increased throughout the world in the past decade. In Israel, as elsewhere, there is much debate regarding the diagnosis of ADHD and methylphenidate use. The aim of this study was to examine methylphenidate use rates for the treatment of ADHD among children in Israel during the years 1998-2004 with a special focus on prescriptions among girls. This was a longitudinal population-based prevalence study wherein we reviewed the computerised database of a major health maintenance organisation (HMO). Subjects studied included all children living in the central district of Clalit HMO in Israel who were prescribed methylphenidate in the 7-year period from 1998-2004. The overall 1-year prevalence rate of methylphenidate use in children aged 0-18 years increased from 0.7% in 1998 to 2.5% in 2004, an increase by a factor of 3.54 (95% CI 3.31, 3.79). In 1998, the rate of methylphenidate prescription ranged from 0.20% among schoolgirls to 1.2% among boys, a 6-fold difference. In 2004, the rate of methylphenidate prescription ranged from 1.1% among schoolgirls to 3.8% among boys; the sex difference had narrowed to only 3.45. Except for kindergarten girls, methylphenidate utilisation increased for all ages from kindergarten to high school, both among boys and among girls. The continuous increasing rate of methylphenidate use in Israel, especially among girls, represents a significant public health issue. There is a need for future research into the relationship between sex and ADHD diagnosis and treatment.

Herpetic Eye Disease in Diabetic Patients

To study the incidence of herpetic eye disease (HED) of the ocular surface in diabetics. Observational historical cohort study. A district of the largest health maintenance organization in Israel (the Central District of Clalit Health Services). We reviewed the electronic medical records of all patients older than 50 years (159634 patients) in the district, and of these, 22382 (14.0%) patients had diabetes mellitus. All filled prescriptions for acyclovir eye ointment between January 1, 2001 and December 31, 2003 (1483 tubes) and all hemoglobin A1c laboratory tests during 2003 (41910 tests) were documented. An ocular surface HED event was defined when a patient consumed at least 1 tube of topical acyclovir per month, whereas no acyclovir use was documented 3 months before and 3 months after that event. Incidence of ocular surface HED events in diabetics compared with nondiabetics adjusted for age and gender. After age and gender adjustment, significantly more diabetics had ocular surface HED (5.21 per thousand) compared with nondiabetics (4.27 per thousand; P<0.0001). Stratification by age revealed a significantly higher prevalence of HED in diabetics, aged 60 to 79 years. Recurrent herpetic events occurred during the study period in 25.2% of HED-affected diabetics, and in 16.6% of HED-affected nondiabetics (P = 0.05). Diabetics with poor glycemic control (mean annual hemoglobin A1c > 9%) consumed significantly more ocular acyclovir (P = 0.01). Multivariate analysis revealed this effect to be independent of age, gender, place of birth, or place of residency. Ocular surface HED is significantly more common among patients with diabetes mellitus. Poor glycemic control correlates with increased consumption of ocular acyclovir in diabetic patients.

The Effect of Combination Pharmacotherapy on the Prescription Trends of Glaucoma Medications

To describe prescription trends within a managed care setting for glaucoma medications and to examine the effect of introduction of Cosopt--a fixed combination of dorzolamide and timolol. All prescriptions dispensed to any of the 470,350 members of an Israeli health maintenance organization were monthly scanned for patients treated for glaucoma, between January 2000 and May 2003. The monthly mean number of glaucoma patients was 3899 +/- 104 (mean +/- SD). All topical glaucoma prescriptions were documented, and the monthly prescription rate of each medication was calculated and plotted. The monitored glaucoma medications were: beta-adrenergic antagonists, dorzolamide, latanoprost, pilocarpine, brimonidine, Cosopt, and others. beta-adrenergic antagonists were the top prescribing drug (>35% of all glaucoma prescriptions). The prescription rates of pilocarpine and beta-adrenergic antagonists were in constant decline, while latanoprost and brimonidine increased steadily. The introduction of Cosopt changed the prescription trends of dorzolamide from increasing to rapidly decreasing, and accelerated the long-term decline of beta-adrenergic antagonists. Concomitant with the introduction of Cosopt the prescription rate of beta-adrenergic antagonists temporarily increased. This was due to a total increase in glaucoma prescriptions. When Cosopt was introduced, 37.5% of patients were prescribed Cosopt together with beta-adrenergic antagonists, and 16.5% also received dorzolamide. Thereafter the co-prescription decreased steadily. Introduction of a combination drug should be accompanied by physicians', pharmacists', and patients' education to prevent its inappropriate usage together with its components.

Gender differences in healthcare utilization and medical indicators among patients with diabetes

Objective. To describe differences in healthcare utilization and health indicators of patients with diabetes, according to gender. Study design. A population-based outcome study conducted on 21,277 diabetic patients between the ages of 45 and 64 years who are members of the second largest health maintenance organization in Israel. Methods. Data on healthcare utilization (process indicators) and health problems (outcome indicators) were obtained from computerized medical records that are stored routinely by the organization. The study period was the year 2002. Results. Significantly ( P<0.05) lower healthcare utilization was observed in men compared with women for all indicators examined (number of visits to physicians and the performance of urine, lipids and creatinine tests). Nonetheless, men showed better health outcomes (lower low-density lipoprotein cholesterol, triglycerides, HbA1c). Conclusions. Women who suffer from diabetes use more healthcare services and have a higher morbidity rate compared with men. Future research should seek to identify the factors contributing to this observation, which can potentially make an important contribution to the development of disease management strategies that target diabetic women.

Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money.

Current Israeli guidelines for the empiric treatment of uncomplicated urinary tract infection (UTI) in women recommend nitrofurantoin for 5 days. Some physicians nevertheless opt for ofloxacin, which should be prescribed for 3 days according to universally accepted guidelines. To evaluate the economic consequences of longer than recommended durations of antibiotic therapy in the empiric treatment of uncomplicated UTI in women. Data were derived from the electronic records of one of the four health maintenance organizations in Israel. The sample included all women aged 18-75 years who were diagnosed with acute cystitis or UTI from January 2001 to June 2002 and were empirically treated with antibiotics. Of the 7738 patients identified, 1138 received nitrofurantoin and 1054 ofloxacin. The excess expenditure accrued due to longer than recommended therapy with these drugs was evaluated. The rate of adherence was 22.23% for nitrofurantoin (95% CI=19.81%, 24.65%), and 4.08% for ofloxacin (95% CI=2.88%, 5.28%). The average excess expenditure per case was 5.78 USD (US Dollar) with ofloxacin and 3.43 USD with nitrofurantoin, resulting in an annual loss to the health maintenance organizations of approximately 19,000 USD. When extrapolated to the national population of 6.5 million, the loss due to inappropriate treatment of adult women is 190,000 USD. The lack of adherence to national and international guidelines with regard to the recommended duration of antibiotic treatment of UTI in women resulted in a significant and avoidable waste of health system resources. This study suggests that drug utilization analyses that concentrate solely on the choice of drug may be overlooking important information.

Demonstrating Value-Added Utilization of Existing Databases for Organizational Decision-Support

Managers of healthcare organizations are increasingly aware that the potential of medical information systems exceeds mere support of routine administrative and clinical transaction processing. This article describes a case study about Maccabi Health Services, the second largest health maintenance organization in Israel and the first one to computerize clinical records resulting from routine transactions in doctors’ offices, laboratories, and pharmacies. In this case about decision-making support practices, recycling the content of existing databases made it possible to discover patterns of sub-optimal treatment without having to invest time and money in additional data-collection procedures. The case study thus demonstrates value-added utilization of patient data, beyond uses intended at the beginning, for effectively supporting the implementation and evaluation of disease-management programs. Lessons learned about organizational benefits reaped from the organization’s decision-support practices include implications for such initiatives as data warehousing, data mining, and online analytical processing.

The formulary of a large health maintenance organization in Israel

The Pharmacy Abroad section of AJHP features brief informal, and topical communications related to pharmacy in other countries. Contributions are welcomed from pharmacists abroad or from pharmacists who have traveled abroad. AJHP also encourages pharmacists from outside of the United States to submit traditional manuscripts (e.g., scientific studies, descriptions of practice innovations), which are evaluated for publication in the primary sections of the journal.

Effects of a fundholding discontinuation. An Israeli Health Maintenance Organization natural experiment

Objective - To evaluate the effects of fundholding on cost containment and after termination of the project. Design and setting - Primary care practices participating in the project were allocated an itemized budget. Practices assumed authority for hospitalization, drugs, ambulatory medical diagnostic, consultant services and acquisition of minor equipment. Financial incentives were offered, but no penalties were imposed on practices where expenditure exceeded budget. Subjects - Nine primary care practices in southern Israel. Main outcome measure - Total expenditure and a breakdown of expenditure per capita. Results - Fundholding practice expenditure was compared with expenditure in the district as a whole. During the study period, total expenditure in fundholding practices rose by 12%, whereas that of the district rose by 37%. With discontinuation of the project, expenditure of the designated practices returned to the original levels, equivalent to those of the district. Conclusion - Fundholding is an efficient method of cost-containment. The effect will be long lasting only if motivation is maintained.

Continuing medical education and primary physicians' job stress, burnout and dissatisfaction.

The association between opportunities for continuing medical education (CME) and primary physicians' job stress, burnout and job dissatisfaction has not been investigated. It was hypothesized that participation in CME activities and perceived opportunities at work for keeping up-to-date with medical and professional developments would be correlated negatively with job stress and burnout, and positively with job satisfaction. 309 primary care physicians (183 family physicians and 126 paediatricians) employed in health maintenance organizations in Israel responded to a mailed questionnaire. The independent variables were the extent of engagement in CME activities and perceived opportunities at work for professional updating. The dependent variables were job stress, burnout and job satisfaction. Multiple regression analyses were employed. After controlling for age, sex and professional status, participation in CME activities was associated negatively with job stress and positively with job satisfaction, among family physicians. Among paediatricians, CME was associated negatively with burnout. Perceived opportunities for professional updating were associated negatively with burnout and (marginally) with stress among family physicians, and negatively with stress and positively with satisfaction among paediatricians. A third of the paediatricians and a quarter of the family physicians wanted to increase their involvement in CME. In this cross-sectional study, causality cannot be established and the CME measures should be refined. However, the results are consistent with the study's hypotheses and suggest that opportunities for CME and professional updating may reduce physicians' job distress and dissatisfaction.

Nationwide program for improving the care of diabetic patients in Israeli primary care centers.

To improve the effectiveness of primary care providers in Israel to monitor and control glycemic levels of diabetic patients. We designed a 2-year program to improve the effectiveness of primary care providers to administer diabetes care. The program was conducted by the largest Israeli health maintenance organization, which insures 60% of the population. Interventions included continuing medical education and establishing guidelines and diabetes registers in every clinic. A retrospective cohort study was conducted from 1995 to 1997 to evaluate the project's effect on the care of diabetic patients. One patient was randomly chosen for review from each of the physicians' updated diabetes registers. The same indicators and variables were collected for each year. The response rate was 72.7%. Nationwide, 876 physicians participated in the review. From 1995 to 1997, there was a statistically significant improvement in the prevalence of performing all of the parameters for monitoring the primary care of diabetic patients. The process parameters showed a considerable improvement: the prevalence of recording weight increased from 35% of the diabetic patients in 1995 to 60% in 1997: the prevalence of conducting foot inspections increased from 40 to 63%; the prevalence of conducting fundus examinations increased from 38.5 to 68.3%; and the prevalence of measuring HbAlc values increased from 30.6 to 69.9%. As a result, metabolic control significantly improved: the percentage of diabetic patients with HbAlc concentration >9% decreased from 33.2% in 1995 to 22.5% in 1997; the percentage of diabetic patients with HbAlc concentration <7.4% increased from 45.1 to 50.5%. A major intervention plan based on quality assurance principles can improve physicians' performance on a national scale without the use of punitive administrative measures.

A Controlled Trial of Desmopressin and Behavioral Therapy for Nocturnal Enuresis

The combination of desmopressin (DDAVP) and behavioral therapy for treatment of nocturnal enuresis was compared with use of each of these modes alone. We randomly assigned 226 enuretic children being treated in primary care clinics of a major medical center in the largest health maintenance organization in Israel into 3 groups: Group A) DDAVP plus behavioral therapy (double-blind); Group B) behavioral therapy plus placebo (double-blind); and Group C) DDAVP alone (open group). DDAVP (20 micrograms/naris) and placebo were administered by intranasal spray. Both pharmacologic and behavioral therapy were initiated after a 2-week observation period and continued for 8 weeks. All patients were followed for 2 months after completion of treatment. A significant reduction in the number of wet nights/week was registered for all 3 groups: 49% in Group A, 45% in Group B, and 19% in Group C. After controlling for confounding factors, no significant difference in effect was noted among the 3 types of treatment during the trial period. However, on follow-up the results for the DDAVP patients were significantly less stable compared with the other 2 groups (p = 0.015). Minor side effects were registered, but none of the participants withdrew from the trial. To our knowledge, this is the largest randomized trial of nocturnal enuresis conducted to date. Our findings suggest that simply discussing the problem with the patient and family leads to improvement, and that behavioral therapy is also beneficial. DDAVP can help, but the relapse rate on discontinuation is high.

The Phenotype of Ostensibly Healthy Women Who Are Carriers for Ornithine Transcarbamylase Deficiency

Ornithine transcarbamylase (OTC) deficiency is an X-linked disorder of urea synthesis. Among females who carry a mutant OTC allele, there is a wide range of phenotypic variability, ranging from apparent normality to a severe onset and the resulting profound neurologic impairment observed in hemizygous males. This study was designed to define the phenotypic variability of OTC deficiency in ostensibly healthy carrier females and to compare them to noncarrier females from their own and other families. One hundred seventy-five women from 89 families participated in this study. Each completed a mailed questionnaire, allopurinol testing, and fasting plasma amino acid determinations. OTC carrier status was determined by pedigree analysis, allopurinol test results, and/or DNA mutation analysis. Overall, 79 women were identified as carriers of a mutant OTC allele (60 proband mothers, 19 relatives), and 96 women (32 proband mothers, 64 female relatives) were determined to be noncarriers. Comparison of biochemical phenotypes indicated that carriers and noncarriers do not differ in daily urinary creatinine excretion, but that carriers excrete significantly less urea nitrogen and total nitrogen, reflecting their significantly lower historically reported daily protein intake. Carriers had significantly higher levels of fasting plasma glutamine and alanine, and significantly lower levels of citrulline and arginine compared with noncarriers. Carriers and noncarriers reported similar demographic characteristics, anthropometric measurements, level of education, and medical and pregnancy histories. There was no indication of increased incidence of migraine headaches among carriers. Thus, we found no evidence that asymptomatic adult female OTC heterozygotes are at increased risk for previously unidentified health problems apart from an unknown risk for hyperammonemic encephalopathy as occurred in 3 of the carriers in this study. Because these episodes appear to be related to physiologic stress (fracture, parturition), it would seem medically prudent for carriers to be aware of this risk.