Health Maintenance Organization Research Articles

Group-Based Acceptance and Commitment Therapy for PTSD in a HMO Psychiatry Clinic: An Open Trial

AbstractMindfulness and acceptance-based approaches have shown promise as alternative interventions to trauma-focused therapies for PTSD. This open trial examined the potential effectiveness of an 8-session Acceptance and Commitment Therapy (ACT) group in reducing psychiatric symptoms and improving quality of life in outpatient adults (N = 86, 79% female) receiving treatment for PTSD in a health maintenance organization (HMO) psychiatry clinic. The group therapy was an adjunct to usual care and utilized the six core processes of ACT: acceptance, cognitive defusion, mindfulness, self-as-context, values, and committed action. Participants completed self-report measures of PTSD symptoms, depression, anxiety and quality of life; and self-report ACT-specific process measures of acceptance, cognitive defusion and mindfulness at pretreatment, posttreatment and 3-month follow-up. Repeated measures analyses of variance conducted with a completer sample (n = 55) demonstrated significant improvements on all variables with medium to large effect sizes at posttreatment and follow-up. The study findings support further investigation in a randomized controlled trial.

Implementation of AZD7442 (Tixagevimab/Cilgavimab) COVID-19 Pre-exposure Prophylaxis (PrEP) in the Largest Health Maintenance Organization in Israel: Real-world Uptake and Sociodemographic and Clinical Characteristics Across Immunocompromised Patient Groups.

AZD7442 is a combination of two neutralizing antibodies (tixagevimab/cilgavimab) with demonstrated efficacy in reducing the risk of symptomatic coronavirus disease 2019 (COVID-19) among individuals at high risk of severe COVID-19 ≤ 6months after administration. On February 15, 2022, the Israeli Ministry of Health (IMoH) authorized the administration of 300mg AZD7442 as pre-exposure prophylaxis (PrEP) against severe acute respiratory syndrome coronavirus 2infection among immunocompromised individuals aged ≥ 12years. This study describes the real-world uptake of AZD7442 in Israel. This descriptive, observational study analyzed data from Israel's largest health maintenance organization, Clalit Health Services (CHS). Individuals were assessed for AZD7442 eligibility between February 13 and December 11, 2022, and were included if they were aged ≥ 12years, had ≥ 1year of continuous CHS membership, had≥ 1 moderate or severe immunocompromising condition, and were eligible for AZD7442 per IMoH recommendations during this time frame. Overall, 19,161 AZD7442-eligible individuals with immunocompromising conditions were identified during the study period; 2829 (14.8%) received AZD7442. A higher proportion of individuals receiving AZD7442 were older (aged ≥ 65years), male, not current smokers and residents in large cities; required more physician visits (> 50 visits); and had ≥ 1 COVID-19 hospitalization over 12months, while uptake was lowest among ultra-orthodox Jewish individuals. AZD7442 uptake was also higher among individuals with multiple comorbidities (Charlson Comorbidity Index ≥ 5), including hypertension, diabetes and chronic kidney disease. In specific immunocompromised types, AZD7442 uptake was highest among individuals with lung transplantation (41%), primary immunodeficiency (32%), bone marrow transplantation (29%) and multiple myeloma (25%) or those receiving anti-CD20 therapy (26%) and was lowest in individuals with lymphoma (8%). These results show AZD7442 uptake among the eligible population of Israel in 2022 was relatively low, at 14.8%. Uptake was generally higher among immunocompromised individuals who may be perceived to be frail or at highest risk of COVID-19 infection and complications, although at 25-41%, further improvements in uptake would be more impactful. These results also indicate there is opportunity to expand AZD7442 uptake across immunocompromised groups and ensure more equitable uptake among some other sociodemographic groups. Overall, this study will help inform and reassess future implementation strategies for vulnerable populations.

Adherence to diabetes quality indicators in primary care and all-cause mortality: A nationwide population-based historical cohort study

Background In the last three decades, much effort has been invested in measuring and improving the quality of diabetes care. We assessed the association between adherence to diabetes quality indicators and all-cause mortality in the primary care setting. Methods A nationwide, population-based, historical cohort study of all people aged 45–80 with pharmacologically-treated diabetes in 2005 (n = 222,235). Data on annual performance of quality indicators (including indicators for metabolic risk factor management and glycemic control) and vital status were retrieved from electronic medical records of the four Israeli health maintenance organizations. Cox proportional hazards and time-dependent models were used to estimate hazard ratios (HRs) for mortality by degree of adherence to quality indicators. Results During 2,000,052 person-years of follow-up, 35.8% of participants died. An inverse dose–response association between the degree of adherence and mortality was shown for most of the quality indicators. Participants who were not tested for proteinuria or did not visit an ophthalmologist during the first-5-years of follow-up had HRs of 2.60 (95%CI:2.49–2.69) and 2.09 (95%CI:2.01–2.16), respectively, compared with those who were fully adherent. In time-dependent analyses, not measuring LDL-cholesterol, blood pressure, HbA1c, or HbA1c>9% were similarly associated with mortality (HRs ≈1.5). The association of uncontrolled blood pressure with mortality was modified by age, with increased mortality shown for those with controlled blood pressure at older ages (≥65 years). Conclusions Longitudinal adherence to diabetes quality indicators is associated with reduced all-cause mortality. Primary care professionals need to be supported by health care systems to perform quality indicators.

Expanded targeted preconception screening panel in Israel: findings and insights

BackgroundWe aimed to analyse the efficacy and added value of a targeted Israeli expanded carrier screening panel (IL-ECSP), beyond the first-tier test covered by the Israeli Ministry of Health (IMOH)...

Abstract PO3-03-08: Use of adjuvant Capecitabine after neoadjuvant chemotherapy: A Cohort Study among Elderly Patients with Early-Stage Triple-Negative Breast Cancer

Abstract Background: The use of capecitabine in the adjuvant setting in patients with residual disease after neoadjuvant chemotherapy has been incorporated into practice based on the results of the CREATE-X trial. We evaluate utilization patterns of adjuvant capecitabine use, its association with outcomes, and subsequent hospitalizations and emergency room (ER) visits among elderly patients with early-stage triple-negative breast cancer (TNBC). Methods: We identified patients aged ≥66, diagnosed with early-stage TNBC between 2010 and 2017 in the SEER and Texas Cancer Registry (TCR)-linked Medicare databases. All patients were treated with neoadjuvant chemotherapy for localized or regional-stage disease. All patients had continuous enrollment in Medicare Parts A & B without a Health Maintenance Organization enrollment 12 months before cancer diagnosis and 12 months after cancer diagnosis. Chemotherapy administration was identified using HCPCS codes from outpatient and physician’s carrier claims. We analyzed the patterns of capecitabine use, its association with survival outcomes, and the frequency of ER visits and hospitalizations during treatment (between the first capecitabine claim and 30 days after the last claim for capecitabine). Descriptive statistics were used. Primary analyses included logistic regression, Kaplan-Meier estimates, and Cox regression models with propensity score adjustments. This study adhered to the STROBE guidelines for cohort studies. Results: 1,239 patients with localized or regional TNBC treated with neoadjuvant chemotherapy were included (median 72 years). Of them, 96 (7.7%) were prescribed adjuvant capecitabine. Treatment with capecitabine was associated with recent year of diagnosis, regional disease, and residing in non-metropolitan areas. Specifically, the use of capecitabine increased from 1% in 2010 to 10% in 2016 and 21% in 2017. The median duration of capecitabine treatment was 4 cycles. In multivariable logistic regression analyses, older age was associated with decreased odds of receiving ≥4 cycles of capecitabine (OR=0.25; 95% CI: 0.11–0.60; p =0.002). Among capecitabine users, 3-year OS was 46% and 78% for patients who received 1-3 and ≥4cycles of capecitabine, respectively (p< 0.001). The 3-year estimate of BCSS was 43% and 85% respectively (p< 0.001). After multivariable adjustment for comorbidity score, stage, and propensity score, receiving ≥4 cycles of capecitabine was associated with decreased risk of death (HR=0.29; 95%CI 0.13–0.63, p=0.002) and breast cancer-specific death (HR=0.15; 95%CI: 0.05–0.51, p=0.002) compared to receiving 1-3 cycles. Twenty-seven (28%) patients had ER/hospitalization during capecitabine treatment; median time from initial capecitabine claim to ER/hospitalization was 24 days (IQ 13-39). The median number of capecitabine cycles was 3 (IQR 2-5) and 5 (IQR 3-8) for those with and without ER/hospitalization (p=0.02). The most common diagnosis codes associated with ER/hospitalization included pleural effusion, GI symptoms, pneumonia, and acute kidney failure. A higher comorbidity score at diagnosis was associated with an increased risk of ER/hospitalization (HR=2.76; 95%CI 1.05-7.28, p=0.04). Conclusion: We demonstrate an increasing trend in capecitabine utilization among elderly patients with early-stage TNBC. Although the limited sample size hindered a conclusive analysis, more cycles of capecitabine were associated with improved survival outcomes. Notably, a significant proportion of patients undergoing capecitabine treatment experienced ER/hospitalizations. These findings contribute valuable information on the risks and benefits of capecitabine treatment, aiding evidence-based decision-making to prevent serious complications. Citation Format: Marija Sullivan, Xiudong Lei, Catalina Malinowski, Sharon Giordano, Marianna Chavez. Use of adjuvant Capecitabine after neoadjuvant chemotherapy: A Cohort Study among Elderly Patients with Early-Stage Triple-Negative Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-03-08.

Real-world effectiveness of sodium-glucose cotransporter-2 inhibitors on the progression of chronic kidney disease in patients without diabetes, with and without albuminuria.

To examine the renal effects of sodium-glucose cotransporter-2 (SGLT2) inhibition among non-diabetic individuals with chronic kidney disease (CKD) in a real-world setting. We collected de-identified data on adults without diabetes and with an estimated glomerular filtration rate (eGFR) of 25-60 mL/min/1.73 m2, who initiated the SGLT2 inhibitors dapagliflozin or empagliflozin between September 2020 and November 2022 at Maccabi Healthcare Services, an Israeli health maintenance organization. We assessed the effects of SGLT2 inhibitors on renal function (changes in eGFR slope/time). Index date was defined as the date of the first dispensing of SGLT2 inhibitors. Annual baseline slope was calculated using all eGFR measurements during the 2 years prior to index date (median = 7 measurements), while annual follow-up slope was calculated from all evaluations during 90-900 days post index date, along with baseline measurement at index date (median = 6 measurements). Paired t tests were used to compare differences between baseline and follow-up annual slopes. Of a total of 354 participants with CKD, without diabetes, who received SGLT2 inhibitors and were followed for a median of 527 days, the mean age was 72.8 ± 11.8 years, 26% were female, and 91% used renin-angiotensin system blockade. The mean eGFR was 45.4 ± 9.5 mL/min/1.73 m2. The mean body mass index was 29.1 ± 5.4 kg/m2. During the year before index date, 146 participants (41%) had a urinary albumin to creatinine ratio (UACR) <30 mg/g, 81 (23%) had a UACR of 30-300 mg/g, 74 (21%) had a UACR >300 mg/g, and 53 (15%) had no UACR evaluation. The mean eGFR slope over time was -5.6 ± 7.7 mL/min/1.73 m2 per year at baseline, which improved to -1.7 ± 6.8 mL/min/1.73 m2 per year after SGLT2 inhibitor administration (p <0.001). This effect was independent of UACR. In a real-world study of primarily older non-diabetic adults with CKD, SGLT2 inhibition was associated with a slower rate of kidney function decline, regardless of baseline UACR level.

A primer on brand-name prescription drug contracting.

Prescription drug contracting in the United States has evolved over decades from discounts provided to members of early health maintenance organization plans to rebate contracts to more complex value-based purchasing arrangements. This primer describes the history of contracting between pharmaceutical manufacturers and managed care pharmacy organizations and details the various contracting methods used today.

Prenatal exposure to acid suppressor medications and development of ductus arteriosus in term newborn.

The ductus arteriosus normally closes after birth. Histamine2 Receptor Antagonist (H2RA) has been associated with patent ductus arteriosus (PDA). We aimed to study the characteristics of term infants with PDA and their possible association with prenatal exposure to antacids - Proton Pump Inhibitors (PPI) and H2RA. Population-based matched case-control study of mothers registered at "Clalit" Health Maintenance Organization (HMO) and their infants born at "Soroka" University Medical Center (SUMC) between 2001-2018. Cases are defined as term infants born with PDA diagnosed by echocardiography and registered in the post-delivery discharge form. Each case was matched with four term newborns without PDA diagnosis. Exposure window was defined by the timing of first purchase of H2RA or PPI during pregnancy and based on information from a computerized medication database (Clalit HMO, SUMC) Results. PDA was diagnosed in 1,884 term infants (4.9%). Characteristics included a significantly higher percentage of lack of prenatal care, cesarean section, in vitro fertilization, polyhydramnios, oligohydramnios, Apgar 1 minute <5, and prenatal exposure to H2RA (OR4.18) and PPIs (OR3.50) (all p<0.001). PDA association with exposure window was similar in each trimester (1.5-2%) for both H2RA and PPI. PDA Incidence in term infants in our population was greater than previously reported. PPI and H2RA are both anti-acids with different mechanisms of action. The similar OR for exposure to one as well as the other, and the lack of influence of the initial exposure period, are compatible with bias.

Usability of Health Care Price Transparency Data in the United States: Mixed Methods Study.

Increasing health care expenditure in the United States has put policy makers under enormous pressure to find ways to curtail costs. Starting January 1, 2021, hospitals operating in the United States were mandated to publish transparent, accessible pricing information online about the items and services in a consumer-friendly format within comprehensive machine-readable files on their websites. The aims of this study are to analyze the available files on hospitals' websites, answering the question-is price transparency (PT) information as provided usable for patients or for machines?-and to provide a solution. We analyzed 39 main hospitals in Florida that have published machine-readable files on their website, including commercial carriers. We created an Excel (Microsoft) file that included those 39 hospitals along with the 4 most popular services-Current Procedural Terminology (CPT) 45380, 29827, and 70553 and Diagnosis-Related Group (DRG) 807-for the 4 most popular commercial carriers (Health Maintenance Organization [HMO] or Preferred Provider Organization [PPO] plans)-Aetna, Florida Blue, Cigna, and UnitedHealthcare. We conducted an A/B test using 67 MTurkers (randomly selected from US residents), investigating the level of awareness about PT legislation and the usability of available files. We also suggested format standardization, such as master field names using schema integration, to make machine-readable files consistent and usable for machines. The poor usability and inconsistent formats of the current PT information yielded no evidence of its usefulness for patients or its quality for machines. This indicates that the information does not meet the requirements for being consumer-friendly or machine readable as mandated by legislation. Based on the responses to the first part of the experiment (PT awareness), it was evident that participants need to be made aware of the PT legislation. However, they believe it is important to know the service price before receiving it. Based on the responses to the second part of the experiment (human usability of PT information), the average number of correct responses was not equal between the 2 groups, that is, the treatment group (mean 1.23, SD 1.30) found more correct answers than the control group (mean 2.76, SD 0.58; t65=6.46; P<.001; d=1.52). Consistent machine-readable files across all health systems facilitate the development of tools for estimating customer out-of-pocket costs, aligning with the PT rule's main objective-providing patients with valuable information and reducing health care expenditures.

Detecting bone lesions in X-ray under diverse acquisition conditions.

The diagnosis of primary bone tumors is challenging as the initial complaints are often non-specific. The early detection of bone cancer is crucial for a favorable prognosis. Incidentally, lesions may be found on radiographs obtained for other reasons. However, these early indications are often missed. We propose an automatic algorithm to detect bone lesions in conventional radiographs to facilitate early diagnosis. Detecting lesions in such radiographs is challenging. First, the prevalence of bone cancer is very low; any method must show high precision to avoid a prohibitive number of false alarms. Second, radiographs taken in health maintenance organizations (HMOs) or emergency departments (EDs) suffer from inherent diversity due to different X-ray machines, technicians, and imaging protocols. This diversity poses a major challenge to any automatic analysis method. We propose training an off-the-shelf object detection algorithm to detect lesions in radiographs. The novelty of our approach stems from a dedicated preprocessing stage that directly addresses the diversity of the data. The preprocessing consists of self-supervised region-of-interest detection using vision transformer (ViT), and a foreground-based histogram equalization for contrast enhancement to relevant regions only. We evaluate our method via a retrospective study that analyzes bone tumors on radiographs acquired from January 2003 to December 2018 under diverse acquisition protocols. Our method obtains 82.43% sensitivity at a 1.5% false-positive rate and surpasses existing preprocessing methods. For lesion detection, our method achieves 82.5% accuracy and an IoU of 0.69. The proposed preprocessing method enables effectively coping with the inherent diversity of radiographs acquired in HMOs and EDs.

Access to Total Knee Arthroplasty in Medicare Advantage Patients

Background: Total knee arthroplasty (TKA) is one of the most frequently performed procedures in Medicare patients in the United States. Among this population, enrollment in Medicare Advantage (MA) plans is rising but rates of elective TKA are 10-20% lower in MA health maintenance organization (HMO) plans compared to Traditional Medicare (TM). The purpose of this study was to evaluate the effect of Medicare type on patient access to TKA within the large population in Florida. Methods: The AAOS directory was queried for total joint surgeon practices within five Florida counties. Each office was called to assess the response to four insurance scenarios (Traditional Medicare, Blue Medicare Select PPO, Humana Gold Plus HMO, and commercial Cigna). Investigators used a Secret Shopper methodology with a standardized script to request a TKA. Data was gathered on insurance types accepted and number of business days to the next available appointment. Results: Of the 133 orthopaedics clinics called, 63 were accepting new TKA patients. Of those accepting new TKA patients, 91.7% accepted commercial Cigna, 96.8% accepted TM, 70.5% accepted MA HMO Humana Gold Plus, and 50.8% accepted MA PPO Blue Medicare Select. Compared to TM and commercial Cigna, both MA plans had significantly lower appointment success rates (all p&lt;.003). Time to earliest appointment did not significantly vary by insurance type or county (p&gt;.14). Conclusions: Patients in Florida with MA have decreased access to TKA compared to those with TM or commercial insurance, possibly explaining the lower rates of TKA utilization in the MA population.

The Effect of Accreditation in Health Care Services: Case Study at HMO- Health Maintenance Organization in Israel

The healthcare sector is a critical component of a well-functioning society that formed any society, we can depend on it and is responsible for maintaining the health of the people, and to offer them the services they need. The nature of healthcare is such that it is a service on which the health of human beings depends and helps them to live a healthy life without suffering. Quality is something that is universally desired by individuals in every kind of product or service. However, there is no aspect of society in which quality is as essential as in healthcare because if the person has a good health he will do his best to serve his society and he will be a benefit citizen to his society and country. Poor quality of services in healthcare can be the cause of physical harm or even death for a patient. As such, the ramifications of quality are nowhere as serious as in the particular domain of medicine and healthcare.

Rheumatology High Blood Pressure Protocol Reduces Disparities, But Delays Remain for External Primary Care.

To address high blood pressure (BP) in rheumatology patients, we previously implemented BP Connect, a brief staff-driven protocol to address high BP. Although timely follow-up and hypertension rates improved for patients with in-system primary care (PC), many receive PC and rheumatology care in separate health systems. In this cohort study, we compared rates of timely PC follow-up for high BP across-system health maintenance organizations (HMOs) before and after BP Connect implementation. All adult patients with high rheumatology clinic BP and PC in that HMO were eligible. BP Connect's protocol engaged the staff in remeasuring high BP (≥140/90 mm Hg), advising cardiovascular disease risk, and connecting timely PC follow-up, which for patients with PC across system includes written follow-up instructions. After an eligible rheumatology visit, the next HMO PC visit with BP was used to determine rates and odds of timely follow-up before and after using multivariable logistic regression. Across 1327 rheumatology visits with high BP and across-system PC (2013-2019), 951 occurred after 2015 BP Connect implementation; 400 had confirmed high BP. Primary care follow-up rose from 20.5% to 23.5%. The odds of timely PC BP follow-up insignificantly changed (odds ratio, 1.19; confidence interval, 0.85-1.68). For visits with Black patients, the odds of timely follow-up did significantly increase (1.95; confidence interval, 1.02-3.79). Timely follow-up for Black patients did improve, highlighting protocol interventions for more equitable health care. In contrast to our prior in-system study, BP Connect did not significantly improve follow-up with an across-system PC, indicating a need for direct scheduling. Future directions include piloting direct across-system scheduling.

Correlation of Refractive Error with Anisometropia Development in Early Childhood

This study aims to investigate the relationship between the type and severity of refractive error and anisometropia development in preschool children. Retrospective cohort study. Data from Maccabi Healthcare Services, Israel's second-largest Health Maintenance Organization (HMO), were analyzed. The study included all isometropic children aged 1-6 years, re-examined for refraction at least two years following their initial examination between 2012 and 2022. Anisometropia was defined as a ≥1 diopter interocular difference in spherical equivalent. Relationships were assessed using logistic regression models adjusted for key sociodemographic factors. Among 33,496 isometropic children (51.2% male, mean age 3.2 ± 1.5 years), the prevalences of emmetropia, myopia, and hyperopia were 26.7% (n=8,944), 4.2% (n=1,397), and 69.1% (n=23,155), respectively. Over a mean follow-up period of 5.1 ± 2.4 years, 2,593 children (7.7%) were diagnosed with anisometropia. Adjusted odds ratios (ORs) for anisometropia gradually increased with baseline refractive error severity, reaching 13.90 (5.32-36.34) in severe myopia and 4.19 (3.42-5.15) in severe hyperopia. This pattern was also evident in cylindrical anisometropia, where ORs increased with greater baseline astigmatism, peaking at 12.10 (9.19-15.92) in children with high astigmatism (≥ 3 D). Associations remained consistent in sensitivity and subgroup analyses including across both genders and when using a stricter anisometropia criterion. Children aged 1-6 years, initially without anisometropia but showing increasing severity of myopia, hyperopia, or astigmatism, are more likely to develop anisometropia. This underscores the importance of follow-up refractive measurements within this population to promptly diagnose and treat anisometropia and prevent potential visual complications.

Dietary Counseling Documentation Among Patients Recently Hospitalized for Cardiovascular Disease

BackgroundDiet intervention forms the cornerstone for cardiovascular disease (CVD) management. ObjectiveThe objective was to measure the frequency of dietary counseling documentation for patients recently hospitalized with CVD. DesignThis was an observational study. Participants and settingPatients were included from the Michigan Value Collaborative Multipayer Claims Registry from October 2015 to February 2020. Main outcome measureThe study measured the frequency of medical claims that document dietary counseling ≤90 days after hospitalization (ie, an episode of care) for CVD events (coronary artery bypass grafting, acute myocardial infarction, congestive heart failure, and percutaneous coronary intervention). Dietary counseling documentation was defined as having an encounter-level International Classification of Diseases 10th Revision code for dietary counseling or current procedural terminology code for medical nutrition therapy or cardiac rehabilitation. Statistical analyses performedMultivariable logistic regression was used to measure variation in documentation across gender, age, comorbidities, hospital geography, CVD event, and insurer. ResultsThere were 175,631 episodes of care (congesitve heart failure 47.1%, acute myocardial infarction 28.7%, percutaneous coronary intervention 17.0%, and coronary artery bypass grafting 7.3%) among 146,185 individuals. Most episodes occurred among men (55.8%) and those older than age 65 years (71.9%). Dietary counseling was documented for 22.8% of episodes and was more common as cardiac rehabilitation (18.6%) than other encounter types (5.1%). In multivariable analysis, there was lower odds for dietary counseling documentation among those older than age 65 years (odds ratio [OR] 0.77; P < .001), women (OR 0.83; P < .001), with chronic kidney disease (OR 0.74; P < .001), or diabetes (OR 0.95; P < .001), but greater odds for those with obesity (OR 1.28; P < .001) and nonmetropolitan hospitals (OR 1.31; P < .001). Compared with coronary artery bypass grafting, acute myocardial infarction (OR 0.29; P < .001), confestive heart failure (OR 0.12; P < .001), and percutaneous coronary intervention (OR 0.36; P < .001) episodes had lower odds to have dietary counseling coded. Compared with Traditional Medicare, Medicaid and Medicare Advantage health maintenance organization plans had lower odds, whereas Commercial or Medicare Advantage preferred provider organization and Commercial health maintenance organization plans had higher odds to have dietary counseling documented. Results were mostly similar when evaluated by race. ConclusionsDietary counseling was infrequently documented after hospitalization for CVD episodes in medical claims in a Michigan-based multipayer claims database with large variation by reason for hospitalization and patient factors.

"When everyone is responsible, no one takes responsibility": exploring pediatric physiotherapy services in Israel.

According to Israel's National Health Insurance Law (1994), the Ministry of Health is responsible for the provision of health services in the country including physiotherapy services; moreover, the Special Education Law (1988), stipulates that physiotherapy services for children with motor disabilities, as well as other allied health services, are provided by the Ministry of Education in educational settings. Thus, children with motor disabilities are entitled PT services under two different laws by two different ministries. To describe the physiotherapy services for children with motor disabilities and examine how policymakers view these services, we conducted a qualitative study including in-depth semi-structured interviews with 10 policymakers from the Ministry of Health and the Ministry of Education, and the national directors of physiotherapy services from three of the four health maintenance organizations in Israel. Study results indicate that there is an array of physiotherapy services and providers. Despite the regulation of these services for children with motor disabilities, uncertainty and lack of knowledge were found about various issues. Therefore, the thematic analysis was structured around four descriptive questions: Where do the children receive physiotherapy? Who is eligible for physiotherapy treatment and who receives treatment? What interventions do children with motor disabilities receive? Who provides therapy for children with motor disabilities? Policymakers are dubious regarding the provision of these services, questioning whether children with motor disabilities receive physiotherapy services according to their needs. In addition, the abundance of suppliers does not necessarily improve the quality of services provided to children with motor disabilities, which may ultimately harm their developmental potential.

The Impact of Market Factors on Meaningful Use of Electronic Health Records Among Primary Care Providers: Evidence From Florida Using Resource Dependence Theory and Information Uncertainty Perspective.

Using federal funds from the 2009 Health Information Technology for Economic and Clinical Health Act, the Centers for Medicare and Medicaid Services funded the 2011-2021 Medicaid electronic health record (EHR) incentive programs throughout the country. Identify the market factors associated with Meaningful Use (MU) of EHRs after primary care providers (PCPs) enrolled in the Florida-EHR incentives program through Adopting, Improving, or Upgrading (AIU) an EHR technology. Retrospective cohort study using 2011-2018 program records for 8464 Medicaid providers. MU achievement after first-year incentives. The resource dependence theory and the information uncertainty perspective were used to generate key-independent variables, including the county's rurality, educational attainment, poverty, health maintenance organization penetration, and number of PCPs per capita. All the county rates were converted into 3 dichotomous measures corresponding to high, medium, and low terciles. Descriptive and bivariate statistics were calculated. A generalized hierarchical linear model was used because MU data were clustered at the county level (level 2) and measured at the practice level (level 1). Overall, 41.9% of Florida Medicaid providers achieved MU after receiving first-year incentives. Rurality was positively associated with MU ( P <0.001). Significant differences in MU achievements were obtained when we compared the "high" terciles with the "low" terciles for poverty rates ( P =0.002), health maintenance organization penetration rates ( P =0.02), and number of PCPs per capita ( P =0.01). These relationships were negative. Policy makers and health care managers should not ignore the contribution of market factors in EHR adoption.

Glucagon-like Peptide 1 Receptor Agonists and Cardiovascular Outcomes in Solid Organ Transplant Recipients With Diabetes Mellitus.

Glucagon-like peptide 1 receptor agonists (GLP1-RAs) reduce cardiovascular events and mortality in type 2 diabetes. Limited data are available on diabetes treatment after solid organ transplantation. We aimed to explore the effect of GLP1-RAs on cardiovascular outcomes in transplanted recipients with diabetes. We extracted data on adult transplant recipients (kidney, lungs, liver, heart) insured in a large health maintenance organization. Death-censored patients with diabetes treated with GLP1-RAs were matched with nonusers. The primary outcome was a composite of major cardiovascular events (MACEs): a nonfatal cardiac event (myocardial infarction, stable/unstable angina, coronary bypass, and coronary angiography), ischemic stroke and all-cause mortality. Secondary outcomes were MACE or peripheral vascular disease (MACE-PVD), and all-cause mortality. Safety outcomes included biliopancreatic adverse events. We included 318 patients (69% males, average age 58.3 ± 11.0 y) with a 3.1-y median follow-up. The incidence of MACE was 101 of 1000 patient-years in GLP1-RAs users compared with 134 of 1000 in controls (hazard ratio [HR] 0.46; 95% confidence interval [CI], 0.27-0.78). GLP1-RAs similarly reduced the risk of MACE-PVD (HR 0.53; 95% CI, 0.33-0.88) and the risk of all-cause mortality (HR 0.39; 95% CI, 0.18-0.84). Biliopancreatic adverse events occurred less in GLP1-RA users. Transplant recipients with diabetes who used GLP1-RAs had lower risks for MACE and all-cause mortality. These results may profoundly implicate the daily management of posttransplant recipients with diabetes, a population with a high prevalence of cardiometabolic risk factors and cardiovascular death. Transplant patients are usually excluded from randomized controlled trials and, hence might be undertreated with disease-modifying drugs. Larger prospective studies are needed in this unique population.

Risk factors for recurrent acute mastoiditis in pediatric patients: a registry-based cohort study.

To describe characteristics of pediatric patients with recurrent acute mastoiditis, and to identify risk factors for this condition. A retrospective cohort study. Data based on electronic medical records of the largest Health Maintenance Organization in Israel. Children hospitalized due to acute mastoiditis during the years 2008-2018 were identified, and their diagnosis was verified. Patients with recurrent acute mastoiditis were identified and grouped, and their characteristics were outlined and compared to those of the original group to identify risk factors for recurrence. During the 11-year period, a total of 1115 cases of children hospitalized due to acute mastoiditis were identified with a weighted incidence rate of 7.8/100,000. Of this group, 57 patients were diagnosed with recurrence following a full clinical recovery. The incidence proportion of recurrent acute mastoiditis was 5.1% (57/1115), male-to-female ratio was 27:30, 73.4% were younger than 24 months, the median period from the first episode was 3.4 months (IQR 2.0;10.0), and 82.5% of the patients (n = 47) had a single recurrence, whereas 18.5% (n = 10) had two recurrences or more. Mastoidectomy and swelling over the mastoid area during the first episode were identified as the main risk factors for recurrent mastoiditis HR = 4.7 [(2.7-8.2), p < 0.001] and HR = 2.55 [(1.4-4.8), p = 0.003], respectively. Mastoidectomy was the only independent significant risk factor for recurrence in a multivariate analysis. Mastoidectomy and swelling over the mastoid area during the first episode of acute mastoiditis were found strongly related independent risk factor for future recurrent episodes of acute mastoiditis.

Rehabilitation after brain tumor resection: A national study of postacute care service use through insurance claims data.

To assess postacute rehabilitation service use and length of stay among a national sample of patients with brain tumors after surgery. A retrospective review was conducted of health care claims data of a national sample of patients via The Optum Clinformatics DataMart. This study included adult individuals (≥18 years of age) who were diagnosed with a brain tumor between 2015 and 2019 and underwent a craniotomy or craniectomy within 180 days of diagnosis. Descriptive statistics were used to characterize patients by tumor type. Multivariate models assessed factors associated with discharge setting and length of stay. Of the 10,275 individuals identified, 69% had malignant tumors. Over two thirds of patients were discharged directly home (with or without home health care) and 9.3% and 9.5% were discharged to acute rehabilitation facilities (inpatient rehabilitation facilities [IRF]) and skilled nursing facilities (SNF/ICF), respectively. About 13.5% were discharged to other settings. The average length of stay during the episode of care was 8.6 (SD = 9.6) days. After adjusting for confounders, individuals with benign brain tumors were more likely to be discharged to either IRF or SNF/ICF than return home after acute care stay, as were those with greater comorbidities, older age, fee-for-service and health maintenance organization insurance. Wealthier patients were less likely to be discharged to a SNF/ICF than home, although income was not a factor affecting discharge to an IRF. Patients with benign tumors, the oldest old (80+), those with more comorbidities as well as Black and Hispanic patients had a longer length of stay during the acute hospitalization. Individuals with brain tumors have deficits amenable to rehabilitation; however, this study finds that service use differs by tumor type and demographic and socioeconomic factors. Further study is needed to identify if there are barriers to access and use of rehabilitation services in this population.