Maccabi Health Services Research Articles

Health Disparities Among Ultra-Orthodox and Non-Ultra-Orthodox Residents in Neighboring Cities in Israel: A Cross-Sectional Study.

Socioeconomic status and religion are associated with health indicators. This study compared the correlations between religious observance, socioeconomic status, and select health indicators among adults in neighboring cities in Israel based on data collected from the Maccabi Health Services database. One city is characterized by religious observance, while the other is primarily secular. Lower smoking rates and higher rates of low cholesterol, triglycerides and LDL levels were observed in the religious city. No significant differences were found for low HDL rates or diabetes. Unique characteristics of populations must be considered when planning health interventions.

Strength in Numbers - Identifying a Significant Association Between High Serum Ferritin Levels and Newly diagnosed Malignancy in a Large Health Organization Cohort.

Ferritin, an iron storage protein and acute phase reactant, has been implicated in various aspects of human health and disease, including cancer. Previous studies have identified elevated serum ferritin (SF) levels in several cancer types, but a comprehensive examination across different malignancies remains lacking. This study aims to fill this gap by utilizing anonymized data from Maccabi Health Services (MHS), one of Israel's largest health organizations, to explore the association between elevated SF levels and the diagnosis of different malignancies. An extensive dataset from MHS, comprising 2.7 million members, including 1.3 million individuals who underwent SF level testing, was analyzed. Odds Ratios (OR) and 95% confidence intervals (CI) were calculated to assess the association between high SF levels and cancer diagnosis. Subgroup analysis was conducted to investigate variations across different malignancies. The analysis revealed a significant association between elevated SF levels and cancer diagnosis among MHS members, with an OR of 1.9 (95% CI 1.71-2.15). Sub- group analysis unveiled differences in the association across malignancy types, with hematological, hepatobiliary and respiratory malignancies more strongly associated with high SF levels. This study provides further support for the link between elevated SF levels and malignancy, leveraging a vast dataset from MHS, underscoring potential utilities of elevated SF levels as a potential indicator for cancer with a variable role among different malignancy types. The identification of elevated SF levels as a potential indicator for underlying malignancy for seemingly-healthy individuals.

Stuttering in adolescence and the risk for dysglycemia in early adulthood

AbstractAimsTo investigate the association between stuttering during adolescence and the onset of dysglycemia (prediabetes or type 2 diabetes) in early adulthood among men and women.Materials and MethodsThis cohort study included Maccabi Health Services members assessed for mandatory military service at ages 16–19 during 1990–2019 and followed until 31 December 2020. Stuttering status was recorded in the baseline medical evaluation. Incident cases of dysglycemia were identified systematically using prediabetes and diabetes registries. Cox proportional hazard models were applied for men and women separately, adjusting for sociodemographics and medical status.ResultsThe study cohort comprised 866,304 individuals (55% men; 0.21% with stuttering) followed for a total of 12,696,250 person‐years. During the study period, 7.6% (n = 36,603) of men and 9.0% (n = 34,723) of women were diagnosed with dysglycemia. The mean ages at diagnosis were 34 and 32 years for men and women, respectively. Women with stuttering exhibited the highest dysglycemia incidence rate (102.3 per 10,000 person‐years) compared with the other groups (61.4, 69.0, and 51.9 per 10,000 person‐years for women without stuttering, men with stuttering, and men without stuttering, respectively). For both men and women, those with stuttering showed an increased risk of being diagnosed with dysglycemia compared with those without (adjusted hazard ratios 1.18 [1.01–1.38] and 1.61 [1.15–2.26], respectively). The associations persisted in extensive sub‐analyses.ConclusionsStuttering in adolescence is associated with a higher risk of dysglycemia in early adulthood for men and women. Screening and targeted prevention in this population, especially women, may be beneficial.

Epidemiology and Treatment Patterns of Patients with Vitiligo: A Real-World Analysis.

Vitiligo, a chronic autoimmune skin depigmentation disease with an unpredictable course, has been associated with several comorbid autoimmune and psychological conditions. Our current understanding of vitiligo burden and management in the real world is limited. This real-world analysis presents data on vitiligo epidemiology, comorbidities, and treatment of patients in Israel. This retrospective study analyzed data from the Maccabi Health Services database. Prevalent patients with vitiligo in 2021 were matched to patients in the general population on the basis of age group, gender, and socioeconomic status. Patient demographics, vitiligo incidence and prevalence, comorbidities, and treatment patterns are reported. Data are presented as percentages, mean, median, P values, and standard mean differences (SMD). In this analysis, 11,412 patients with vitiligo were matched to patients from the general population. Incidence and prevalence rates increased over time from 2005 to 2021. Compared to the general population, patients with vitiligo were more likely to have an immune-mediated comorbidity (29.7% vs 18.4% [P < 0.001; SMD 0.27]) or psychological comorbidity (18.7% vs 15.9% [P < 0.001; SMD 0.07]). Comorbidities included atopic dermatitis (patients with vitiligo vs general population 12.5% vs 8.4%), psoriasis (5.8% vs 3.6%), Hashimoto's thyroiditis (2.9% vs 1.1%), alopecia areata (2.2% vs 0.9%), depression (10.8% vs 9.5%), and sleep disorder/insomnia (5.9% vs 4.4%). Only 74.8% of all patients with vitiligo had ever received treatment, with topical corticosteroids (51.5%) and calcineurin inhibitors (36.5%) most commonly prescribed. At the end of 2021, 83.7% of patients were untreated. Patients with vitiligo are more likely to have various immune-related and psychological comorbidities, highlighting the significant impact of the condition on well-being. Nearly a quarter of patients had never received treatment, with many receiving only topical treatments, and medication persistence was low. This highlights the lack of adequate treatment in this population and the need for more effective management options.

Arrhythmia Burden Among Adult PatientsWith Congenital Heart Disease: APopulation-Based Study.

A significant percentage of patients with congenital heart disease surviving into adulthood will develop arrhythmias. These arrhythmias are associated with an increased risk of adverse events and death. We aimed to assess arrhythmia prevalence, risk factors, and associated health care usage in a large national cohort of patients with adult congenital heart disease. Adults with a documented diagnosis of congenital heart disease, insured by Clalit and Maccabi health services between January 2007 and December 2011, were included. We assessed the associations between arrhythmia and subsequent hospitalization rates and death with mixed negative binomial and Cox proportional hazard models, respectively. Among 11 653 patients with adult congenital heart disease (median age, 47 years [interquartile range, 31-62]), 8.7% had a tachyarrhythmia at baseline, 1.5% had a conduction disturbance, and 0.5% had both. Among those without a baseline arrhythmia, 9.2% developed tachyarrhythmias, 0.9% developed a conduction disturbance, and 0.3% developed both during the study period. Compared with no arrhythmia (reference group), arrhythmia in the previous 6 months was associated with a higher multivariable adjusted hospitalization rate, 1.33-fold higher than the rate of the reference group (95% CI, 1.00-1.76) for ventricular arrhythmia, 1.27-fold higher (95% CI, 1.17-1.38) for atrial arrhythmias, and 1.33-fold higher (95% CI, 1.04-1.71) for atrioventricular block. Atrial tachyarrhythmias were associated with an adjusted mortality hazard ratio (HR) of 1.65 (95% CI, 1.44-2.94), and ventricular tachyarrhythmias with a >2-fold increase in mortality risk (HR, 2.06 [95% CI, 1.44-2.94]). Arrhythmias are significant comorbidities in the adult congenital heart disease population and have a significant impact on health care usage and survival.

Does the Diagnostic Accuracy and Rates of Face-to-Face Visits Occurring Shortly after an Asynchronized Teledermatology Consultation Justify Its Implementation? An 18-Month Cohort Study

Introduction: In 2019, Maccabi Health Services (MHS) rolled out the store-and-forward “Dermadetect” teledermatology consultation (TC) application. Study goal was to analyze MHS records of TCs (August 2019–February 2021) for the rate and reasons for face-to-face consultations (FTFC) occurring shortly after a TC with emphasis on FTFCs resulting in a different diagnosis for the same indication. Methods: The records of FTFCs held up shortly after TCs were reviewed and classified into cases marked as unsuited for teledermatology, cases in which the indication differed, and cases with the same indication, which were analyzed for concordance of diagnoses. Results: Dermadetect was used by 12,815 MHS beneficiaries. In 30% of cases, following FTFC occurred within the subsequent 5 months, and 901 of them occurred in the subsequent 2 weeks and were analyzed. Thirty percent were not suited for teledermatology, 15% were held for a different indication, and 55% occurred for the same indication. The diagnosis concordance between the TC and recurrent FTFC for the same indication was 97.4%, with full concordance at 68.1% and partial concordance at 29.3%. Overall, 13 patients (1.4%) of the 901 patients using the application only once had a subsequent FTFC within 2 weeks and received a different diagnosis than the one given in the TC. Conclusions: When considering the implementation of store-and-forward TC’s, a 30% rate of following FTFC’s during the next 5 months should be considered when planning the reimbursement model. Diagnosis discordance may be disregarded due to its low rates.

Safety of GLP-1 Receptor Agonists and Other Second-Line Antidiabetics in Early Pregnancy

Increasing use of second-line noninsulin antidiabetic medication (ADM) in pregnant individuals with type 2 diabetes (T2D) may result in fetal exposure, but their teratogenic risk is unknown. To evaluate periconceptional use of second-line noninsulin ADMs and whether it is associated with increased risk of major congenital malformations (MCMs) in the infant. This observational population-based cohort study used data from 4 Nordic countries (2009-2020), the US MarketScan Database (2012-2021), and the Israeli Maccabi Health Services database (2009-2020). Pregnant women with T2D were identified and their live-born infants were followed until up to 1 year after birth. Periconceptional exposure was defined as 1 or more prescription fill of sulfonylureas, dipeptidyl peptidase 4 (DPP-4) inhibitors, glucagon-like peptide 1 (GLP-1) receptor agonists, and sodium-glucose cotransporter 2 (SGLT2) inhibitors, or insulin (active comparator) from 90 days before pregnancy to end of first trimester. Relative risks (RRs) and 95% CIs for MCMs were estimated using log-binomial regression models, adjusting for key confounders in each cohort and meta-analyzed. Periconceptional exposure to second-line noninsulin ADMs differed between countries (32, 295, and 73 per 100 000 pregnancies in the Nordics, US, and Israel, respectively), and increased over the study period, especially in the US. The standardized prevalence of MCMs was 3.7% in all infants (n = 3 514 865), 5.3% in the infants born to women with T2D (n = 51 826), and among infants exposed to sulfonylureas was 9.7% (n = 1362); DPP-4 inhibitors, 6.1% (n = 687); GLP-1 receptor agonists, 8.3% (n = 938); SGLT2 inhibitors, 7.0% (n = 335); and insulin, 7.8% (n = 5078). Compared with insulin, adjusted RRs for MCMs were 1.18 (95% CI, 0.94-1.48), 0.83 (95% CI, 0.64-1.06), 0.95 (95% CI, 0.72-1.26), and 0.98 (95% CI, 0.65-1.46) for infants exposed to sulfonylureas, DPP-4 inhibitors, GLP-1 receptor agonists, and SGLT2 inhibitors, respectively. Use of second-line noninsulin ADMs is rapidly increasing for treatment of T2D and other indications, resulting in an increasing number of exposed pregnancies. Although some estimates were imprecise, results did not indicate a large increased risk of MCMs above the risk conferred by maternal T2D requiring second-line treatment. Although reassuring, confirmation from other studies is needed, and continuous monitoring will provide more precise estimates as data accumulate.

Age disparity among severe aortic stenosis patients: AVR treatment rates and clinical outcomes among octogenarians

Abstract Introduction Aortic valve replacement (AVR) is considered one of the most effective disease-modifying procedures among patients with severe Aortic Stenosis (sAS). Accordingly, we can witness a consistent increase in procedure rates in recent years. Nevertheless, the elderly population, particularly octogenarians, remains relatively undertreated. Purpose The current study aims to document the baseline characteristics, disparities in AVR rates, and prognostic significance of AVR among octogenarian vs. non-octogenarian patients with sAS. Methods A vast database of Maccabi health services, the second largest health maintenance organization (HMO) in Israel, counting nearly 2.8 million members, was retrospectively analyzed from 2005 to 2021 for all patients over 60 years, with a detailed echocardiography report compatible with a diagnosis of sAS. Patients who underwent AVR previously or on the same day of their diagnostic echocardiography were excluded. The database was extracted using the MDClone ADAMS healthcare data platform, generating synthetic data reliably representing the original population. All-cause mortality was set to be the primary outcome, and survival models utilizing adjusted multivariable analyses for several clinical and echocardiographic parameters were applied. Results A total of 1359 patients with high-gradient sAS were included in the final analysis, of which 574 (42%) are octogenarians. The octogenarian group included more females (56% vs. 48%), and they had a significantly higher prevalence of hypertension (83% vs. 78%), atrial fibrillation (22% vs. 14%), previous myocardial infarction (12% vs. 8%) and heart failure (20% vs. 10%). Substantial differences were documented regarding AVR-treatment rates between the two groups, with the undertreatment of the octogenarian group (39% vs. 60% of AVR within 18 months from diagnosis of sAS, p&amp;lt;0.001). Differences remained significant in a fully adjusted time-to-event model (HR 0.54, 95% CI 0.46-0.64, p&amp;lt;0.001 for octogenarians) A time-dependent analysis showed that AVR was associated with reduced all-cause mortality (HR 0.30, 95% CI 0.23-0.41, p&amp;lt;0.001) within the octogenarian group in 5 years. A similar protective effect was shown in the non-octogenarian group (HR 0.32, 95% CI 0.22-0.46, p&amp;lt;0.001). Conclusions Despite having comparable survival benefits, octogenarian patients with sAS still receive lower AVR treatment rates than non-octogenarians

Early cardiologist follow-up determines treatment rates and survival among aortic stenosis patients

Abstract Background Aortic valve replacement (AVR) has been constant as it is considered an effective disease-modifying procedure for patients with severe aortic stenosis (sAS). However, the implanter is only one part of it. Patients with sAS generally require ongoing care and support from a multidisciplinary team that includes general cardiologists (GC) and other primary care providers, who guide and manage the patient through the therapeutic process. Purpose The current study aims to assess the impact of a cardiologist or other primary care provider managing the therapeutic process in the early period first phase following the sAS diagnosis. Methods A large-scale database of Maccabi Health Services, the second largest health maintenance organization (HMO) in Israel, counting Israel with nearly 2.8 million members, was retrospectively analyzed from 2005 to 2021 for all patients over 60 years, with detailed echocardiography compatible with a diagnosis of sAS. The database was extracted using the MDClone healthcare data platform, generating the synthetic cohort database reliably representing the original population. sAS patients managed by GC versus non-GC care providers were assessed for differences in AVR rates, and all-cause mortality was assessed in sAS patients managed by GC versus non-GC care providers. Results A total of 1570 sAS patients were included in the final analysis. Of them, GCs managed GC managed 65% in the early phase (3 months) following the sAS diagnosis. sAS with heart failure (21% vs. 17%) and atrial fibrillation (26% vs. 19%) were less likely managed by GC. No statistically significant differences were observed in other baseline characteristics, including age, gender, and comorbidities. A propensity score matching analysis revealed a significant difference in 12-month and 24-month AVR rates following diagnosis between the GC versus non-GG groups (19% vs. 3%, and 28% vs. 9%, respectively. P&amp;lt;0.01 for both). sAS patients managed by a GC show a significant survival benefit, 31% vs. 36% within five years after diagnosis P &amp;lt; 0.05. Conclusions Patients with sAS managed by a GC within three months after diagnosis had significantly higher chances for AVR and, consequently, better prognosis. These findings emphasize the importance of GC management in sAS.

The use of digital health services and its predicting factors among health maintenance organizations

Abstract Background In line with insights whereby digital health services (DHS) can increase the accessibility and availability of health services, health maintenance organizations (HMO) have developed various DHS, with the aim of improving services and reducing disparities in health. Specifically, the COVID-19 crisis forced HMO to accelerate the use of DHS, to allow for remote health services. Yet, the implementation of technology-based services in healthcare is complex, due to a range of obstacles related to technological, ethical, and human aspects. This study aimed at identifying and comparing the predicting factors of DHS use, including digital health literacy and attitudes towards DHS, to understand its implementation among the four HMO in Israel. Methods The study included a correlative cross-sectional design. Data was gathered via a closed-end questionnaire, distributed through an online panel to 609 Israeli respondents, aged ≥20, regarding demographics and attitudes towards DHS, digital health literacy, and the extent of DHS use. Hierarchical regression was performed to examine whether the research variables predict DHS use. One-way ANOVA was conducted to compare between HMO. Results Higher use of DHS was found to be predicted by ethnicity (Jews), income (average and above), belonging to a certain HMO (Maccabi and Leumit Health Services), positive attitudes towards DHS, and higher digital health literacy (R2=.26). In addition, significant differences were seen between HMO in the degree of use (moderate effect) and attitudes towards DHS (weak effect): members of Maccabi and Leumit Health Services held more positive attitudes towards DHS, and made greater use of them, compared to members of Clalit and Meuhedet Health Services. Conclusions As use of DHS differs across HMO, the latter should act to adapt DHS to meet the characteristics and needs of certain target groups among their members, as a means for increasing the use of digital services. Key messages • HMO should adapt their DHS to meet members’ demographic characteristics and needs. • Adjusting DHS may improve members’ attitudes towards such services and increase their involvement in using them.

Unique patterns of healthcare utilization following the opening of the Samson Assuta Ashdod University Hospital

Our aim was to examine the influence of the market entry of Samson Assuta Ashdod University Hospital on community and hospital-based healthcare utilization (HCU). A retrospective study was conducted among Maccabi Health Services enrollees in the regions of Ashdod (n = 94,575) and Netanya (control group, n = 80,200) before and after this market entry. Based on difference-in-differences framework, we examined the change in HCU of Ashdod region’s enrollees compared to the control group and following the market entry using multivariable generalized estimating equations models. Our results revealed that, as hypothesized, after the market entry and compared to the control group, there was a 4% increase in specialists visits not requiring referral (RR = 1.04, 95% CI 1.03–1.06, p < 0.001), a 4% increase in MRI and CT scans (RR = 1.04, 95% CI 1.01–1.08, p = 0.022), and a 33% increase in emergency room visits (RR = 1.33, 95% CI 1.29–1.38, p < 0.001). Unexpectedly, no changes were observed in the number of hospital admissions (RR = 1.05, 95% CI 0.97–1.14, p = 0.250), and hospitalization days (RR = 0.99, 95% CI 0.94–1.04, p = 0.668). Moreover, and unexpectedly, there was a 1% decrease in primary care physician visits (RR = 0.99, 95% CI 0.98–1.00, p = 0.002), a 11% decrease in specialists visits requiring a referral (RR = 0.89, 95% CI 0.86–0.91, p < 0.001), and a 42% decrease in elective surgeries (RR = 0.58, 95% CI 0.55–0.60, p < 0.001). We conclude that this market entry was not translated to an increase in utilization of all services. The unique model of maintaining the continuity of care that was adopted by the hospital and patients’ loyalty may led to the unique inter-relationship between the hospital and community care.

DXA assessment and fracture prevention in hormone positive breast cancer patients after treatment initiation with aromatase inhibitors: A registry-based cohort study

BackgroundSeveral guidelines have been proposed to prevent aromatase inhibitors induced bone loss (AIBL), but there is scarce data on their endorsement in clinical practice. AimTo assess bone health evaluation and fracture prevention in postmenopausal women with estrogen receptor (ER)-positive breast cancer after aromatase inhibitors (AI) initiation. MethodsAn historical cohort analysis based on data from the cancer and osteoporosis Maccabi Health Services (MHS) registries from Jan 1st 2009 to Dec 31st 2020. Cases of estrogen receptor (ER)-positive breast cancer were extracted. Index date was set as the first aromatase inhibitors (AI) purchase. Variables such as age, BMI, smoking history, alcohol use, rheumatoid arthritis, diabetes, glucocorticosteroid use, previous fractures, BMD T-scores and purchases of AI and anti-resorptive agents were collected. Age under 50, previous cancer, prior major osteoporotic fractures and prior anti-resorptive treatment were exclusion criteria. Kaplan-Meier curves were generated to assess the time to outcomes. Multivariable Cox's proportional hazards survival model was performed. ResultsA total of 8617 women initiating AI were eligible. The median follow up was 6.1 years. The mean (SD) age at index was 62.8 (9.2), the mean (SD) BMI was 29.1 (5.6). The mean (SD) T-score was −1.3 (1.2) at the lumbar spine, −1.5 (0.9) at the femoral neck and −1.0 (1.0) at the total hip. Twenty percent had type 2 diabetes, 8.1 % were active smokers, 3.8% had rheumatoid arthritis and 1.2% were exposed to glucocorticoids.A total of 37% and 53% underwent a DXA scan at 1 and 2 years from AI initiation, and 12% and 17% were prescribed an anti-resorptive agent at 1 and 2 years from index. Advanced age was associated with a higher rate of evaluation and treatment, while obesity and diabetes were associated with a lower rate. The cumulative incidence of a major osteoporotic fracture was 8.8 and 15.8 % at 5 and 10 years, respectively. ConclusionsDespite the excess risk of fractures, bone health assessment and preventive treatment are still partial and postponed in breast cancer AI treated patients. Strategies to ensure appropriate care are needed.

Incidence of cardiovascular morbidity among Parkinson's disease patients; a large-scale cohort study in a 16-year time window around disease onset

ObjectivesTo examine the risk of any or specific types of cardiovascular diseases (CVDs) in patients with Parkinson's disease (PD), in the 16 years around disease onset, and to compare it to that in the general population. MethodsThis is a large-scale population-based retrospective cohort study of newly diagnosed PD patients, members of Maccabi Health Services (MHS), who started taking anti-parkinsonian drugs (APD) between 1/1/2000-31/12/2019 (study period). We collected information about CVD incidence (Congestive heart failure-CHF, Myocardial infarction-MI, Stroke) from MHS-CVD registry. We applied Cox regression to estimate adjusted-HR and 95%CI of CVD risks. We calculated Standardized-Incidence-Ratio (SIR) comparing CVD risks in the PD cohort to that of MHS population. ResultsThe PD cohort comprised 10,840 patients. During a mean follow up of 16.3 ± 4.3y around disease onset, 20.7% (n = 2241) were diagnosed with any CVD: 7.9% with CHF; 6.7% with MI, and 10.5% with stroke. Risks were higher for men: HR = 1.95 (95%CI 1.58–2.40), and for above age 75y at first APD treatment, HR = 2.00 (95% CI 1.65–2.43). Compared to the MHS population, the PD cohort exhibited a significantly lower risk for CVDs, especially for men: SIRmen = 0.21 (95%CI 0.20–0.22), SIRwomen = 0.29 (95% CI 0.27–0.31). These trends were similar for the specific CVDs. ConclusionsThe findings suggest that the risks that PD patients and particularly men, will develop any type of CVD are lower than those of the general population. Further studies are needed to confirm this finding and examine the underlying mechanisms.

The National Israel Brain Repository: Characterizing those who sign and do not sign intent to autopsy

AbstractBackgroundCollection of postmortem human brain and spinal cords for research is invaluable, especially in neurodegeneration, since human clinicopathologic data may lead to better understanding their pathophysiology and to new therapeutic targets. The National Israel Brain Repository was established in 2018 and began recruiting donors from two large‐scale community‐based studies of individuals at high dementia risk: older adults with type 2 diabetes (Israel Diabetes and Cognitive Decline study‐IDCD) and middle‐aged offspring of AD patients (The Israel Registry for Alzheimer’s Prevention‐ IRAP).We compared sociodemographic, cardiovascular (CVRFs)and cognitive characteristics of individuals who agreed and did not agree to sign intent to autopsy (ITA)MethodIn the IDCD, of the 750 active participants, we approached 636. Of them, 196 (31%) agreed to sign ITA.IRAP has 480 active participants of whom 395 were approached and of them 176 (45%) agreed to sign ITA. All participants are from the Maccabi Health Services, providing CVRF data since 1998. Using t‐test we compared the groups on sociodemographic and CVRFs. For IDCD, which averages 36‐months cognitive follow ups, mixed regression models adjusting for age, sex and education tested whether signing ITA predicted cognitive trajectories. For IRAP, whose follow‐ups have only recently begun, we used linear regressions adjusting for the same covariates, compared cognitive functioning between those the two groupsResultIn the IRAP sample, participants who signed ITA did not differ from those who did not sign on any of the characteristics except for HbA1c (Table 1). In the IDCD sample, those who signed ITA had higher education, creatinine, and BMI and better motor function (hand grip and 3‐meter walk). Finally, those who signed ITA had a slower rate of decline in episodic memory (Estimate = 0.002, SE = 0.001, p = 0.05)ConclusionOur results suggest that middle‐aged adults at high AD risk willing to donate their brains to science do not differ in sociodemographic or CVRFs from those who do not wish to be organ donors. In contrast, older adults at high dementia risk due to T2D who signed ITA are more educated, have better motor function and a slower rate of cognitive decline suggesting a selection bias towards better health.Development of strategies to diminish this selection bias are warranted.

Adherence to colchicine prophylaxis among patients with familial Mediterranean fever treated with interleukin-1 inhibitors

ObjectiveInterleukin-1 (IL-1) inhibitors are approved for treating familial Mediterranean fever (FMF) that is resistant to colchicine. However, continued concomitant treatment with colchicine is imperative, as it is the only drug proven to prevent secondary amyloidosis. We aimed to compare the adherence to colchicine between patients with colchicine-resistant FMF (crFMF) who were treated with IL-1 inhibitors and patients with colchicine-sensitive FMF (csFMF) who were treated only with colchicine. MethodsThe databases of Maccabi Health Services, a 2.6-million-member state-mandated health provider in Israel were searched for patients with FMF diagnosis. The medication possession ratio (MPR), calculated from the day of the first colchicine purchase (index date) until the last colchicine purchase was the main outcome measure. Patients with crFMF were matched in a 1:4 ratio to patients with csFMF. ResultsThe final cohort included 4526 patients. Of them, 108 (2.4%) were with crFMF, and were matched to 432 with csFMF. The total mean MPR in each of the matched groups was similar (78.9 ± 41.4 and 82.5 ± 80.6, respectively, P = 0.5). Statistically significant differences in MPR were not found between the groups according to age or duration of colchicine use. However, adherence to colchicine was insufficient (MPR<80%) among more than 50% of the patients in both groups. ConclusionIn contrast to initial concerns, adherence to colchicine was similar between patients with crFMF and csFMF. However, in both groups, adherence to colchicine was poor. Education of both caregivers and patients is essential to increase adherence.

P264 Machine learning can accurately predict development of Inflammatory Bowel Disease

Abstract Background Prediction of inflammatory bowel disease (IBD) development is the subject of intense study. We have previously shown that significant changes occur in routine laboratory tests in the 5 years preceding IBD diagnosis. Using routinely collected laboratory results, we developed machine learning models to predict development of IBD. Methods We extracted data from the electronic medical records of Maccabi Health Services and included patients with IBD ≥ 16 years of age with a minimum of 5 years follow up and an age and sex matched healthy cohort. The outcome measured was entry into the IBD registry. The study population was split into training and validation cohorts and using laboratory values in the 5 years prior to IBD diagnosis as features, we assessed the performance of supervised learning models and performed interpretability analysis with unsupervised dimensionality reduction. Results 5643 patients with IBD and 17199 healthy people were included in this study. 3039 (53.8%) had Crohn’s disease (CD), 2322 (41.1%) ulcerative colitis (UC) and 282 (5%) indeterminate colitis. The mean age of the IBD and healthy cohorts at study inclusion was 39.3 ± 16.5 and 38.5 ± 15.6 years, respectively. Weighted nearest neighbour imputation was used to correct for data missingness. Unsupervised Uniform Manifold Approximation Projection dimensionality reduction correctly separated the cohort into healthy and IBD clusters (Figure 1A). Furthermore, this algorithm identified two distinct groups correlating to CD or UC diagnosis (Figure 1B). Supervised learning models, namely neural net (AUC 0.95), linear support vector machine (SVM) (AUC 0.93), radial basis function SVM (AUC 0.85) and logistic regression (AUC 0.93) models, accurately predicted IBD diagnosis (Figure 2). These models were repeated without C-reactive protein and the predictive value was not significantly changed. Moreover, we excluded data in the 2 years preceding IBD diagnosis to determine whether model performance was reduced and the predictive value remained the same. Interestingly, using only data from 3-5 years preceding IBD diagnosis, the model could better distinguish between CD and UC (Figure 3). Conclusion In this study, machine learning models could accurately predict a diagnosis of IBD using laboratory data from the 5 years preceding IBD diagnosis. Prospective studies are needed to test these models in a real world setting.

Trends in Biochemical Parameters, Healthcare Resource and Medication Use in the 5 Years Preceding IBD Diagnosis: A Health Maintenance Organization Cohort Study.

Few data describing pre-diagnosis changes in patients with inflammatory bowel disease (IBD) exist. We aimed to determine if there is a pattern of change in use of health resources, medications and laboratory results in the years preceding diagnosis. This retrospective study used electronic medical records of Maccabi Health Services (MHS). Patients with IBD ≥ 16years of age and minimum of 5-years follow-up were identified by entry into the MHS IBD registry and included in the analysis. Demographic, clinical, medication and laboratory data were collected. Generalized estimating equation model was applied to study trends and compare between years. This study included 5643 patients with IBD. Of these, 3039 (53.8%) had Crohn's disease (CD), 2322 (41.1%) had ulcerative colitis (UC) and 282 (5%) had indeterminate colitis (IC). Laboratory parameters including white blood cells, platelets and C-reactive protein showed significant increases while haemoglobin and mean cell volume showed significant decreases in mean values in the 2years prior to diagnosis with stable values prior to that (p < 0.0001). Parameters such as creatinine, total protein and albumin showed significant, progressive decreases in mean values starting 5years prior to diagnosis (p < 0.0001). Patients with CD had distinct laboratory trends when compared with patients with UC. Changes in laboratory parameters, healthcare service and medication use occur during the 5-year period before IBD diagnosis. These data can have future clinical applicability by developing a composite score and referral algorithm introducing red flags into primary care visits and appropriate referral for specialist care.

Using the Gaucher Earlier Diagnosis Consensus (GED-C) Delphi Score in a Real-World Dataset

Early and accurate diagnosis of Gaucher disease, a rare, autosomal recessive condition characterized by hepatosplenomegaly, thrombocytopenia, and anemia, is essential to facilitate earlier decision-making and prevent unnecessary tests and procedures. However, diagnosis can be challenging for non-specialists, owing to a wide variability in age, severity of disease, and types of clinical manifestation. The Gaucher Earlier Diagnosis Consensus (GED-C) scoring system was developed by a panel of 22 expert physicians using Delphi methodology on the signs and covariables considered important for diagnosing Gaucher disease. This study aimed to use the scoring system in a real-world dataset. We applied the GED-C scoring system to 265 confirmed cases of Gaucher disease identified in the Maccabi Health Services (MHS) database from 1998 to 2022. Overall Delphi scores were calculated using features applicable to type 1 Gaucher disease. Based on all available patient data up to one year after diagnosis, the median (interquartile range (IQR)) Delphi score was 8.0 (5.5–11.5), with patients reporting up to 15 variables each. A score of 9.5 (6.5–12.5) was determined for 205 patients diagnosed from 2000 to 2022. The overall GED-C score was highly dependent on the extraction of all relevant data. The number of features collected in the MHS database was fewer than those required to achieve a high score on the GED-C score.

The implementation of clinical guidelines concerning return to work after myocardial infarction

Purpose To examine the implementation, clinical effects, and adherence of occupational physicians to the clinical practice guidelines (CPG) published in 2003 in Israel, regarding return to work following acute myocardial infarction (AMI). Methods We analyzed 3 populations referred to Maccabi Health Services occupational clinics for fitness for work examinations following AMI, either before the guidelines were published (group 1), after their first publications in 2003 (group 2) or after they were re-published in Harefuah Journal in 2007 (group3). Results The documentation among groups 1,2,3 of different parameters like years of education (18.8%, 45.1%. 57.5%, p < 0.001), type of occupation (86.5%, 98.2%, 100.0%, p < 0.001) and New York Heart Association (NYHA) class (69.8%, 81.4%, 92.5%, p < 0.001) has all improved respectively over the years. No significant difference in sick leave was noted between the three populations. Conclusion The CPG should be interdisciplinary in the phase of writing and publication. Economical resources are needed in order to implement CPG. Implications for Rehabilitation The clinical practice guidelines should be interdisciplinary in the phase of writing and should involve all rehabilitation professionals as a team. The clinical practice guidelines need disseminating widely alongside a resource plan in order to implement it.

Childhood Asthma - The Effect of Asthma Specialist Intervention on Asthma Control: A Retrospective Review.

BackgroundChildhood asthma is the most common chronic disease throughout the western world. Improving asthma control is a leading health management goal.PurposeTo evaluate the effect of an intervention by a visit to an asthma specialist on asthma control in children.Materials and MethodsThis retrospective study was conducted using the electronic database of Maccabi Health Services. All members ages 5–16 with an asthma diagnosis during 2000–2016, and at least one visit to a specialist were included. Asthma outcomes during the 2 years before and after the visit to the asthma specialist were compared.ResultsA total of 37,066 children were diagnosed with asthma. Among them, 13,533 (36.5%) had at least one visit to an asthma specialist and were included. Children with asthma visited their primary care physician more often in the period before the specialist visit (4.4± 4.4 vs 3.16± 3.9 visits, respectively; p<0.01). After visiting a specialist, average number of visits to emergency departments (0.52± 1.3 vs 0.45±1), all cause hospitalizations (0.13±0.45 vs 0.08±0.4) and hospitalizations due to asthma exacerbations (0.08±0.345 vs 0.05±0.3) decreased (p<0.01 for all comparisons). Prescription of short-acting beta agonists decreased (2.85±3.6 vs 2.2 ±3.7, p<0.01) and inhaled steroid prescriptions increased (1.9±2.9 vs 2.7±3.7, p<0.01), respectively, after the intervention. A substantial reduction in the prescription of corticosteroids (0.81±1.9 vs 0.43±1.4, p<0.01) after specialist visit was also noted.ConclusionWe found significant positive outcomes after a single consultation with an asthma specialist. Referring pediatric asthma patients to an asthma specialist should be one of the goals of an asthma management plan.