RESUMO
PURPOSE: Primary care physicians have an important role in encouraging adequate cancer screening. Disparities in cancer screening by socioeconomic status (SES) may affect presentation stage and cancer survival. This study aimed to examine whether breast, colorectal, and cervical cancer screening rates in women differed by SES and age, and whether screening rates and SES disparities changed after introduction of a primary care-based national quality indicator program. METHODS: This repeated cross-sectional study spanning 2002-2017 included all female Israeli residents in age ranges appropriate for each cancer screening assessed. SES was measured both as an individual-level variable based on exemption from copayments and as an area-level variable using census data. RESULTS: In 2017, the most recent year in the study period, screening rates among 1,529,233 women were highest for breast cancer (70.5%), followed by colorectal cancer (64.3%) and cervical cancer (49.6%). Women in the highest area-level SES were more likely to undergo cervical cancer screening compared with those in the lowest (odds ratio = 3.56; 99.9% CI, 3.47-3.65). Temporal trends showed that after introduction of quality indicators for breast and colorectal cancer screening in 2004 and 2005, respectively, rates of screening for these cancers increased, with greater reductions in disparities for the former. The quality indicator for cervical cancer screening was introduced in 2015, and no substantial changes have occurred yet for this screening. CONCLUSIONS: We found increased uptake and reduced socioeconomic disparities after introduction of cancer screening indicators. Recent introduction of a cervical cancer screening indicator may increase participation and reduce disparities, as has occurred for breast and colorectal cancer screening. These findings related to Israel's quality indicators program highlight the importance of primary care clinicians in increasing cancer screening rates to improve outcomes and reduce disparities.
Assuntos
Neoplasias da Mama , Neoplasias do Colo do Útero , Estudos Transversais , Detecção Precoce de Câncer , Feminino , Disparidades em Assistência à Saúde , Humanos , Programas de Rastreamento , Indicadores de Qualidade em Assistência à Saúde , Fatores Socioeconômicos , Neoplasias do Colo do Útero/diagnósticoRESUMO
BACKGROUND: A large vaccination campaign was initiated worldwide in December 2020 in order to prevent infection with SARS-CoV-2 and severe Covid-19 disease. However, long-term adverse effects of vaccination remain unclear. Therefore, our objective was to examine the association between vaccination and the incidence of autoimmune diagnoses in the first year after vaccine uptake. METHODS: This retrospective cohort study based on Clalit Health Services (CHS) comprehensive database compared the rates of immune-mediated diagnoses among BNT162b2 vaccinated versus unvaccinated individuals. As a reference, a secondary cohort compared individuals infected with Sars-CoV-2 versus uninfected individuals. The minimum follow-up period was 4 months. The cohorts were divided into 4 age groups (12-17, 18-44, 45-64, 65 years or older). Multivariate Cox proportional hazard regression models were applied, followed by a correction for multiple comparisons using the False Discovery Rate (FDR) method, hence accounting for the investigation of multiple clinical outcomes. RESULTS: Increased risk for immune-mediated diagnoses following vaccination with BNT162b2 was observed for psoriasis in all age groups (HR 1.41-1.69), colitis among patients younger than 65 years (HR 1.38-1.93), vitiligo in patients aged 45-64 (HR 2.82, 95 %CI: 1.57-5.08) and for polymyalgia-rheumatica in patients aged 65 years or older (HR 2.12, 95 % CI: 1.3-3.47). In the reference cohort, patients who were infected by Covid-19 were at increased risk for fibromyalgia (HR 1.72, 95 % CI: 1.36-2.19 in individuals aged 18-44; HR 1.71, 95 % CI: 1.31-2.22 in individuals aged 45-64), and hypothyroidism (HR 1.54, 95 % CI: 1.15-2.07 in individuals aged 65 years or older). CONCLUSIONS: The BNT162b2 vaccine was associated with increased risk (though rare) for psoriasis, colitis and polymyalgia rheumatica. These findings should be considered as a part of the risk-benefit assessment when planning future vaccination programs for various population groups.
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Vacina BNT162 , COVID-19 , Humanos , Vacina BNT162/imunologia , Vacina BNT162/efeitos adversos , Pessoa de Meia-Idade , Estudos Retrospectivos , Masculino , Adulto , Feminino , COVID-19/prevenção & controle , COVID-19/epidemiologia , COVID-19/imunologia , Idoso , Adolescente , Adulto Jovem , Incidência , Criança , Vacinação/efeitos adversos , Vacinação/estatística & dados numéricos , SARS-CoV-2/imunologia , Comorbidade , Doenças Autoimunes/epidemiologia , Doenças Autoimunes/etiologia , Vacinas contra COVID-19/efeitos adversos , Vacinas contra COVID-19/imunologia , Vacinas contra COVID-19/administração & dosagem , Psoríase/epidemiologia , Psoríase/imunologiaRESUMO
Importance: Evidence regarding the relative effectiveness of bariatric metabolic surgery (BMS) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) in reducing mortality and major adverse cardiovascular events (MACEs) is limited. Objective: To compare all-cause mortality and nonfatal MACEs associated with BMS vs GLP-1RAs for adults with obesity and diabetes and without known cardiovascular disease. Design, Setting, and Participants: This observational, retrospective cohort study was based on data obtained from the electronic medical records of Clalit Health Services (Clalit), the largest health care organization in Israel. The study included 6070 members aged 24 years or older, who had diabetes and obesity and no prior history of ischemic heart disease, ischemic stroke, or congestive heart failure. Patients who underwent BMS and patients who received GLP-1RAs from January 1, 2008, through December 31, 2021, were matched 1:1 by age, sex, and clinical characteristics. Follow-up ended December 31, 2022. Exposures: Initiation of BMS or GLP-1RAs. Main Outcomes and Measures: The primary outcome was all-cause mortality, assessed by multivariate Cox proportional hazards regression models. The secondary outcome was nonfatal MACEs, assessed by multivariate competing risk models. Results: The study included 3035 matched pairs of patients (total, 6070; mean [SD] age, 51.0 [9.5] years; 3938 women [64.9%]), who were followed up for a median of 6.8 years (IQR, 4.1-9.4 years). Among those with a diabetes duration of 10 years or less (2371 pairs), mortality was lower for those who underwent BMS than for those treated with GLP-1RAs (hazard ratio [HR], 0.38; 95% CI, 0.25-0.58). This association became nonsignificant when weight loss during the follow-up period was also included in the model (HR, 0.79; 95% CI, 0.43-1.48). Among patients with a duration of diabetes longer than 10 years (664 pairs), no survival advantage was demonstrated for BMS over GLP-1RA (HR, 0.65; 95% CI, 0.39-1.08). The risk for nonfatal MACEs did not differ between the treatment groups (HR, 0.74; 95% CI, 0.49-1.10 among patients with a diabetes duration of ≤10 years; HR, 1.21; 95% CI, 0.80-1.85 among patients with a diabetes duration of >10 years). Conclusions and Relevance: In this cohort study, BMS was associated with greater reduced mortality compared with first-generation GLP-1RAs among individuals with a diabetes duration of 10 years or less, mediated via greater weight loss. No differences in the risk for mortality were observed between the treatment modalities among individuals with a longer duration of diabetes, nor in the occurrence of nonfatal MACEs among all patients.
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Cirurgia Bariátrica , Receptor do Peptídeo Semelhante ao Glucagon 1 , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Receptor do Peptídeo Semelhante ao Glucagon 1/agonistas , Cirurgia Bariátrica/mortalidade , Cirurgia Bariátrica/métodos , Adulto , Israel/epidemiologia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/mortalidade , Obesidade , Hipoglicemiantes/uso terapêutico , Doenças Cardiovasculares/mortalidade , Modelos de Riscos Proporcionais , Agonistas do Receptor do Peptídeo 1 Semelhante ao GlucagonRESUMO
BACKGROUND: A substantial drop in emergency department (ED) visit volume was previously demonstrated at the onset of the COVID-19 pandemic. OBJECTIVE: To examine changes in the number of non-COVID adult ED visits and their associated 30-day mortality during 14 months of the pandemic in Israel. METHODS: This is a retrospective cohort study including 1,285,270 adult ED visits between 1st March, 2018 and 30th April, 2021 to the internal and surgical EDS in eight general hospitals of the largest healthcare organization in Israel. The 14 months of the pandemic period (March 2020-April 2021) were divided into seven periods according to dates of the three lockdowns. Exposure to each of these periods was compared to the parallel period during the two previous years. March 2020-April 2021 was compared to the parallel periods in 2018 and 2019. RESULTS: During the pandemic period, the largest decline in ED visits (44.6% and 50.9% for internal and surgical EDs, respectively) and the highest excess 30-day mortality following an ED visit (internal EDs Adjusted OR (ORadj), 1.49; 95% CI, 1.34-1.66 and surgical EDs: ORadj 1.50; CI, 1.16-1.94) were 95%, observed during the first lockdown. Both gradually levelled-off subsequently until near-normalization was reached in March-April 2021 for both parameters. CONCLUSIONS: A substantial decline in non-COVID ED visits and excess mortality at the beginning of the pandemic, are probably the results of social distancing restrictions alongside patients' fear of exposure to COVID-19, which gradually moderated thereafter, until near normalization was reached after 14 months. Gradual return to pre-pandemic ED utilization patterns were noticed as the population and the healthcare system acclimatize to life alongside COVID.
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COVID-19 , Pandemias , Adulto , COVID-19/epidemiologia , Controle de Doenças Transmissíveis , Serviço Hospitalar de Emergência , Humanos , Israel/epidemiologia , Estudos RetrospectivosRESUMO
BACKGROUND: In view of increasing global and local trends in population ageing and the high healthcare utilization rates among the elderly, this study assesses the quality of primary care provided to the elderly population in Israel. It examines changes in quality over time, how quality varies across sub-groups of the elderly, and how quality in Israel compares with other countries. Data originate from the National Program for Quality Indicators in Community Healthcare (QICH), which operates in full collaboration with Israel's four HMOs. METHODS: The study population included all elderly Israeli residents aged 65 years or older during 2002-2015 (N = 879,671 residents in 2015). Seven elderly-specific quality indicators from within the QICH framework were included: influenza and pneumococcal vaccinations, benzodiazepine overuse, long-acting benzodiazepine use, body weight documentation, weight loss and underweight. In addition, two non-age specific quality indicators relating to diabetes mellitus were included: the rate of HbA1C documentation and uncontrolled diabetes. Data were collected from patient electronic medical records (EMR) in accordance with each HMO, and aggregated by three variables: gender, age, and socio-economic position (SEP). RESULTS: During the measurement period, vaccination rates significantly increased (Influenza: from 42.0% in 2002 to 63.2% in 2015; and pneumococcal vaccination: from 25.8% in 2005 to 77.0% in 2015). Body weight documentation (in 65-74 year old persons) increased from only 16.3% in 2003 to 80.9% in 2015. The rate of underweight (BMI < 23 kg/m2) and significant weight-loss (10% or more of their body weight) was only measured in 2015. The overall rate of benzodiazepine overuse remained steady from 2011 to 2015 at around 5%, while the rate of long-acting benzodiazepine use decreased from 3.8% in 2011 to 2.4% in 2015. The rate of HbA1c documentation for elderly diabetics was higher than for non-elderly diabetics in 2015 (92.2% vs 87.9%). The rate of uncontrolled diabetes was lower for the elderly than the non-elderly population in 2015 (6.9% vs. 15.7%). Gender disparities were observed across all measures, after age stratification, with worse indicator rates among females compared to males. SEP-disparities were not consistent across measures. In all indicators except benzodiazepine overuse, Israel showed a higher quality of care for the elderly in comparison with the international healthcare community. CONCLUSIONS: Overall, the quality of care received by elderly Israelis has improved substantially since measurements first began; yet, females receive lower quality care than males. Monitoring results of primary care quality indicators can contribute to population's successful aging; both chronic conditions at earlier ages (e.g. diabetes), and short-term hazardous conditions such as the use of potentially harmful medications and weight loss should be evaluated.