Priority setting for health technology adoption at the national level: Lessons learned over 25 years' experience.

BACKGROUND: Limited health budgets and continual advancement of health technologies require mechanisms for prioritization. Israel, with a publicly funded health service basket, has implemented and optimized such a health technology assessment process since 1999.We describe the process of evaluating technologies according to the Israeli model, analyze its outputs and benefits over two decades of implementation, and compare its key features with international experience. METHODS: Retrospective data were collected between 1998 and 2023, including work processes, committee composition, number of applications submitted and approved by a clinical domain, and yearly cost of the basket. Features were evaluated within the evidence-informed deliberative process (EDP) framework. RESULTS: This national model involves relevant stake holders in a participatory and transparent process, in a timely manner, and is accepted by the public, health professionals, and policy makers, facilitating early adoption of the newest medical technologies. Between 11 and 19 percent of applications are approved for reimbursement annually, mostly pharmaceuticals. On average 26 percent of approved technologies are added to the list without additional budget. Major domains of approved technologies were oncology, cardiology, and neurology. CONCLUSIONS: Israel created a unique model for the expansion of the health service basket. Despite an increasing number of applications and rising costs, the mechanism enables a consensus to be reached on which technologies to fund, while remaining within budget constraints and facilitating immediate implementation. The process, which prioritizes transparency and stake holder involvement, allows just a resource allocation while maximizing the adoption of novel technologies, contributing to an outstanding national level of health despite relatively low health spending.

Less Is More (Healthy): Overuse of Healthcare Services.

BACKGROUND: Overuse of healthcare services is a common phenomenon defined as: "a healthcare service that is provided under circumstances in which its potential for harm exceeds the possible benefit." It is expressed in the gap between desired services and available ones and is accompanied by high financial and human life costs. One-fifth to one-third of patients receives unnecessary, ineffective, or potentially harmful treatments or services. One of the greatest challenges to understanding overuse is the lack of definition for appropriate use. Apart from the physical and mental damage caused by overuse or improper use of medical services, this phenomenon has many implications, such as increasing waiting times for services, creating long queues, and incurring considerable financial costs as over 10% of hospital expenses are used to correct medical errors or preventable infections. Government intervention through economic arrangements such as deductibles and pre-authorization of services by the insurer are partially effective in reducing the overuse of health services. Additional solutions include ensuring safety and quality of care as well as shared decision-making.

Examining the use of health systems and policy research in the health policymaking process in Israel: views of researchers.

BACKGROUND: All too often, health policy and management decisions are made without making use of or consulting with the best available research evidence, which can lead to ineffective and inefficient health systems. One of the main actors that can ensure the use of evidence to inform policymaking is researchers. The objective of this study is to explore Israeli health systems and policy researchers' views and perceptions regarding the role of health systems and policy research (HSPR) in health policymaking and the barriers and facilitators to the use of evidence in the policymaking process. METHODS: A survey of researchers who have conducted HSPR in Israel was developed. The survey consisted of a demographics section and closed questions, which focused on support both within the researchers' organisations and the broader environment for KTE activities, perceptions on the policymaking process, and the potential influencing factors on the process. The survey was sent to all health systems and policy researchers in Israel from academic institutions, hospital settings, government agencies, the four health insurance funds, and research institutes (n = 107). All responses were analyzed using descriptive statistics. For close-ended questions about level of agreement we combined together the two highest categories (agree or strongly agree) for analysis. RESULTS: Thirty-seven respondents participated in the survey. While many respondents felt that the use of HSPR may help raise awareness on policy issues, the majority of respondents felt that the actual use of HSPR was hindered for many reasons. While facilitators do exist to support the use of research evidence in policymaking, numerous barriers hinder the process such as challenges in government/provider relations, policymakers lacking the expertise for acquiring, assessing, and applying HSPR and priorities in the health system drawing attention away from HSPR. Furthermore, it is perceived by a majority of respondents that the health insurance funds and the physician organisations exert a strong influence in the policymaking process. CONCLUSIONS: Health system and policy researchers in Israel need to be introduced to the benefits and potential advantages of evidence-informed policy in an organised and systematic way. Future research should examine the perceptions of policymakers in Israel and thus we can gain a broader perspective on where the actual issues lie.

[Professionalism in healthcare organizations--a unique model in the Assuta Medical Centers Network].

"Medical professionalism signifies a set of values, behaviors, and relationships that underpin the trust the public has in doctors". Healthcare organizations and medical schools are expected to ensure that their employees and graduates possess these values, behaviors and skills. The importance of maintaining professionalization within the organization led the Assuta Medical Centers Network to establish a School of Professionalism in January 2014. All of the employees within Assuta are scheduled to participate in a training program focused on Professionalism in Healthcare. Training includes a unique, interactive teaching initiative facilitated by leaders chosen from among Assuta employees. Each training class comprises heterogeneous sets of employees from all divisions within the organization (medical, administrative, support employees etc.). Until February 2015, a total of 1,225 workers participated in this program. This novel intervention initiative is being evaluated and assessed in order to understand how the trainees perceive professionalism before and after the interventions; to observe changes in their attitudes, behaviors and skills following the training; and to assess short and long-term outcomes as this program progresses over the years.

Health systems and policy research evidence in health policy making in Israel: what are researchers' practices in transferring knowledge to policy makers?

BACKGROUND: Ensuring the use of research evidence in health system management and policy decisions is an important challenge in this century. Knowledge transfer and exchange (KTE) has emerged as a paradigm to address the challenges and start closing the 'know-do' gap. This area of work is gaining momentum in most developed countries, yet, to date, no work has been performed in Israel within this area. The purpose of this study was to identify which KTE activities health systems and policy researchers in Israel have undertaken. METHODS: A cross-sectional web-based survey of researchers who have conducted health systems and policy research in Israel was developed. The survey consisted of a demographics section, quantitative scales, and open-ended questions. The survey was sent to all health systems and policy researchers in Israel (n = 125). RESULTS: The study response rate (28%) was relatively low as compared to other studies in the same field (range of 42% to 88%). Our survey found that more than a third of the health systems and policy researchers in Israel reported that they were frequently or always involved in the following KTE activities: interactions with target audience through the research process (i.e., during developing a research question or executing the research; 35% to 42%) or through formal or informal meetings during conferences, workshops, or conversations (40%). Less than half of the health systems and policy researchers in Israel are engaged in bridging activities aimed to facilitate target audiences to use research. CONCLUSIONS: This is a fairly new area in Israel and therefore the level of engagement of researchers in KTE activities is not very high. The low response rates could be because KTE is a new field in Israel and minimal KTE initiatives have been undertaken. It is preferable to have higher response rates, yet, after several initiatives, this was the outcome. While the findings are relevant, they may not reflect the total population of health system and policy researchers in Israel. Health system and policy researchers in Israel need to be introduced to the benefits and potential advantages of KTE in an organized and systematic way.

The patient-perceived difficulty in diabetes treatment (PDDT) scale identifies barriers to care.

OBJECTIVE: The objective of this study is to describe the design and validation of a newly developed brief, treatment-focused scale for use with type 1 and type 2-diabetes, exploring patient-perceived difficulties that are associated with treatment. METHODS: The content of the construct was derived from consultation with experts, from existing instruments and the literature, as well as from diabetic patients. The original draft was comprised of 11 attributes. Based on an interim analysis, an additional 12th attribute was added. The final scale was tested on 988 diabetic patients from 25 practices in Israel. Respondents also completed a diabetes-specific quality of life (QoL) questionnaire and indicated their current perceived overall health status. RESULTS: The patient-perceived difficulty of diabetes treatment (PDDT) scale contains 12 items reflecting diabetes-treatment characteristics: adherence to self-monitoring of glucose schedule, frequency of self-monitoring of glucose, adherence to medication administration schedule, frequency of medication administration, multiple number of medications, synchronization between meals and medications, dependence on the medications, pain associated with treatment, diet restrictions, self-care, multiple healthcare providers, and costs of treatment. Response rate to all attributes was very high. Construct validity was shown by significant correlations between PDDT attributes and diabetes-specific quality of life (r = 0.31-0.46) and self-report adherence to recommended treatment (r = 0.14-0.28), as well as between overall perceived difficulty and diabetes-specific quality of life (r = 0.60). Furthermore, the PDDT items showed discriminant capabilities with respect to known groups of patients. CONCLUSIONS: The PDDT scale is a simple and valid instrument that may assist in identifying potential barriers in adherence to recommended treatments and to new treatment options.

[Risk-sharing scheme in Israel--Kuvan as an allegory].

Healthcare systems worldwide are dealing with the uncertainty characterizing new and expensive health technoLogies, particularly aspects involving drug effectiveness and the extent and doses required for utilization. Reducing this uncertainty can be achieved mainly by using either coverage with evidence development methods or risk-sharing schemes (RSS). In 2011, the first phenylketonuria (PKU) risk-sharing scheme was set up in Israel, through the public funding health services updating process. This was done in order to ensure that people with PKU could access PKU sole treatment--sapropterin dihydrochloride, Kuvan. The apparent effectiveness of the treatment, on one hand, and the uncertainty regarding the number of patients and average treatment dosage, on the other hand, dictated the RRS. This scheme determined a ceiling number of tablets to be funded by the insurer, above this ceiling the manufacturer would finance Kuvan. Furthermore, it was agreed that after 3 years Kuvan would be brought to the public committee for updating reimbursement decisions. It is inevitable that risk sharing and conditional coverage agreements will become a common practice in the reimbursement process in the future. This will allow competent authorities and pharmaceutical companies to build clinical experience and other required data with medicines which might normally not be eLigible for reimbursement. Before it becomes the common practice in Israel, the RSS for Kuvan, process and outcomes, should be monitored and analyzed by the Ministry of Health, to ensure patients access to treatment, the effective collection of the research data and the effective interaction between Israel's four health funds and the manufacturer.

[Medical resonance imaging (MRI)--the technology, the regulation and the utilization pattern in Israel].

Medical resonance imaging (MRI) is a technology for imaging and diagnosis of tissues and organs which does not use ionizing radiation. It was developed in the 1960's and 1970's and has been in clinical use since the 1980's. Over the last two decades there has been a substantial increase in utilization of MRI due to: improvements in imaging technology and image processing, the development of new indications for its use, and the increase in availability and accessibility of MRI in several medical fields. However, there is also overutilization of this technology due to: the use of imaging as a substitute for regular physical examinations, repeated examinations for the same medical reason, "defensive" medicine, and due to the public's desire for sophisticated examinations. These issues are all responsible for the increased use of MRI. MRI is an expensive technology and therefore, cost-lowering medical and economic mechanisms are employed to Limit its use. Until recently there were ten MRI scanners in Israel and this review presents their utilization patterns. The number of MRI scanners will double in the coming years. This may improve accessibility in different regions of the country, shorten waiting times, and improve medical diagnosis due to implementation for new indications. An international comparison showed that the number of MRI scanners in Israel is lower than the average number of MRI scanners in OECD countries. However, the utilization of MRI scanners in Israel is high relative to other OECD countries, indicating the high level of efficiency of the Israeli healthcare system.

[Personalized medicine--the future is already here].

Personalized medicine is pharmaceuticals or biological treatments paired with diagnostic tests (companion tests) that personalized the medicine in question with genetics or genetic signatures. Target-specific cancer therapeutics has remarkably improved the outcomes of patients and represents the frontline approach to treatments in oncology today. The molecular basis governing the deveLopment of colorectal cancer is well established. K-ras is one of the early key components in the development of colorectal cancer (CRC) and is involved in many signal transduction pathways of the epidermal growth factor receptor--EGFR. Both cetuximab and panitumumab, EGFR monoclonal antibodies, are approved for the treatment of colorectal cancer. Patients with mutations in oncogene K-ras are not considered candidates for those treatments. Therefore, identifying patients with K-ras mutations is critical prior to treatment selection. In Israel, cetuximab is approved as third line therapy in CRC patients and K-ras testing is required before choosing therapy. The study by Segal et at, pubLished in this issue, assessed the prevalence of molecular types of K-ras mutations in stage IV CRC patients who failed two lines of treatment. Those results revealed a pattern similar to that seen in other studies. This editorial discusses the results of this study in the context of personalized medicine and presents the need for promoting the understanding and use of personalized medicine within the Israeli healthcare system. Use of personalized medicine Leads to better health outcomes and may result in saving healthcare costs.

[Robot-assisted surgery--point of no return?].

INTRODUCTION: Robot-assisted laparoscopic surgery is a rapidly evolving technology, becoming widely applied as an alternative to open or laparoscopic gynecologic surgeries. The penetration of robot-assisted laparoscopic surgery into gynecologic surgeries in the past 6 years has been remarkable. The greatest advantages of this surgical technique are smaller incisions, leading to lower morbidity, less postoperative pain and shorter hospital stays. These techniques have been applied successfully in a wide variety of clinical fields including urology, cardiology, orthopedics, ophthalmology, neurosurgery and gynecology and have become important treatments of choice for patients. Although robot-assisted laparoscopic surgery is performed worldwide, only limited evidence of its superiority over traditional laparoscopic surgery exists. With the intent of reducing the invasiveness of traditional laparotomy (open surgery) and improving functional results, both in terms of decreased postoperative morbidity and faster postoperative recovery, surgical techniques evolve to become minimally invasive, first laparoscopic hysterectomy and then robot-assisted laparoscopic hysterectomy techniques. In Israel, approximately 45,000 gynecological surgeries are performed every year, and about tenth of these are hysterectomies. In this issue, Mejia-Gomez et al. describe the results of the first experience with robot-assisted Laparoscopic hysterectomy in Israel in 14 women in Hadassah Ein Kerem Hospital. Whilst debate continues about the evidence-based superiority of robot-assisted Laparoscopic hysterectomy, it appears that where robot-assisted systems exist, most patients will opt for the robotic-assisted approach and gynecologists will step forward to fill this niche because of its minimally invasive characteristics and clinical benefits, despite the lack of level I evidence.

[The over the counter drugs reform in Israel--two years later].

INTRODUCTION: In the last two decades there has been a world wide increase in the number of drugs that are being switched from the prescription-only category to non-prescription categories. In Israel, until recently, non-prescription medicines were only permitted to be sold by a pharmacist in pharmacies. In May 2005, following amendments to the law, several non-prescription medicines which were previously sold under a pharmacist's supervision, were reclassified as general-sales-list (GSL) medicines and permitted to be displayed and sold directly off the shelves in pharmacies and in other places such as grocery stores and petrol stations. OBJECTIVE: To study the change in the patterns of consumption of non-prescription drugs in Israel two years after the reform began. METHODS: A representative sample of the population of Israel was chosen and interviews were conducted at two time points: before the reform commenced and two years after the beginning of the reform. Statistical processing was performed in order to examine the changes in patterns of consumption of non-prescription drugs in Israel between these two time points. RESULTS: In both surveys it was found that: approximately 70% of the Israeli public buys non-prescription medicines; 70% of the people interviewed said that they had been aware of the reform, but of these, about 75% continued buying nonprescription drugs from the pharmacist while 21% bought medicines off the shelves at the pharmacy and 4% purchased medications at grocery stores. The most common reasons for buying medicines off the shelves without a pharmacist were earlier knowLedge about the medication, convenience and availabiLity when the pharmacies were closed. An insignificant difference was observed for the purchase of non-prescription drugs from the different types of pharmacies: the health maintenance organizations (HMO) pharmacies continue to be the leading pharmacies from which the public purchased their non-prescription medicines, white there was a slight increase in the purchases from pharmacy chains. In the two surveys, the purchaser's personal experience was the biggest factor influencing the decision to buy a certain drug, followed by the doctor's and the pharmacist's recommendation. Only 15% thought that non-prescription medicines are not safe. IN CONCLUSION: Two years after the reform began no breakthrough was observed in the pattern of purchase of non-prescription medicines. Despite exposure to the reform, most Israelis continue to buy these medicines from the pharmacists. Therefore, it appears that more time will be needed for this reform to actually start making an impact and changing the habits of Israeli consumers when purchasing non-prescription drugs.

[Over the counter drugs--a new era in Israel].

The reformation in the marketing of non-prescription medicinal products has been launched. As of May 10th 2005, the pharmacist regulations 2004 (marketing of over-the-counter (OTC) drugs outside of pharmacies, as well as not by a pharmacist) will be in effect. This change aLlows the marketing of medicines outside of pharmacies, as has been the custom in the U.S.A., England and some of the European Union countries for many years. This reformation is incorporated in a policy that encourages self-medication by the use of non-prescription drugs. The self-medication policy originates from the point of view of the consumers who wish to be responsible for their own health and save precious time wasted on doctor visits; and the government's assumption that self-medication of OTC medicines by citizens wiLL decrease expenses for the HMOs in both doctor's billings as well as medication costs. In order to regulate the marketing terms of these medicinal products, regulations and complimentary guidelines were written and published. These documents encompass the following issues: the list of OTC medicines, marketing reguLations, packaging regulations, Licensed marketing Locations, storage regulations as well as display regulations, advertising regulations, monitoring and control. The medicinal products in this category only included medicines containing "safe" active ingredients with restrictions regarding the strength/concentration and packaging size; this category does not include medicines requiring special storage conditions (such as refrigeration or freezing), medicines containing an active ingredient that is addictive, medicines containing an active ingredient with danger of poisoning if misused, and medicines containing an active ingredient that has the potential to harm. The implementation of the regulations and guidelines will improve the consumer's ability to diagnose and treat oneself when sick with minor ailments, without consulting a doctor.

EQ-5D as a generic measure of health-related quality of life in Israel: reliability, validity and responsiveness.

BACKGROUND: The European Quality of Life 5-Dimensions questionnaire is one of the most commonly used measures of health-related quality of life. OBJECTIVES: To present the feasibility, reliability and validity of the Hebrew version of the EQ-5D. METHODS: We conducted face-to-face interviews with a representative sample (n = 1666) of the Israeli Jewish population. The data collected included demographic and medical information, and self-valuation of health using the EQ-5D descriptive system, Visual Analogue Scale and Time Trade-Off. Construct validity was assessed by assuming that older individuals, those with a greater burden of diseases, and those reporting experience with their own severe illness would have lower EQ-5D indexes, VAS and TTO values. Test-retest reliability was assessed in a small sample (n = 50) that was reevaluated after a 3 week interval. RESULTS: Test-retest reliability of the EQ-5D and VAS was very high (r > or = 0.85). Reliability of the TTO was moderate (r = 0.48). There were significant differences in the EQ-5D index, profiles, VAS and TTO between healthy and sick respondents and younger and older respondents, indicating good validity of the instrument. CONCLUSIONS: The Hebrew translation of the EQ-5D is a practical, reliable and valid instrument for assessing the health-related quality of life of the general Israeli Jewish population.

[Lifestyle modification--a behavioral and educational challenge].

Lifestyle modification in the treatment of obesity is difficult to achieve and maintain over time. However, simple inexpensive interventions in special populations show promise.

[Counterfeit drugs in Israel and worldwide. Part I: the extent of occurrence and impending threats].

A counterfeit drug is one which is deliberately and fraudulently mislabeled with respect to identity and/or source. Counterfeit drugs can be found worldwide, both in deveLoped and developing countries, and their dissemination is a major threat to public health and safety, and has major economic effects on the consumers, the pharmaceutical industry, and society at Large. One of the first measures in confronting this problem is bringing it to the awareness of medical staff and public. This review aims to describe the extent of the problem, to discuss its negative effect, and to present actual and possible consequences.

[Counterfeit drugs in Israel and worldwide. Part II: distribution profile and anti-counterfeiting strategies and actions].

Counterfeit drugs are a major threat to public health and safety around the world. This review describes the various distribution methods and channels of counterfeit drugs, including the growing use of the internet. National, regional and international efforts to confront this problem are presented, as well as a wide range of technologies that may assist in detection and enforcement. Finally, the Israeli perspective and actions are illustrated.

Health technology management in Israel: HTA in action.

OBJECTIVES: The aim of this study was to describe the history and present situation with health technology assessment (HTA) in Israel. METHODS: The method used in this study was a historical analysis based mainly on the knowledge of the authors, but supplemented by the published literature. RESULTS: HTA originated in Israel as a centralized function conducted under the auspice of research, developing into an active multidisciplinary center. Throughout the expansion of the field, HTA was performed in affiliation with several local and international bodies, while providing direct and indirect support at the national level. Today, mainly as a result of vigorous dissemination of the principles, methodology and tools for HTA by the Israeli Center for Technology Assessment in Health Care (ICTAHC), this discipline is increasingly a decentralized activity conducted by a great variety of institutions. Israeli health policy decisions are increasingly based on the results of HTA. CONCLUSIONS: ICTAHC's role and functioning has expanded since its beginnings. HTA has become an important part of health care in Israel.