Automated opportunistic osteoporotic fracture risk assessment using computed tomography scans to aid in FRAX underutilization.

Methods for identifying patients at high risk for osteoporotic fractures, including dual-energy X-ray absorptiometry (DXA)1,2 and risk predictors like the Fracture Risk Assessment Tool (FRAX)3-6, are underutilized. We assessed the feasibility of automatic, opportunistic fracture risk evaluation based on routine abdomen or chest computed tomography (CT) scans. A CT-based predictor was created using three automatically generated bone imaging biomarkers (vertebral compression fractures (VCFs), simulated DXA T-scores and lumbar trabecular density) and CT metadata of age and sex. A cohort of 48,227 individuals (51.8% women) aged 50-90 with available CTs before 2012 (index date) were assessed for 5-year fracture risk using FRAX with no bone mineral density (BMD) input (FRAXnb) and the CT-based predictor. Predictions were compared to outcomes of major osteoporotic fractures and hip fractures during 2012-2017 (follow-up period). Compared with FRAXnb, the major osteoporotic fracture CT-based predictor presented better receiver operating characteristic area under curve (AUC), sensitivity and positive predictive value (PPV) (+1.9%, +2.4% and +0.7%, respectively). The AUC, sensitivity and PPV measures of the hip fracture CT-based predictor were noninferior to FRAXnb at a noninferiority margin of 1%. When FRAXnb inputs are not available, the initial evaluation of fracture risk can be done completely automatically based on a single abdomen or chest CT, which is often available for screening candidates7,8.

Second opinion utilization by healthcare insurance type in a mixed private-public healthcare system: a population-based study.

OBJECTIVES: To evaluate the utilisation (overall and by specialty) and the characteristics of second-opinion seekers by insurance type (either health fund or supplementary insurance) in a mixed private-public healthcare. DESIGN: An observational study. SETTING: Secondary care visits provided by a large public health fund and a large supplementary health insurance in Israel. PARTICIPANTS: The entire sample included 1 392 907 patients aged 21 years and above who visited at least one specialist over an 18 months period, either in the secondary care or privately via the supplementary insurance. OUTCOMES MEASURES: An algorithm was developed to identify potential second-opinion instances in the dataset using visits and claims data. Multivariate logistic regression was used to identify characteristics of second-opinion seekers by the type of insurance they used. RESULTS: 143 371 (13%) out of 1 080 892 patients who had supplementary insurance sought a single second opinion, mostly from orthopaedic surgeons. Relatively to patients who sought second opinion via the supplementary insurance, second-opinion seekers via the health fund tended to be females (OR=1.2, 95% CI 1.17 to 1.23), of age 40-59 years (OR=1.36, 95% CI 1.31 to 1.42) and with chronic conditions (OR=1.13, 95% CI 1.08 to 1.18). In contrast, second-opinion seekers via the supplementary insurance tended to be native-born and established immigrants (OR=0.79, 95% CI 0.76 to 0.84), in a high socioeconomic level (OR=0.39, 95% CI 0.37 to 0. 4) and living in central areas (OR=0.88, 95% CI 0.85 to 0.9). CONCLUSIONS: Certain patient profiles tended to seek second opinions via the supplementary insurance more than others. People from the centre of the country and with a high socioeconomic status tended to do so, as medical specialists tend to reside in central urban areas. Further research is recommended to examine the availability of medical specialists by specialty and residence.

Prediction Accuracy With Electronic Medical Records Versus Administrative Claims.

OBJECTIVE: The objective of this study was to evaluate the incremental predictive power of electronic medical record (EMR) data, relative to the information available in more easily accessible and standardized insurance claims data. DATA AND METHODS: Using both EMR and Claims data, we predicted outcomes for 118,510 patients with 144,966 hospitalizations in 8 hospitals, using widely used prediction models. We use cross-validation to prevent overfitting and tested predictive performance on separate data that were not used for model training. MAIN OUTCOMES: We predict 4 binary outcomes: length of stay (≥7 d), death during the index admission, 30-day readmission, and 1-year mortality. RESULTS: We achieve nearly the same prediction accuracy using both EMR and claims data relative to using claims data alone in predicting 30-day readmissions [area under the receiver operating characteristic curve (AUC): 0.698 vs. 0.711; positive predictive value (PPV) at top 10% of predicted risk: 37.2% vs. 35.7%], and 1-year mortality (AUC: 0.902 vs. 0.912; PPV: 64.6% vs. 57.6%). EMR data, especially from the first 2 days of the index admission, substantially improved prediction of length of stay (AUC: 0.786 vs. 0.837; PPV: 58.9% vs. 55.5%) and inpatient mortality (AUC: 0.897 vs. 0.950; PPV: 24.3% vs. 14.0%). Results were similar for sensitivity, specificity, and negative predictive value across alternative cutoffs and for using alternative types of predictive models. CONCLUSION: EMR data are useful in predicting short-term outcomes. However, their incremental value for predicting longer-term outcomes is smaller. Therefore, for interventions that are based on long-term predictions, using more broadly available claims data is equally effective.

Reasons, perceived outcomes and characteristics of second-opinion seekers: are there differences in private vs. public settings?

BACKGROUND: In most countries, patients can get a second opinion (SO) through public or private healthcare systems. There is lack of data on SO utilization in private vs. public settings. We aim to evaluate the characteristics of people seeking SOs in private vs. public settings, to evaluate their reasons for seeking a SO from a private physician and to compare the perceived outcomes of SOs given in a private system vs. a public system. METHODS: A cross-sectional national telephone survey, using representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, on the same medical concern. We modeled SO utilization in a public system vs. a private system by patient characteristics using a multivariate logistic regression model. RESULTS: 214 of 339 respondents who obtained a SO during the study period, did so in a private practice (63.1%). The main reason for seeking a SO from a private physician rather than a physician in the public system was the assumption that private physicians are more professional (45.7%). However, respondents who obtained a private SO were neither more satisfied from the SO (p = 0.45), nor felt improvement in their perceived clinical outcomes after the SO (p = 0.37). Low self-reported income group, immigrants (immigrated to Israel after 1989) and religious people tended to seek SOs from the public system more than others. CONCLUSIONS: The main reason for seeking a SO from private physicians was the assumption that they are more professional. However, there were no differences in satisfaction from the SO nor perceived clinical improvement. As most of SOs are sought in the private system, patient misconceptions about the private market superiority may lead to ineffective resource usage and increase inequalities in access to SOs. Ways to improve public services should be considered to reduce health inequalities.

Evaluating an organization-wide disparity reduction program: Understanding what works for whom and why.

BACKGROUND: Disparity-reduction programs have been shown to vary in the degree to which they achieve their goal; yet the causes of these variations is rarely studied. We investigated a broad-scale program in Israel's largest health plan, aimed at reducing disparities in socially disadvantaged groups using a composite measure of seven health and health care indicators. METHODS: A realistic evaluation was conducted to evaluate the program in 26 clinics and their associated managerial levels. First, we performed interviews with key stakeholders and an ethnographic observation of a regional meeting to derive the underlying program theory. Next, semi-structured interviews with 109 clinic teams, subregional headquarters, and regional headquarters personnel were conducted. Social network analysis was performed to derive measures of team interrelations. Perceived team effectiveness (TE) and clinic characteristics were assessed to elicit contextual characteristics. Interventions implemented by clinics were identified from interviews and coded according to the mechanisms each clinic employed. Assessment of each clinic's performance on the seven-indicator composite measure was conducted at baseline and after 3 years. Finally, we reviewed different context-mechanism-outcome (CMO) configurations to understand what works to reduce disparity, and under what circumstances. RESULTS: Clinics' inner contextual characteristics varied in both network density and perceived TE. Successful CMO configurations included 1) highly dense clinic teams having high perceived TE, only a small gap to minimize, and employing a wide range of interventions; (2) clinics with a large gap to minimize with high clinic density and high perceived TE, focusing efforts on tailoring services to their enrollees; and (3) clinics having medium to low density and perceived TE, and strong middle-management support. CONCLUSIONS: Clinics that achieved disparity reduction had high clinic density, close ties with middle management, and tailored interventions to the unique needs of the populations they serve.

Examining Public Health Workers' Perceptions Toward Participating in Disaster Recovery After Hurricane Sandy: A Quantitative Assessment.

OBJECTIVE: We aimed to quantitatively gauge local public health workers' perceptions toward disaster recovery role expectations among jurisdictions in New Jersey and Maryland affected by Hurricane Sandy. METHODS: An online survey was made available in 2014 to all employees in 8 Maryland and New Jersey local health departments whose jurisdictions had been impacted by Hurricane Sandy in October 2012. The survey included perceptions of their actual disaster recovery involvement across 3 phases: days to weeks, weeks to months, and months to years. The survey also queried about their perceptions about future involvement and future available support. RESULTS: Sixty-four percent of the 1047 potential staff responded to the survey (n=669). Across the 3 phases, 72% to 74% of the pre-Hurricane Sandy hires knew their roles in disaster recovery, 73% to 75% indicated confidence in their assigned roles (self-efficacy), and 58% to 63% indicated that their participation made a difference (response efficacy). Of the respondents who did not think it likely that they would be asked to participate in future disaster recovery efforts (n=70), 39% indicated a willingness to participate. CONCLUSION: The marked gaps identified in local public health workers' awareness of, sense of efficacy toward, and willingness to participate in disaster recovery efforts after Hurricane Sandy represent a significant infrastructural concern of policy and programmatic relevance. (Disaster Med Public Health Preparedness. 2016;10:371-377).

Sustained Reduction in Health Disparities Achieved through Targeted Quality Improvement: One-Year Follow-up on a Three-Year Intervention.

OBJECTIVE: To assess a quality improvement disparity reduction intervention and its sustainability. DATA SOURCES/STUDY SETTING: Electronic health records and Quality Index database of Clalit Health Services in Israel (2008-2012). STUDY DESIGN: Interrupted time-series with pre-, during, and postintervention disparities measurement between 55 target clinics (serving approximately 400,000 mostly low socioeconomic, minority populations) and all other (126) clinics. DATA COLLECTION/EXTRACTION METHODS: Data on a Quality Indicator Disparity Scale (QUIDS-7) of 7 indicators, and on a 61-indicator scale (QUIDS-61). PRINCIPAL FINDINGS: The gap between intervention and nonintervention clinics for QUIDS-7 decreased by 66.7 percent and by 70.4 percent for QUIDS-61. Disparity reduction continued (18.2 percent) during the follow-up period. CONCLUSIONS: Quality improvement can achieve significant reduction in disparities in a wide range of clinical domains, which can be sustained over time.

Is socioeconomic status associated with utilization of health care services in a single-payer universal health care system?

OBJECTIVES: To assess an association of Socio-economic status with utilization of health care services between years 2002 and 2008 in Israel. METHODS: We retrospectively analyzed the utilization of health care services in a cohort of 100,000 members, 21 years and older, of a Clalit Health Services. The research compared utilization according to the neighborhood SES status; and clinic's location as another SES proxy. Data included: Charlson Score morbidity factor, utilization of health care services (visits to primary physicians and specialists, purchase of pharmaceuticals, number of hospitalization days, visits to ED, utilization of laboratory tests and imaging). The analysis was performed using Generalized Linear Model (GLM) technique. RESULTS: People with lower SES visited more the ED and primary physicians and were hospitalized for longer periods. People with higher SES visited more specialists, bought more prescription drugs and used more medical imaging. The associations between SES and most of the services we analyzed did not change between 2002 and 2008. However, the gap between lower and higher SES levels in ED visits and the use of prescription drugs slightly increased over time, while the gap in visits to specialists decreased. CONCLUSIONS: The research shows that even in a universal health care system SES is associated with utilization of health care services. In order to improve equity in utilization of services the Israeli public health should reduce economic barriers and in parallel invest in making information accessible to improve "navigation skills" for all.

Cost-effectiveness of influenza vaccination in prior pneumonia patients in Israel.

Pneumonia is a common complication of influenza infection, and accounts for the majority of influenza mortality. Both the WHO and the Ministry of Health in Israel prioritize seasonal influenza vaccination primarily on the basis of age and specific co-morbidities. Here we consider whether the targeting of individuals previously infected with pneumonia for influenza vaccination would be a cost-effective addition to the current policy. We performed a retrospective cohort data analysis of 163,990 cases of pneumonia hospitalizations and 1,305,223 cases of outpatient pneumonia from 2004 to 2012, capturing more than 54% of the Israeli population. Our findings demonstrate that patients infected with pneumonia in the year prior had a substantially higher risk of becoming infected with pneumonia in subsequent years (relative risk >2.34, p<0.01). Results indicated that the benefit of targeting for influenza vaccination patients hospitalized with pneumonia in prior year would be cost-saving regardless of age. Complementing the current policy with the targeting of prior pneumonia patients would require vaccination of only a further 2.3% of the Israeli population to save additional 204-407 quality-adjusted life years (QALYs) annually at a mean price of 58-1056 USD/QALY saved. Global uncertainty analysis demonstrates that the cost-effectiveness of adding this policy is robust over a vast range of conditions. As prior pneumonia patients are currently not prioritized for influenza vaccination in Israel, nor elsewhere, this study suggests a novel supplement of current policies to improve cost-effectiveness of influenza vaccination. Future studies should use case-control study to further evaluate the effectiveness of vaccination in prior pneumonia patients.

Seasonality of asthma: a retrospective population study.

OBJECTIVES: Seasonal variations in asthma are widely recognized, with the highest incidence during September. This retrospective population study aimed to investigate whether this holds true in a large group of asthmatic children in primary care and to assess the impact of age, gender, urban/rural living, and population sector. METHODS: The key study outcomes were the diagnosis of asthma exacerbations and asthma medication prescriptions, recorded by family physicians during 2005 to 2009. These were analyzed by "week of diagnosis" in Clalit Health Services' electronic medical record database. Regression models were built to assess relative strength of secular trends, seasonality, and age-group in explaining the incidence of asthma exacerbations. RESULTS: A total of 919,873 children aged 2 to 15 years were identified. Of these, 82,234 (8.9%) were asthmatic, 61.6% boys and 38.4% girls; 49.1% aged 2 to 5 years, 24.1% 6 to 9 years, and 26.8% 10 to 15 years. We observed a 2.01-fold increase in pediatric asthma exacerbations and 2.28-fold increase in prescriptions of asthma bronchodilator medications during September (weeks 37-39 vs weeks 34-36) compared with August. The association between the opening of school and the incidence of asthma-related visits to the primary care physician was greatest in children aged 2 to 5 years (odds ratio, 2.15) and 6 to 11 years (1.90-fold). Adolescents (age 12-15 years) had a lesser peak (1.81-fold). In late fall there was a second rise, lasting with fluctuations throughout winter, with a trough in summer. CONCLUSIONS: Returning to school after summer is strongly associated with an increased risk for asthma exacerbations and unscheduled visits to the primary care physician.

Assessment of medical reserve corps volunteers' emergency response willingness using a threat- and efficacy-based model.

The goal of this study was to investigate the willingness of Medical Reserve Corps (MRC) volunteers to participate in public health emergency-related activities by assessing their attitudes and beliefs. MRC volunteers responded to an online survey organized around the Extended Parallel Process Model (EPPM). Respondents reported agreement with attitude/belief statements representing perceived threat, perceived efficacy, and personal/organizational preparedness in 4 scenarios: a weather-related disaster, a pandemic influenza emergency, a radiological ("dirty bomb") emergency, and an inhalational anthrax bioterrorism emergency. Logistic regression analyses were used to evaluate predictors of volunteer response willingness. In 2 response contexts (if asked and regardless of severity), self-reported willingness to respond was higher among those with a high perceived self-efficacy than among those with low perceived self-efficacy. Analyses of the association between attitude/belief statements and the EPPM profiles indicated that, under all 4 scenarios and with few exceptions, those with a perceived high threat/high efficacy EPPM profile had statistically higher odds of agreement with the attitude/belief statements than those with a perceived low threat/low efficacy EPPM profile. The radiological emergency consistently received the lowest agreement rates for the attitude/belief statements and response willingness across scenarios. The findings suggest that enrollment with an MRC unit is not automatically predictive of willingness to respond in these types of scenarios. While MRC volunteers' self-reported willingness to respond was found to differ across scenarios and among different attitude and belief statements, the identification of self-efficacy as the primary predictor of willingness to respond regardless of severity and if asked highlights the critical role of efficacy in an organized volunteer response context.

Immigrating to a universal health care system: utilization of hospital services by immigrants in Israel.

BACKGROUND: During the 1990s, Israel absorbed approximately 1 million immigrants. The entitlement to citizenship and social rights in a country with universal health care coverage makes the Israeli case of special interest concerning immigrants' utilization of health care services. OBJECTIVES: 1. To describe utilization patterns of emergency room and in-hospital services among recent immigrants to Israel. 2. To determine if and when there is convergence of health care utilization patterns on the part of recent immigrants with native-born and long-established immigrants to Israel. METHODS: Data was obtained from Clalit Health Services computerized database and included sociodemographics, date of immigration,presence of chronic disease, emergency room visits, and hospitalization days among all covered residents.Descriptive analysis of the group characteristics, multivariate analyses to determine influential factors, and tests for trend were conducted. RESULTS: Rates of emergency room and hospitalization were lower for immigrants, and remained so even after 10 years. CONCLUSIONS: Economic and cultural factors influence health care utilization among immigrants and may lead to inequity in health care delivery and consequent health outcomes. A better understanding is needed for the differences in health care utilization patterns between immigrants and veteran Israelis.

Seroepidemiology of Epstein-Barr virus and cytomegalovirus among Israeli male young adults.

PURPOSE: To assess the seroprevalence and seroconversion of Epstein-Barr virus (EBV) and cytomegalovirus (CMV) Immunoglobulin G (IgG) antibodies and identify associated socioeconomic and smoking variables among male young adults in Israel, to explore health disparities and aid prevention efforts. METHODS: A population-based seroprevalence study of EBV and CMV IgG antibodies in a systematic sample of Israeli males upon recruitment to mandatory military service during 1994-2004. Associations between socioeconomic and smoking variables and the seroprevalence of EBV/CMV were evaluated, controlling for possible confounders. A subset of seronegative subjects was assessed for seroconversion upon discharge from military service. RESULTS: Overall seroprevalence rates were 87% for EBV and 59% for CMV. An association between the seroprevalence of EBV and CMV was observed. Seroconversion was 56% for EBV as compared with 31% for CMV. Lower paternal education was found to be associated with both EBV and CMV seroprevalence. Lower socioeconomic status, North African origin, and urban residence were found to be associated with CMV seropositivity, as was smoking for EBV seropositivity. CONCLUSIONS: Socioeconomic disparities exist in the seroprevalence rates of CMV and EBV among Israeli male young adults. The results of the study could aid public health efforts and determine target populations when a vaccine becomes available.

Smoking and other correlates of health care services utilization among mandatory military recruits in Israel.

INTRODUCTION: Data on utilization of ambulatory care and the impact of lifestyle on health among young adults are scarce. Israeli mandatory military service provides a unique opportunity to investigate these topics. Study objective was to analyze the utilization of health care services (HCS) during the first year of military service, and its associations with health behavior at recruitment, in order to plan health services, health classification, and health promotion activities. METHODS: We conducted a retrospective cohort study among a representative sample of 5,751 mandatory new recruits between January 1, 2004, and December 31, 2008. Data were collected from the Israeli Defense Force computerized medical and administrative records and from an ongoing health survey among military recruits. RESULTS: During their first year of service, recruits had, on average, more than 7 visits to the primary care clinic, more than 10 dispensed nonchronic medications, and more than 5 days of sick leave. Female sex (OR = 1.27; 1.06-1.51) and current cigarette smoking (OR = 1.57; 1.34-1.84) were significantly associated with increased use of HCS, after controlling for possible confounders. CONCLUSIONS: Our findings indicate high utilization of HCS during the first year of military service and highlight the potential effect of cigarette smoking as a risk factor for increased morbidity among apparently healthy young adults. These findings support adding smoking status to fitness assessments and could aid health promotion efforts to reduce smoking rates among adolescents.

Factors associated with the type of psychotropic medications purchased for common mental disorders in the largest managed care organization in Israel.

OBJECTIVE: To evaluate patient and physician characteristics associated with the type of psychotropic medications (anti-anxiety, antidepressant, or both) purchased. METHODS: The Clalit Health Care Services is the largest managed care health fund in Israel, a country that employs a universal healthcare system. We randomly sampled 30,000 primary care patients over the age of 22 as of January, 2006. RESULTS: Overall, 2,217 purchased either antidepressant or antianxiety medications at least once during the year 2006 and had no prior purchases during the last quarter of 2005. The majority (1,518; 68.4%) purchased only anti-anxiety medications and as many as 264 (12%) purchased both anti-anxiety and antidepressant medications. The remaining 435 (19.6%) patients purchased only antidepressant medications. Physician level characteristics explained only a small portion of the variance and, thus, were not included in further analysis. Several patient level characteristics, including age, somatic, and psychiatric diagnosis were associated with the purchase of different types of medications. CONCLUSIONS: Contrary to clinical guidelines, the purchase of anti-anxiety medications is more prevalent than the purchase of antidepressant medications. In a managed care setting, patient characteristics have a greater role in determining purchasing patterns than provider characteristics; potentially, because of the managed care characteristics that actively guide the care provided to patients.

Disparities in antidepressant adherence in primary care: report from Israel.

OBJECTIVES: To evaluate patient and physician characteristics associated with the purchase of antidepressant medication for at least 6 months. STUDY DESIGN AND METHODS: Clalit Health Services is the largest managed care health fund in Israel, a country that uses a universal healthcare system. We randomly sampled 30,000 primary care patients over the age of 22 years. Our analytic sample consisted of those 949 patients who did not purchase antidepressant medication during the last quarter of 2005 and purchased antidepressant medication at least once in 2006. We used multilevel analysis, with whether or not medication was purchased for at least 6 months as an indicator of adherence. Patient and physician characteristics were evaluated as potential predictors. RESULTS: Only 23% of the sample was classified as adherent. Physician characteristics explained only a small portion of the variance in adherence and, as a result, were not included in multivariate analysis. Patients who did not have a somatic diagnosis, had a depression diagnosis, and were of higher socioeconomic status were more likely to be classified as adherent. Patients who purchased tricyclic antidepressants were less likely to be classified as adherent. CONCLUSIONS: The findings suggest that in a managed care setting, there is high uniformity among physicians. Although physician characteristics explain little of the variability associated with adherence, certain patient characteristics as determined by their physicians (eg, antidepressant drug class, psychiatric diagnosis) do play a role in adherence.

[President Obama's health care reform: lessons to and from the Israeli health care system].

In March 2010 the United States enacted the most significant health care reform in several decades. The Patient Protection and Affordable Care Act, amongst other provisions, addresses two of the main current shortcomings of the U.S. health system: the large portion of the population that are uninsured and the high percentage of hsealth expenditures (mostly private] which amounts to about 16% of the GDP. Changes to the current structure and financing of the U.S. health system will have implications for other health systems, for science (e.g., through enhanced federal funding for comparative effectiveness research), and for technological advance (e.g., through accelerated development and use of electronic health records). There are several lessons from the reform, and the factors leading to its implementation, for the Israeli health system. Firstly, the basic principles of the Israeli health system are a source of pride, and undermining its main values can have deleterious effects. Overreliance on private, out-of-pocket, spending and lack of support for public practice of medicine (in community and hospital settings) will weaken the public sector, strengthen the private sector, and could result in a tiered lower quality and less accessible public system with greater widening of gaps in health and health care utilization. This paper reviews the main provisions of the U.S. health care reform and the potential implications for the IsraeLi health system.

Challenges and opportunities in the Israeli 2009 pandemic influenza vaccination program.

Vaccines are a cornerstone in any pandemic influenza preparedness plan. Successful supplementary mass vaccination programs require proper advance planning. We aimed to identify general, and Israeli specific, challenges and opportunities before initiating the Israeli pandemic influenza vaccination program in order to better plan implementation of the program. Following the vaccination campaign the analysis was retrospectively examined in order to determine whether the challenges were properly identified and whether the opportunities were indeed realized. The major challenges identified were prioritization; ongoing communication with the public; balancing between central management and accessibility; and preventing vaccination errors. The major opportunity was expected to be the chance to enhance cooperation and communication between different organizations both within and outside of the health system at local, national and international levels. The vaccination program was planned based on this analysis. In retrospect, the analysis identified the key challenges and opportunities and appropriate measures were taken. However, the criticalness of acceptance of the vaccine among health care practitioners was not given sufficient attention and should be addressed in future vaccination programs. Analysis of global and local challenges and opportunities served as a useful tool for planning a pandemic influenza vaccination program. Lessons learned from this analysis could serve to foster cooperation and communication between various agencies in the event of planning rapid mass vaccination programs as well as for more routine public health vaccination campaigns.

Assessing socioeconomic health care utilization inequity in Israel: impact of alternative approaches to morbidity adjustment.

BACKGROUND: The ability to accurately detect differential resource use between persons of different socioeconomic status relies on the accuracy of health-needs adjustment measures. This study tests different approaches to morbidity adjustment in explanation of health care utilization inequity. METHODS: A representative sample was selected of 10 percent (~270,000) adult enrolees of Clalit Health Services, Israel's largest health care organization. The Johns-Hopkins University Adjusted Clinical Groups® were used to assess each person's overall morbidity burden based on one year's (2009) diagnostic information. The odds of above average health care resource use (primary care visits, specialty visits, diagnostic tests, or hospitalizations) were tested using multivariate logistic regression models, separately adjusting for levels of health-need using data on age and gender, comorbidity (using the Charlson Comorbidity Index), or morbidity burden (using the Adjusted Clinical Groups). Model fit was assessed using tests of the Area Under the Receiver Operating Characteristics Curve and the Akaike Information Criteria. RESULTS: Low socioeconomic status was associated with higher morbidity burden (1.5-fold difference). Adjusting for health needs using age and gender or the Charlson index, persons of low socioeconomic status had greater odds of above average resource use for all types of services examined (primary care and specialist visits, diagnostic tests, or hospitalizations). In contrast, after adjustment for overall morbidity burden (using Adjusted Clinical Groups), low socioeconomic status was no longer associated with greater odds of specialty care or diagnostic tests (OR: 0.95, CI: 0.94-0.99; and OR: 0.91, CI: 0.86-0.96, for specialty visits and diagnostic respectively). Tests of model fit showed that adjustment using the comprehensive morbidity burden measure provided a better fit than age and gender or the Charlson Index. CONCLUSIONS: Identification of socioeconomic differences in health care utilization is an important step in disparity reduction efforts. Adjustment for health-needs using a comprehensive morbidity burden diagnoses-based measure, this study showed relative underutilization in use of specialist and diagnostic services, and thus allowed for identification of inequity in health resources use, which could not be detected with less comprehensive forms of health-needs adjustments.

Reducing health disparities: strategy planning and implementation in Israel's largest health care organization.

OBJECTIVE: To describe an organization-wide disparity reduction strategy and to assess its success in quality improvement and reduction of gaps in health and health care. STUDY SETTING: Clalit Health Services, Israel's largest non-for-profit insurer and provider serving 3.8 million persons. STUDY DESIGN: Before and after design: quality assessment before and 12-month postinitiation of the strategic plan. A composite weighted score of seven quality indicators, measuring attainment of diabetes, blood pressure, and lipid control, lack of anemia in infants, and performance of mammography, occult blood tests, and influenza vaccinations. DATA EXTRACTION METHODS: Quality indicator scores, derived from Clalit's central data warehouse, based on data from electronic medical records. PRINCIPAL FINDINGS: Low-performing clinics, of low-socioeconomic and minority populations, were targeted for intervention. Twelve months after the initiation of the project continuous improvement was observed coupled with a reduction of 40 percent of the gap between disadvantaged clinics, serving ~10 percent of enrollees, and all other medium-large clinics. CONCLUSION: The comprehensive strategy, following a quality improvement framework, with a top-down top-management incentives and monitoring, and a bottom-up locally tailored interventions, approach, is showing promising results of overall quality improvement coupled with disparity reduction in key health and health care indicators.