Primary care indicators for disease burden, monitoring and surveillance of COVID-19 in 31 European countries: Eurodata Study.

BACKGROUND: During the COVID-19 pandemic, the majority of patients received ambulatory treatment, highlighting the importance of primary health care (PHC). However, there is limited knowledge regarding PHC workload in Europe during this period. The utilization of COVID-19 PHC indicators could facilitate the efficient monitoring and coordination of the pandemic response. The objective of this study is to describe PHC indicators for disease surveillance and monitoring of COVID-19's impact in Europe. METHODS: Descriptive, cross-sectional study employing data obtained through a semi-structured ad hoc questionnaire, which was collectively agreed upon by all participants. The study encompasses PHC settings in 31 European countries from March 2020 to August 2021. Key-informants from each country answered the questionnaire. Main outcome: the identification of any indicator used to describe PHC COVID-19 activity. RESULTS: Out of the 31 countries surveyed, data on PHC information were obtained from 14. The principal indicators were: total number of cases within PHC (Belarus, Cyprus, Italy, Romania and Spain), number of follow-up cases (Croatia, Cyprus, Finland, Spain and Turkey), GP's COVID-19 tests referrals (Poland), proportion of COVID-19 cases among respiratory illnesses consultations (Norway and France), sick leaves issued by GPs (Romania and Spain) and examination and complementary tests (Cyprus). All COVID-19 cases were attended in PHC in Belarus and Italy. CONCLUSIONS: The COVID-19 pandemic exposes a crucial deficiency in preparedness for infectious diseases in European health systems highlighting the inconsistent recording of indicators within PHC organizations. PHC standardized indicators and public data accessibility are urgently needed, conforming the foundation for an effective European-level health services response framework against future pandemics.

Patient-level predictors of temporal regularity of primary care visits.

BACKGROUND: Patients with chronic diseases should meet with their primary care doctor regularly to facilitate proactive care. Little is known about what factors are associated with more regular follow-up. METHODS: We studied 70,095 patients age 40 + with one of three chronic conditions (diabetes mellitus, heart failure, chronic obstructive pulmonary disease), cared for by Leumit Health Services, an Israeli health maintenance organization. Patients were divided into the quintile with the least temporally regular care (i.e., the most irregular intervals between visits) vs. the other four quintiles. We examined patient-level predictors of being in the least-temporally-regular quintile. We calculated the risk-adjusted regularity of care at 239 LHS clinics with at least 30 patients. For each clinic, compared the number of patients with the least temporally regular care with the number predicted to be in this group based on patient characteristics. RESULTS: Compared to older patients, younger patients (age 40-49), were more likely to be in the least-temporally-regular group. For example, age 70-79 had an adjusted odds ratio (AOR) of 0.82 compared to age 40-49 (p < 0.001 for all findings discussed here). Males were more likely to be in the least-regular group (AOR 1.18). Patients with previous myocardial infarction (AOR 1.07), atrial fibrillation (AOR 1.08), and current smokers (AOR 1.12) were more likely to have an irregular pattern of care. In contrast, patients with diabetes (AOR 0.79) or osteoporosis (AOR 0.86) were less likely to have an irregular pattern of care. Clinic-level number of patients with irregular care, compared with the predicted number, ranged from 0.36 (fewer patients with temporally irregular care) to 1.71 (more patients). CONCLUSIONS: Some patient characteristics are associated with more or less temporally regular patterns of primary care visits. Clinics vary widely on the number of patients with a temporally irregular pattern of care, after adjusting for patient characteristics. Health systems can use the patient-level model to identify patients at high risk for temporally irregular patterns of primary care. The next step is to examine which strategies are employed by clinics that achieve the most temporally regular care, since these strategies may be possible to emulate elsewhere.

Similarities and differences between two well-performing healthcare systems: a comparison between the Israeli and the Danish healthcare systems.

BACKGROUND: Denmark and Israel both have highly rated and well-performing healthcare systems with marked differences in funding and organization of primary healthcare. Although better population health outcomes are seen in Israel, Denmark has a substantially higher healthcare expenditure. This has caused Danish policy makers to take an interest in Israeli community care organization. Consequently, we aim to provide a more detailed insight into differences between the two countries' healthcare organization and cost, as well as health outcomes. METHODS: A comparative analysis combining data from OECD, WHO, and official sources. World Health Organization (WHO) and the Organisation for Economic Co-operation and Development (OECD) statistics were used, and national official sources were procured from the two healthcare systems. Literature searches were performed in areas relevant to expenditure and outcome. Data were compared on health care expenditure and selected outcome measures. Expenditure was presented as purchasing power parity and as percentage of gross domestic product, both with and without adjustment for population age, and both including and excluding long-term care expenditure. RESULTS: Denmark's healthcare expenditure is higher than Israel's. However, corrected for age and long-term care the difference diminishes. Life expectancy is lower in Denmark than in Israel, and Israel has a significantly better outcome regarding cancer as well as a lower number of Years of Potential Life Lost. Israelis have a healthier lifestyle, in particular a much lower alcohol consumption. CONCLUSION: Attempting to correct for what we deemed to be the most important influencing factors, age and different inclusions of long-term care costs, the Israeli healthcare system still seems to be 25% less expensive, compared to the Danish one, and with better health outcomes. This is not necessarily a function of the Israeli healthcare system but may to a great extent be explained by cultural factors, mainly a much lower Israeli alcohol consumption.

Effect of a primary-care-team focused diabetes educational program project on diabetes care quality indicators in a large health maintenance organization.

AIMS: In 2011 the central district of Leumit Health Services (LHS) (a health maintenance organization in Israel) implemented a chronic care program to improve diabetes care in general practice: MESSAGE program (Motivation, Education, Skills and Supervision to Achieve better diabetes care in General practice Environment), included training phase and ongoing time allocation for diabetes care. METHODS: A population-based retrospective analysis of LHS Electronic Medical Records of all patients with diabetes in LHS between 1 June 2015 and 31 May 2018. Data was processed according to the definitions of the Israeli national program for quality indicators in community healthcare. ~442,000 adults were included, ~49,000 in MESSAGE engaged clinics. RESULTS: The prevalence of diabetes in LHS was ~9.7-9.31% during study period. Over 3 years follow up, the prevalence of patients with A1C ≥ 9% declined in all districts of LHS but to a significantly greater extent in MESSAGE clinics [2015: MESSAGE 12.4%, LHS-combined 13.09%; OR 0.92 (0.83-1.01) p = 0.075; 2018: MESSAGE 8.51%, LHS-combined 10.85%; 0.76 (0.69-0.85) p < 0.001]. Other indicators of diabetes care did not change. CONCLUSION: The MESSAGE intervention program resulted in improved glycemic control. It is currently being modified to address all aspects of diabetes care and is implemented across all districts of LHS in Israel.

Unburdening dementia - a basic social process grounded theory based on a primary care physician survey from 25 countries.

OBJECTIVE: To explore dementia management from a primary care physician perspective. DESIGN: One-page seven-item multiple choice questionnaire; free text space for every item; final narrative question of a dementia case story. Inductive explorative grounded theory analysis. Derived results in cluster analyses. Appropriateness of dementia drugs assessed by tertiary care specialist. SETTING: Twenty-five European General Practice Research Network member countries. SUBJECTS: Four hundred and forty-five key informant primary care physician respondents of which 106 presented 155 case stories. MAIN OUTCOME MEASURES: Processes and typologies of dementia management. Proportion of case stories with drug treatment and treatment according to guidelines. RESULTS: Unburdening dementia - a basic social process - explained physicians' dementia management according to a grounded theory analysis using both qualitative and quantitative data. Unburdening starts with Recognizing the dementia burden by Burden Identification and Burden Assessment followed by Burden Relief. Drugs to relieve the dementia burden were reported for 130 of 155 patients; acetylcholinesterase inhibitors or memantine treatment in 89 of 155 patients - 60% appropriate according to guidelines and 40% outside of guidelines. More Central and Northern primary care physicians were allowed to prescribe, and more were engaged in dementia management than Eastern and Mediterranean physicians according to cluster analyses. Physicians typically identified and assessed the dementia burden and then tried to relieve it, commonly by drug prescriptions, but also by community health and home help services, mentioned in more than half of the case stories. CONCLUSIONS: Primary care physician dementia management was explained by an Unburdening process with the goal to relieve the dementia burden, mainly by drugs often prescribed outside of guideline indications. Implications: Unique data about dementia management by European primary care physicians to inform appropriate stakeholders. Key points Dementia as a syndrome of cognitive and functional decline and behavioural and psychological symptoms causes a tremendous burden on patients, their families, and society. •We found that a basic social process of Unburdening dementia explained dementia management according to case stories and survey comments from primary care physicians in 25 countries. •First, Burden Recognition by Identification and Assessment and then Burden Relief - often by drugs. •Prescribing physicians repeatedly broadened guideline indications for dementia drugs. The more physicians were allowed to prescribe dementia drugs, the more they were responsible for the dementia work-up. Our study provides unique data about dementia management in European primary care for the benefit of national and international stakeholders.

Evidence-based HMO care for prostate specific antigen testing.

BACKGROUND: There is pressure in the U.S. system to move away from fee-for-service models to a more pre-paid system, which may result in decreased costs, but the impact on evidence-based care is unclear. We examined a large pre-paid Health Maintenance Organizations (HMO) in Israel to see if evidence-based guidelines are followed for prostate specific antigen (PSA) testing. METHODS: A retrospective cohort of ambulatory visits from 2002 to 2011 of patients age >75 receiving care from Clalit Health Services was conducted. Historically reported U.S. cohorts were used for comparison. The main measure was the percent of patients who had at least one PSA after age 75. RESULTS: In each of the 10 years of follow-up, 22% of the yearly Israeli cohort, with no known malignancy or benign prostatic hyperplasia, had at least one PSA, while for the total 10 years, 30% of the men had at least one PSA. These rates are considerably lower than previously reported U.S. rates. CONCLUSIONS: In a pre-paid system in which physicians have no incentive to order tests, they appear to order PSA tests at a lower rate than has been observed in the U.S. system. Additional quality of measures should continue to be examined as the U.S. shifts away from a fee-for-service model. Copyright © 2016 John Wiley & Sons, Ltd.

A new marker of primary care utilization - annual accumulated duration of time of visits.

BACKGROUND: Most of the research on primary care workload has focused on the number of visits or the average duration of visits to a primary care physician (PCP) and their effect on the quality of medical care. However, the accumulated annual visit duration has yet to be examined. This measure could also have implications for the allocation of resources among health plans and across regions. In this study we aimed to define and characterize the concept of "Accumulated Annual Duration of Time" (AADT) spent with a PCP.  METHOD: A cross-sectional study based on a national random sample of 77,247 adults aged 20 and over. The study's variables included annual number of visits and AADT with a PCP, demographic characteristics and chronic diseases. The time period was the entire year of 2012. RESULTS: For patients older than 20 years, the average annual number of visits to a PCP was 8.8 ± 9.1, and the median 6 ± 10 IQR (Interquartile Range). The mean AADT was 65.8 ± 75.7 min, and the median AADT was 43 ± 75 IQR minutes. The main characteristics of patients with a higher annual number of visits and a higher AADT with a PCP were: female, older in age, a higher Charlson index and a low socio-economic status. Chronic diseases were also found to increase the number of annual visits to a PCP as well as the AADT, patients with chronic heart failure had highest AADT in comparison to others (23.1 ± 15.5 vs. 8.6 ± 8.9 visits; and 165.3 ± 128.8 vs. 64.5 ± 74 min). It was also found that the relationship between AADT and age was very similar to the relationship between visits and age. CONCLUSION: While facing the ongoing increase in a PCP's work load and shortening of visit length, the concept of AADT provides a new measure to compare between different healthcare systems that allocate different time frames for a single primary care visit. For Israel, the analysis of the AADT data provides support for continued use of the number of visits in the capitation formula, as a reliable and readily-accessible indicator of primary care usage.

Interpersonal continuity of care and type two diabetes.

INTRODUCTION: Continuity of care is one of the core principles of primary care. The importance of interpersonal continuity in treating diabetic patients is unclear. AIM: To examine the association of interpersonal continuity of care, by the primary care physician, on the process of diabetic care and on health end points including diabetes control, hospital admissions and mortality. METHODS: We conducted a population based cohort study, 23,294 eligible participants were identified in Clalit Health Services Central Region at January 1, 2011 and followed through to December 31, 2012. Multivariate logistic regression models were applied to the data to study simultaneously the independent relationship between low interpersonal continuity, adjusted for background characteristics, and outcomes of care, including hospitalization and mortality. RESULTS: Achieving clinical targets was more likely in the high interpersonal continuity group HBA1 C OR 1.11 (CI 1.04-1.19), blood pressure OR 1.12 (1.04-1.20), LDL OR 1.14 (1.06-1.22). Patients with high interpersonal continuity had lower odds for mortality OR 0.59 (0.50-0.70). Admissions to hospital were lower in the high interpersonal continuity group, OR 0.82 (0.75-0.90), however when adjusting for background characteristics the difference in OR for hospital admissions became non-significant 0.92 (0.84-1.01). CONCLUSION: High interpersonal continuity was associated with improved outcomes of process, and both primary and secondary clinical targets amongst adult patients with diabetes. This study is the first to find an association between interpersonal continuity and mortality amongst adults with diabetes.

Associated morbidity of nasolacrimal duct obstruction--a large community based case-control study.

BACKGROUND: To evaluate the prevalence and risk factors of various conditions among patients with nasolacrimal duct obstruction (NLDO). METHODS: A retrospective, observational case control study of 2,615 patients diagnosed with NLDO in the Central District of Clalit Health Services HMO in Israel, from 2003 to 2012; 15,650 control patients were randomly selected from the district HMO members. Medical and socio-demographic information were extracted from patients' electronic medical records. The prevalence of various ocular and systemic conditions as risk factors for NLDO was calculated. RESULTS: The average age of NLDO patients was 68.3 ± 14.9 years, 34.4 % were male. Age (p < 0.001), ischemic heart disease (OR = 1.29; CI: 1.15-1.44), glaucoma (OR = 1.17; CI: 1.01-1.36), allergic conjunctivitis (OR = 3.59; CI: 3.28-3.94), dry eye (OR = 1.43; CI: 1.31-1.58), epiphora (OR = 6.34; CI: 5.09-7.91), and allergic rhinitis (OR = 1.51; CI: 1.33-1.71) were significantly associated with NLDO. Smoking (OR = 0.86; CI: 0.77-0.96) was significantly less prevalent among NLDO patients. CONCLUSIONS: The etiology of NLDO is multifactorial. The prevalence of associated demographic, systemic, and periocular conditions varies. A better understanding of the patho-physiological association between these factors and NLDO may help its prevention and treatment.

Oncologists' and family physicians' views on value for money of cancer and congestive heart failure care.

BACKGROUND: Previous studies suggest that cancer-related interventions are valued by policy makers more favorably than interventions for other medical conditions, but the views of practicing physicians have not yet been assessed in Israel. Attitudes and judgments of practicing physicians may assist decision-makers in their deliberations on coverage of new technologies. We conducted a national survey in Israel among oncologists and family physicians to explore their views on access to care, coverage decisions and treatment recommendations for cancer and congestive heart failure (CHF) patients. METHODS: We administered a web-based survey to 300 family physicians and 156 oncologists. The questionnaire included 24 statements and physicians were asked to indicate their level of agreement with each statement on a 5-point Likert scale, ranging from "strongly agree" to "strongly disagree". Where relevant, physicians were asked to express their views on interventions for cancer and CHF respectively. RESULTS: Response rates were 39% for family physicians and 36% for oncologists. Participants expressed similar views on cancer and CHF care and no significant differences were found between the two medical specialties. More than 85% of physicians believe that inclusion of a treatment in the National List of Health Services (NLHS) strongly affects their patients' access to care. Approximately 80% suggest that more use of comparative-effectiveness and cost-effectiveness analysis is needed in coverage decisions. The vast majority of respondents (75%) suggest that assessment of value-for-money should be made by an independent (academic) institution or the national committee responsible for recommending coverage decisions, Seventy percent believe that treatments not included in the NLHS should be included in supplementary health insurance programs and only a small minority of respondents (<30%) believe that cancer-related interventions should receive higher priority than non-cancer interventions in coverage decisions. CONCLUSIONS: Our findings suggest that both oncologists and family physicians value cancer and CHF interventions equally. We could not find evidence for a "cancer premium" as implied from previous surveys and analysis of coverage decisions in various countries.

Which is more valuable, longer survival or better quality of life? Israeli oncologists' and family physicians' attitudes toward the relative value of new cancer and congestive heart failure interventions.

OBJECTIVES: We determined how Israeli oncologists and family physicians value life-prolongation versus quality-of-life (QOL)-enhancing outcomes attributable to cancer and congestive heart failure interventions. METHODS: We presented physicians with two scenarios involving a hypothetical patient with metastatic cancer expected to survive 12 months with current treatment. In a life-prolongation scenario, we suggested that a new treatment increases survival at an incremental cost of $50,000 over the standard of care. Participants were asked what minimum improvement in median survival the new therapy would need to provide for them to recommend it over the standard of care. In the QOL-enhancing scenario, we asked the maximum willingness to pay for an intervention that leads to the same survival as the standard treatment, but increases patient's QOL from 50 to 75 (on a 0-100 scale). We replicated these scenarios by substituting a patient with congestive heart failure instead of metastatic cancer. We derived the incremental cost-effectiveness ratio per quality-adjusted life-year (QALY) gained threshold implied by each response. RESULTS: In the life-prolongation scenario, the cost-effectiveness thresholds implied by oncologists were $150,000/QALY and $100,000/QALY for cancer and CHF, respectively. Cost-effectiveness thresholds implied by family physicians were $50,000/QALY regardless of the disease type. Willingness to pay for the QOL-enhancing scenarios was $60,000/QALY and did not differ by physicians' specialty or disease. CONCLUSIONS: Our findings suggest that family physicians value life-prolonging and QOL-enhancing interventions roughly equally, while oncologists value interventions that extend survival more highly than those that improve only QOL. These findings may have important implications for coverage and reimbursement decisions of new technologies.

Addressing healthcare inequities in Israel by eliminating prescription drug copayments.

OBJECTIVES: To determine whether subsidizing prescription drug copayments for patients with chronic illness and low socioeconomic status would increase their use of prescription drugs and improve their health. STUDY DESIGN: Prospective cohort study. METHODS: Enrolled were 355 patients with low socioeconomic status, as defined by the Israel National Insurance Institute, who were not regularly purchasing prescribed medications. Included were patients (mean age, 64.6 years) with diabetes mellitus, hypertension, or hypercholesterolemia, as these chronic illnesses have easily measurable surrogate end points. Patients were followed up for 24 months. Serum glycated hemoglobin level, blood pressure, and low-density lipoprotein cholesterol concentration were measured. Patients paid their copayments using a "credit card" covered by a donation. RESULTS: Two years after initiation of the subsidized copayment program, the mean (SD) values were significantly below those at the outset of the program for blood pressure (136.2 [16.7]/78.0 [8.7] vs 128.2 [13.3]/74.8 [8.1] mm Hg) and low-density lipoprotein cholesterol concentration (116.2 [38.0] vs 105.3 [38.0] mg/dL) (P <.001 for both). The mean glycated hemoglobin level showed no improvement in the first year, but a significant increase was noted by the second year of the program. CONCLUSIONS: When copayments for prescription drugs were eliminated, low-income patients demonstrated increased compliance with obtaining medications, better response to treatment, and improved blood pressure and low-density lipoprotein cholesterol concentrations. Glycemic control did not improve.

Patient characteristics correlated with quality indicator outcomes in diabetes care.

BACKGROUND: Quality indicators were adopted to compare quality of care across health systems. AIM: To evaluate whether patient characteristics influence primary care physicians' diabetes quality indicators. DESIGN OF STUDY: Retrospective cohort study. SETTING: Primary care setting. METHOD: The study was conducted in the Central District of Clalit Health Service in Israel. The five measures of diabetes follow-up were: the percentage of patients with diabetes for whom glycosylated haemoglobin (HbA(1c)), microalbumin, low-density lipoprotein (LDL)-cholesterol, and blood pressure were measured at least once, and the percentage of patients who were seen by an ophthalmologist, during 2005. Three outcome measures were chosen: the percentage of patients with diabetes and HbA(1c) <7 mg%, the percentage of patients with diabetes and blood pressure <130/80 mmHg, and the percentage of patients with diabetes and LDL-cholesterol <100 mg/dl in 2005. Sociodemographic information was retrieved about all the physicians' patients with diabetes. RESULTS: One-hundred and seventy primary care physicians took care of 18 316 patients with diabetes. The average number of patients with diabetes per physician was 107 (range 10-203). A lower quality indicator score for HbA(1c) <7 mg% was correlated with a higher percentage of patients of low socioeconomic status (P<0.001) and new immigrants (P = 0.002), and correlated with borderline significance with higher mean patients' body mass index (P = 0.024); lower quality indicator score for blood pressure <130/80 mmHg was related to higher patients' age (P = 0.006). None of the diabetes follow-up measures were related to patients' characteristics. CONCLUSION: Achieving good glycaemic control is dependent on patient characteristics. New immigrants, patients of low socioeconomic status, and older patients need special attention to avoid disparities.

Screening practices of Israeli doctors' and their patients.

OBJECTIVE: Doctors' health matters because healthy physicians are more productive and because physicians' health practices affects their patient counseling habits, but there are few objective data on this topic. METHODS: An examination of differences in screening quality health indicators between physicians (n=429) and 1621 age, gender, and socioeconomically matched patient controls from our district Health Maintenance Organization in Israel during the first half of 2008. RESULTS: Doctors and matched patients had similar rates for low-density lipoprotein measurement (85%/84%=NS), colorectal cancer screening (23%/27%=NS), influenza vaccine among the chronically ill (23%/24%=NS), and mammography (for women, 55%/57%=NS). Doctors with hypertension had blood pressures clinically recorded considerably less frequently than matched patients do (56%/77%, p<0.001), and their smoking habits were recorded less often, but their recorded tobacco habits were significantly better. Physician-patient contrasts were also minimal (again except for clinician-recorded blood pressure and smoking) among the chronically ill. CONCLUSIONS: These are the first objective data of which we know that test (and confirm) prior self-reported data that physicians' screening experiences are similar to patients'. Improving physicians' personal screening could also improve patient screening: physicians' self-reported primary prevention habits are considerably better than patients' and have been shown repeatedly to strongly and consistently positively influence patient counseling practices, and hence the health of the public.

Patient attitudes to being treated by junior residents in the community.

OBJECTIVE: Understanding the attitudes of patients to being treated by residents in the community. METHODS: A questionnaire was administered to patients visiting community family medicine teaching clinics. The study methodology included statements to which they agree or disagree. RESULTS: Three hundred and four questionnaires were completed by patients; 94% had visited a resident in the past year; 78.9% agreed that residents were as skilled as senior doctors, but only 45.4% felt that they were as quick at diagnosis as the senior doctors; 73.0% felt that residents spent more time with them; 40.0% were not pleased by the constant change of the residents attending on them. Analysis by logistic regression showed that men had a more positive attitude to the competence of the residents as well as their professionalism (OR 2.73, 95% CI, 1.45-5.10). Frequent visitors to the clinic had a more negative attitude to the residents' professionalism (OR 0.91 (0.85-0.98)) and were more likely to agree with the statement "I would prefer to see the regular doctor and not a different resident each time" (OR 1.09 (1.01-1.18)). Those who were attended more by residents on their visits showed a positive attitude to the professionalism of residents (OR 1.14 (1.01-1.28)) and were less likely to agree with the statement "I would prefer to see the regular doctor and not a different resident each time" (OR 0.90 (0.84-0.98)). CONCLUSIONS: Patients have a positive attitude to being treated by residents in ambulatory clinics, which is associated with repeat exposure to care by residents. PRACTICAL IMPLICATIONS: Departments with ambulatory training should consider having constant presence of residents in their teaching clinics, and teaching staff in the clinics should develop ways to recommend patients to be seen by residents.

Topical beta blockers in asthmatic patients-is it safe?

PURPOSE: To investigate the use of topical ocular anti-glaucoma medications by glaucomatous patients with obstructive pulmonary disease and their effect on related hospitalizations and emergency room visits. PARTICIPANTS: We followed the electronic medical records of all the members in a district of the largest health maintenance organization in Israel (the "central district" of Clalit Health Services) older than 20 years (317,469 members); 6597 of them were on chronic topical anti-glaucoma treatment of which 693 (10.5%) suffered from obstructive pulmonary disease (OPD). METHODS: In a historical cohort study, we documented all anti-glaucoma prescriptions filled in the district between January 1, 2001, and December 31, 2003, and all emergency room (ER) visits and hospitalizations in internal medicine, geriatric, or pulmonology departments. MAIN OUTCOME MEASURES: The rate of hospitalization and emergency room visits during treatment with each anti-glaucoma medication. RESULTS: Five hundred forty-four glaucomatous OPD patients (78.5%) were treated with topical beta-blockers, but only 169 (31.1%) of them received a cardio-selective beta-blocker (betaxolol). Patients treated with betaxolol each received more prescriptions per year than patients treated with timolol (p < 0.0001). Patients on topical betaxolol or timolol had 23.1 and 20.7 hospitalization days as well as 7.3 and 6.1 emergency room visits per 100 treatments per year, respectively, compared to a mean of 10 hospitalization days (p < 0.0001) and 5.0 ER visits for patients on non-beta-blocker anti-glaucoma medications. CONCLUSIONS: A majority of glaucomatous patients with obstructive pulmonary disease were treated with topical beta-blockers, mostly non-cardioselective (timolol). Those patients were more prone to be hospitalized or visit the emergency room while on the medication.

Adherence with statins over 8 years in a usual care setting.

OBJECTIVE: To describe adherence with statin treatment in a usual practice setting and to investigate potential determinants of better adherence. STUDY DESIGN: Retrospective cohort study using administrative claims data. METHODS: Study patients were 47,680 individuals enrolled in the Central District of Clalit Health Services HMO in Israel who filled at least 1 prescription for statins between January 1, 1999, and December 31, 2006. Data were retrieved on patients' sex, year of birth and immigration, socioeconomic status, and whether they had diabetes mellitus, hypertension, and other cardiovascular diseases. RESULTS: Mean age at the beginning of treatment was 61.3 +/- 11.8 years; 53.3% of the study patients were women. The proportion with at least 1 chronic disease before starting statins was 40.1%; and 38.9%, 21.8%, and 9.6% of the patients were continuously adherent after 1, 3, and 6 years, respectively. Risk of discontinuation was highest among new immigrants (hazard ratio [HR] = 1.20; 95% confidence interval [CI] = 1.14, 1.27). Adherence was higher in patients having a chronic disease before starting statins (HR = 0.88; 95% CI = 0.84, 0.94) or after starting statins (HR = 0.90; 95% CI = 0.86, 0.95). Patients age <50 or >79 years had lower adherence rates. Low socioeconomic state did not affect adherence. CONCLUSIONS: Adherence with statin therapy was poor, though adherence rates were better in patients with accompanying chronic diseases. Of particular concern was the low level of adherence in new immigrants. Intervention programs are needed and should target all patient groups.

Long-term adherence to antihypertensive therapy: a survey in four primary care clinics.

BACKGROUND: Many hypertensive patients have suboptimal control of their blood pressure. One of the most common causes is poor adherence with treatment. AIM: To identify factors associated with poorer adherence to antihypertensive treatment. METHODS: The study was conducted in four urban clinics of Clalit Health Services (Israel's largest Health management organization): 3799 patients aged > 20 years with hypertension in whom a new antihypertensive medicine was started in a 3-year period were included. Data included: age; gender; chronic diseases; type of antihypertensive medicine; and adherence with treatment. Reasons for non-adherence had been evaluated in a random sample of 453 of the medical records. RESULTS: Of the patients, 2234/3799 (58.8%) stopped >or= 1 medicine. Lower adherence was associated with female gender, new immigration, ischemic heart disease and being a non-diabetic. Adherence was related to the type of medicine. The highest rates of adherence were found with the use of angiotensin receptor blockers (59.1%) and selective beta-blockers (59%), and the lowest with non-selective beta-blockers (30.1%). There was no documentation of the reason to medicine cessation in 183/453 (40.4%) of the medical records. In 20.1% of cessations, the physician continued to prescribe the drug, despite the fact that the patient had stopped purchasing it. Common reasons for treatment cessation were side effects (15%) and lack of blood pressure control (5.5%). CONCLUSIONS: Adherence with antihypertensive treatment declines with time and is associated with the type of medicine, and sociodemographic and clinical backgrounds. Family physicians must increase their documentation and awareness to medicine adherence.

Cataract surgery is associated with a higher rate of photodynamic therapy for age-related macular degeneration.

PURPOSE: To investigate the association between cataract surgery and the rate of photodynamic therapy (PDT) for age-related macular degeneration (AMD). DESIGN: Observational population-based retrospective case-control study. PARTICIPANTS: All members in a district of the largest health maintenance organization (HMO) in Israel > 50 years old on January 1, 2001, who did not terminate their membership through May 31, 2005 (139 894 members). METHODS: All PDT procedures for AMD performed in the study population between January 1, 2001 and May 31, 2005 (283 patients) and all cataract surgeries performed between January 1, 2001 and December 31, 2003 (5913 patients) were documented. We extracted clinical information from the chronic disease registry of the HMO as well as demographic and socioeconomic information. For each patient that underwent cataract surgery, 5 HMO members matched in age, gender, chronic diseases (systemic hypertension, diabetes, hyperlipemia, and ischemic heart disease), place of residence, country of birth and socioeconomic status, who did not undergo cataract surgery, were randomly chosen as controls (n = 29 565). MAIN OUTCOME MEASURES: The rate for undergoing PDT at different time periods after cataract surgery. RESULTS: Fifty (0.85%) cataract patients and 94 control cases (0.32%) underwent PDT after cataract surgery (P<0.0001, chi-square test). A significant rise in PDT rate was noticed in cataract patients compared to controls during the first 6 months after surgery (P = 0.004, chi-square test). Between 6 and 12 months postoperatively, the PDT rates were similar in both groups. However, a more significant rise in PDT rates occurred between 1 and 1.5 years after surgery (P<0.0001, chi-square test). The Kaplan-Meier PDT-free survival curve of cataract patients was significantly worse than that of the controls (P<0.0001, chi-square test; P = 33.7, log-rank test). The hazard ratio for cataract patients compared to controls to undergo PDT after surgery was 2.7 (confidence interval = 2.4-5.7). The most significant factors to reduce the time to PDT were advanced age followed by having had cataract surgery, place of birth, socioeconomic status, and hyperlipidemia (Cox proportional hazards survival regression). CONCLUSIONS: We identified an increased rate of PDT, presumably for subfoveal AMD, 1 to 1.5 years after cataract surgery.

Increased risk for herpetic eye disease in patients with allergic conjunctivitis.

PURPOSE: To evaluate the risk of ocular surface herpetic eye disease (osHED) in allergic eye disease. METHODS: We calculated the risk for osHED in 11,205 patients on antiallergic ocular topical agents compared with 453,069 controls based on filled prescriptions for topical acyclovir between 2001 and 2003. RESULTS: Significantly more allergic patients, of all age groups, received treatment for osHED (p < 0.01). The age and gender adjusted relative risk for allergic patients to suffer an osHED event was 2.31 (95% CI: 1.84-2.90), raising to 3.55 (95% CI: 2.0-6.4) in patients that filled > or = 4 antiallergic prescriptions. CONCLUSIONS: Patients treated for allergic eye disease have an increased risk of osHED.