Healthcare services utilization following admission for hip fracture in elderly patients.

OBJECTIVES: To assess the effect of hip fracture on healthcare utilization among elderly patients. DESIGN: Retrospective cohort study. SETTING: Eight general hospitals in Israel, owned by Clalit. PARTICIPANTS: Enrollees >65 years, admitted with a hip fracture during 2009-2013. MAIN OUTCOME MEASURES: Data collected included demographics, comorbidities, admission details related to the surgical and rehabilitation hospitalizations, mortality and costs. Mean monthly costs before and after the event were compared. Quantile regression was used to analyze associations between patient characteristics and healthcare expenditure in univariate and multivariate analysis. RESULTS: Of 9650 patients admitted with hip fracture during the study period, 6880 (71%) were Clalit enrollees and included in the present study (69% females, median age: 83 years). Total mean monthly costs increased by 96% during the follow-up year ($1470 vs. $749). Costs for rehabilitation accounted for 40% of costs during the first follow-up year. Mean monthly non-rehabilitation costs increased by 21% ($877 vs. $722). Several factors were found to be consistently associated with increased mean monthly costs during the follow-up year. These included Charlson's comorbidity index, hypertension, baseline expenditure in the base year, the location of the fracture, procedure performed, department on admission, admission to the intensive care unit, discharge to a rehabilitation facility and mortality during the follow-up year. CONCLUSIONS: Hip fractures in adults in Israel are associated with a significant increase in healthcare utilization and costs. The largest increment was seen in costs for rehabilitation. However, increased costs were noted in all sub-categories of healthcare costs.

[TEN YEARS OF OPIOID CONSUMPTION BY CHILDREN (2001-2010)].

BACKGROUND: Opioids are considered a cornerstone in the treatment of pain. They are rarely used in almost half of the countries of the world, especially in children. OBJECTIVE: The aim of this study was to assess opioid use over a ten-year study period from 2001-2010, among children 0-18 years old who are members of Clalit Health Services (CHS), the largest HMO in Israel METHODS: Data on the purchase of opioids, authorized for use in Israel, was obtained from the computerized databases of CHS. In addition, the patient's demographic details and cancer morbidity were also extracted. The data was analyzed after all the doses of all opioids consumed (fentanyl patch, oxycodone, methadone, hydromorphone, oral transmucosal fentanyl) were converted into oral morphine equivalents (OME). RESULTS: In all, 1,098 children purchased at least one opioid prescription during the study period. Of them, 27.3% had a diagnosis of cancer and 55.5% were female. A 42% decrease in total annual OME (mg) purchased, from 209,443 mg to 122,048 mg, was observed from 2001 to 2010. There was no specific pattern or trend in the annual number of pediatric and adolescent patients who purchased at least one opioid drug during the study period. In 86.5% of the cases, children with a non-cancer cause of pain purchased opioids for only one month. CONCLUSIONS: There is a low and inconsistent rate of opioid consumption among pediatric and adolescent members of the CHS. Further study is needed to explore the reasons for this low opioid consumption rate in this population group.

Placental abruption as a significant risk factor for long-term cardiovascular mortality in a follow-up period of more than a decade.

BACKGROUND: To investigate the risk for subsequent cardiovascular events in women having placental abruption during a follow-up period of more than 10 years. METHODS: A population-based study of the incidence of cardiovascular events in women who had placental abruption with women without placental abruption during 1988-99 and with follow-up until 2010. Associations between placental abruption and maternal long-term cardiovascular morbidity and mortality were investigated. Kaplan-Meier survival curves and multivariable Cox regression were used to estimate cumulative incidence of cardiovascular mortality. RESULTS: During the study period, there were 47 585 deliveries meeting the inclusion criteria; of these, 653 occurred in patients with placental abruption. No significant association was noted between placental abruption and subsequent long-term hospitalisations because of cardiovascular causes. However, placental abruption was associated with long-term cardiovascular mortality [odds ratio (OR) = 6.6; 95% confidence interval (CI) 2.3, 18.3]. The cardiovascular case fatality rate for the placental abruption group was 13.0% vs. 2.5% in the comparison group (P < 0.001). Patients with a history of placental abruption had a significantly higher risk for cardiovascular mortality during the follow-up period (Log-rank test P = 0.017). Using Cox multivariable regression models, placental abruption remained an independent risk factor for long-term maternal cardiovascular mortality [adjusted hazard ratio (HR) = 4.3; 95% CI 1.1, 18.6). CONCLUSION: Placental abruption is a significant risk factor for long-term cardiovascular mortality in a follow-up period of more than a decade.

Patterns of opioid consumption in cancer patients.

BACKGROUND: Opioids are considered a cornerstone in the treatment of cancer pain. OBJECTIVES: To assess opioid use during a 6 year period (2001-2006) among cancer patients served by Clalit Health Services, the largest health management organization in Israel. METHODS: Purchasing data of opioids authorized for use in Israel were obtained from the computerized databases of Clalit for the period 2001-2006. Patients' demographic and cancer morbidity data were extracted. The data were analyzed by translating the purchased opioids (fentanyl patch, oxycodone, buprenorphine, methadone, hydromorphone) to oral morphine equivalents (OME). RESULTS: During the study period 182,066 Clalit members were diagnosed with cancer; 58,443 (32.1%) of them died and 31,628 (17.3%) purchased opioids at least once. In 2001, 7.5% of Clalit cancer patients purchased opioids at least once within 5 years of the initial diagnosis. Between 2002 and 2006 this percentage increased consistently, reaching 9.9% in 2006. The average daily dose of opioids increased from 104.1 mg OME in the year 2001 to 115.2 mg OME in 2006 (11% increase). The average duration of opioid purchasing was 5.0 +/- 8.3 months (range 1-84 months, median 2). During the study period 19,426 cancer patients who purchased opioids at least once died; only 14.3% (3274) were still alive 2 years after their first opioid prescription. CONCLUSIONS: Opioid purchasing increased during the study period, especially during the final months of life. Children (0-18 years old) and elderly male patients (> or = 65 years) began opioid treatment later compared to other age groups. Only a few patients had an opioid early enough to relieve their pain.

Residents' choice of a placement in periphery hospitals in Israel: The significance of personal/family and professional considerations.

Physician maldistribution affects remote and rural population health indicators and as such constitutes a major concern for health systems. Various countries, including Israel, have sought to remedy this problem, often by implementing more than one intervention simultaneously. In this paper, we explored the considerations that motivated Israeli residents to opt for a position in the periphery, as well as potential factors that could facilitate their retention in these underserved areas. We found that the motivation driving young physicians to specialize in a specific hospital includes personal- and family-oriented considerations (proximity to the nuclear family, perceived quality of life and lifestyle) as well as professional considerations (prior acquaintance with a hospital and a specific hospital department, department characteristics, availability of a residence position in a preferred specialty, prospective professional advancement). We therefore argue that the key to recruitment and retention of young physicians in remote areas lies in tailored interventions that take personal, professional and regional issues into account, preferably in consultation with the physicians themselves. The prominence of personal issues in the interviews with young physicians suggests that effective interventions should support a work-life balance. Hence success in attracting residents as a first step towards correcting physician maldistribution hinges upon coordinating policies in the medical field with policies in non-medical arenas - education, welfare, local authorities.

Lack of prenatal care in a traditional community: trends and perinatal outcomes.

PURPOSE: To describe the prevalence of lack of prenatal care (LOPC) over the years and to examine the association between LOPC and perinatal complications among Bedouin parturients. METHODS: A retrospective study comparing all singleton births of Bedouin women with and without prenatal care, between the years 1988 and 2009, was conducted. Multiple logistic regression models were used to control for confounders. RESULTS: Out of 123,506 singleton deliveries, 16.5% (n = 20,402) were of women lacking prenatal care. A gradual increase in the rate of LOPC was noted between the years 2006 and 2009. Using multivariable analyses, controlling for parity, LOPC was found to be significantly associated with preterm delivery (PTD) < 37 weeks (odds ratio (OR) 1.13, 95% CI 1.07-1.19), PTD < 34 weeks (OR 1.53, 95% CI 1.40-1.67), low birth weight < 2,500 g (LBW; OR 1.39, 95% CI 1.32-1.46), very LBW < 1,500 g (OR 1.67, 95% CI 1.49-1.86), and perinatal mortality (OR 1.63, 95% CI 1.47-1.80). CONCLUSIONS: Lack of prenatal care in a traditional community is associated with adverse obstetric outcomes and specifically is an independent risk factor for preterm delivery, low birth weight, and perinatal mortality.

Reducing infantile anemia: insight on patterns of process and outcome indicators by ethnicity and socioeconomic class during a 10-year intervention program and 5 years after.

BACKGROUND: In 2005, Clalit Health Services (CHS), the largest health maintenance organization in Israel, initiated an intervention program aimed at reducing the prevalence rate of infantile anemia (IA). This study evaluated the progress made during the intervention (2005-2014) and its yield 5 years after it ended (2019). METHODS: The CHS database was retrospectively reviewed twice yearly from 2005 to 2014 for repetitive samples of children aged 9 to 18 months regarding the previous half-year interval, and a single sample in 2019. Data were collected on gender, ethnicity (Jewish/non-Jewish), socioeconomic class (SEC; low/intermediate/high), hemoglobin testing (yes/no), and hemoglobin level (if tested). Excluded were infants with documented or suspected hemoglobinopathy. RESULTS: At study initiation, the rate of performance of hemoglobin testing was 54.7%, and the IA prevalence rate was 7.8%. The performance rate was lower in the Jewish than the non-Jewish subpopulation. The low-SEC subpopulation had a similar hemoglobin testing rate to the high-SEC subpopulation but double the IA prevalence rate. Overall, by the end of the intervention (2014), the performance rate increased to 87.5%, and the AI prevalence rate decreased to 3.4%. In 2019, there was little change in the performance rate from the end of the intervention (88%) and the IA prevalence was further reduced to 2.7%. The non-Jewish and low-SEC subpopulations showed the most improvement which was maintained and even bettered 5 years after the intervention ended. CONCLUSIONS: The 10-year IA intervention program introduced by CHS in 2005 led to a reduction in IA prevalence rate to about 3.5% in all sub-populations evaluated. By program end, the results in the weaker subpopulations, which had the highest prevalence of IA at baseline, were not inferior to those in the stronger subpopulations. We recommended to the Israel Ministry of Health to adopt the intervention countrywide, and we challenge other countries to consider similar interventions.

The emergency department in a region under missile attack: utilization patterns during Operation Cast Lead.

BACKGROUND: During military escalations emergency departments provide treatment both to victims of conflict-related injuries and to routine admissions. This requires special deployment by the hospitals to optimize utilization of resources. OBJECTIVES: To evaluate routine visits to the ED during Operation Cast Lead in Israel in 2008-2009. METHODS: We obtained data regarding routine visits to the ED at Soroka University Medical Center throughout OCL. The visits one month before and after OCL and the corresponding periods one year previous served as controls. RESULTS: The mean number of daily visits throughout the study period (126 days) was 506 +/- 80.9, which was significantly lower during OCL (443.5 +/- 82) compared with the reference periods (P < 0.001). Compared to the reference periods, during OCL the rates were higher among Bedouins, visitors from the region closest to the Gaza Strip (< 30 km), patients transported to the ED by ambulance and patients of employment age; the rates were lower among children. No difference in the different periods was found in the rate of women patients, the rate of patients referred to the ED by a community physician, and hour of arrival. The overall in-hospital admission rate increased during OCL, mainly in the internal medicine and the obstetric departments. There was no change in the number of in-hospital births during OCL; however, the rate of preterm labors (32-36 weeks) decreased by 41% (P = 0.013). CONCLUSIONS: Throughout OCLthe number of routine ED visits decreased significantly compared to the control periods. This finding could help to optimize the utilization of hospital resources during similar periods.

[OFEK virtual medical records: an evaluation of an integrated hospital-community system].

BACKGROUND: In 2005, an innovative system of hospital-community on-line medical records ("OFEK") was established at Clalit Health Services to reduce costs and improve medical care. GOALS: To examine the utilization of OFEK and its impact on quality indicators and medical-service utilization. METHOD: Examining frequency of use of OFEK with OFEK's own track-log data; "before" and "after" data were used to compare changes in quality indicators and service utilization for experimental versus control groups. RESULTS: Use of OFEK in primary-care clinics increased by hundreds of percent from 2005 to 2006 and continued rising in 2007 and 2008, albeit more slowly. At clinics in hospital catchment areas using OFEK extensively, the system reduced utilization of imaging services and, to a lesser extent laboratory use, and improved several quality measures. Analyses of the data from all catchment areas and from all study clinics revealed much weaker effects. In hospitals, the use of OFEK increased by tens of percent each year internal medicine wards showed a significant decrease in the number of laboratory tests and 3 CT tests compared with the control group. Wards using OFEK extensively showed a greater decrease in CT tests, in one imaging test, and in the average number of ambulatory hospitalizations. No similar changes were found in surgical wards. CONCLUSIONS: The introduction of OFEK affected some of the outcome measures examined. OFEK affects community clinics and hospital wards differently, with more consistent effects in the community. DISCUSSION AND SUMMARY: The study helps assess the extent to which OFEK's targets were achieved. In addition, it contributes to the development of measures to examine the impact of such systems, which can be used to assess a broad range of electronic-medical-information systems.

[The struggle over the establishment of the central hospital in the Negev--the Soroka Medical Center].

In December 1959 the Central Hospital for the Negev (today, the Soroka University Medical Center) opened its doors. This event was preceded by an arduous political battle over the Location of hospital facilities for inhabitants of Israel's south. On one side was the presiding Prime Minister David Ben-Gurion, who opposed the establishment of a hospital in Beer Sheba by the Clalit Sick Fund. On the other side were Beer Sheba's residents, led by David Tuviyahu--mayor of Beer Sheba, and Moshe Soroka--a member of the Clalit Sick Fund's management, who sought to bring about the immediate establishment of a hospital in the city itself, following the decision of the Hadassah Women's Organization to close the temporary hospital they had operated in Beer Sheba since 1948. The work at hand describes the ideological and political struggle between the two sides, the conflicting interests of the Government of Israel and the Labor Federation regarding the health needs of the city, and the factors that, in the end, led to the establishment of the hospital by the Federation's Clalit Sick Fund. The research is based on both archival material and on input from informants from the period who constitute primary sources.

Analyzing admission rates for multiple ambulatory care-sensitive conditions.

OBJECTIVES: This study assessed rates of ambulatory care-sensitive condition (ACSC) admissions within a healthcare system to identify areas for intervention. STUDY DESIGN: This was a multiyear cross-sectional study using the data warehouse of Clalit Health Services (Clalit), the largest payer/provider healthcare system in Israel, with complete clinical records for more than 4 million members. All admissions from 2009 to 2014 were included in the study. Discharge diagnoses were identified using International Classification of Diseases, Ninth Revision codes. METHODS: We provide adjusted rates (per 100,000 Clalit population adjusted by age and sex to the 2005 Organisation for Economic Co-operation and Development population) for all admissions, by discharge diagnoses, for each year. We identify the highest adjusted rates (relative and absolute) by both catchment area and hospital affiliation (Clalit or non-Clalit). RESULTS: ACSC-related admissions made up 16.2% of all admissions for the 5 years studied, and the overall rate increased by 26.8% from 2009 to 2014. The conditions with the highest admission rates in all years and all catchment areas were pneumonia and congestive heart failure. There was extreme variation among catchment areas for hypertension-related admissions. Within the Clalit hospitals, ACSCs accounted for 20.5% of admissions; within non-Clalit hospitals, ACSCs accounted for 13.6% of admissions. CONCLUSIONS: In evaluating the rates of ACSC-related admissions, this study demonstrates the contribution of a single, longitudinal benchmark. This study also suggests that hypertension, congestive heart failure, and pneumonia may be areas for future intervention in Clalit.

Opioid use in an Israeli health maintenance organization: 2000-2006.

OBJECTIVE: The objective of this study was to assess opioid use during 7 years (2000-2006) among Clalit Health Services (CHS) members. DESIGN: Purchasing data of opioids authorized for use in Israel were obtained from the computerized databases of CHS. Patient demographics and cancer morbidity were also extracted. The data were analyzed by converting the purchased opioids to oral morphine equivalents (OMEs). SETTING: CHS is the largest health maintenance organization in Israel (3,774,600) and insures almost 54% of the Israeli population. PATIENTS: All CHS members who purchased an opioid at least once during the 7-year study period (2000-2006). INTERVENTION: There were no interventions in this study. OUTCOME MEASURES: The outcome measures of this study were total OME purchased per year, OME (mg) per capita/per year, and OME (mg) daily dose. RESULTS: There were 119,562 patients who purchased an opioid at least once (3.2% of CHS population). Of them, 57.4% were women, 69.0% aged 65 years and above (average age 56.05 years +/- 26.7), 7.7% purchased opioids for more than 12 months, and 81.3% purchased opioids for only 1-4 months. A 96% increase in total OME purchased was found between 2000 and 2006 (from 56.4 kg to 110.6 kg). The annual OME purchased per capita increased from 15.7 mg in the year 2000 to 29.3 mg in 2006. The total number of patients who received at least one opioid prescription increased by 60%, while the growth in total number of CHS members was smaller (4.8%). CONCLUSIONS: There is a growing use of opioids at CHS during the 7-year period, a potential indicator of the progress made in improving accessibility and availability of opioids in our health care organization in Israel.

Serum thyrotropin measurements in the community: five-year follow-up in a large network of primary care physicians.

BACKGROUND: Subclinical thyroid disease is common; however, screening recommendations using serum thyrotropin (TSH) level determinations are controversial. METHODS: To study the use of serum TSH by primary care physicians and define populations at risk for having an abnormal TSH level at follow-up, based on initial TSH levels, we conducted an observational study of a large health care database in the setting of a health management organization. All outpatients without thyroid disease or pregnancy or taking medication that may alter thyroid function in whom the TSH level was measured in 2002 and during 5-year follow-up were included in this study. Repeated TSH level determinations were compared with the initial TSH level values. RESULTS: In 422 242 patients included, 95% of the initial serum TSH concentrations were within normal limits (0.35-5.5 mIU/L), 1.2% were decreased (<0.35 mIU/L), 3.0% were elevated (>5.5 to 10 mIU/L). In 346 549 patients without thyroid-specific medications, the TSH levels became normal in 27.2%, 62.1%, and 51.2%, whose initial serum TSH level was highly elevated, elevated, and decreased, respectively, and remain normal in 98% of the patients with normal initial TSH levels. When the initial serum TSH level was elevated, patients in the highest quintile of this group, who had a shorter interval between the first and second measurements, had a higher probability of a second highly elevated TSH concentration (P < .001). CONCLUSIONS: When the serum TSH level is normal, the likelihood of an abnormal level within 5 years is low (2%). More than 50% of patients with elevated or decreased serum TSH levels have normal levels in repeated measurements.

Risk factors for overweight and obesity in young healthy adults during compulsory military service.

BACKGROUND: In view of the rising prevalence of obesity, the identification of young adult populations at risk is important for the formulation of intervention and prevention programs. OBJECTIVES: To assess demographic and behavioral factors associated with an increase in body mass index in young healthy adults and to identify the incidence of overweight/obesity in this population. METHODS: Data on anthropometric measures, demographic characteristics, and health behaviors were collected retrospectively for a representative sample of young Israeli adults (11,391 men, 11,280 women) on their release from military service (age 20-22 years) between 1989 and 2003. The incidence of overweight (BMI < 25 < or =30 kg/m2), incidence of obesity (BMI > or =30 kg/m2), and increase in BMI during military service were calculated. RESULTS: The average increase in BMI during military service was 1.11 kg/m2 in males and 1.08 kg/m2 in females. Agreater increase was positively associated with low paternal education and smoking cessation, and negatively associated with high physical activity. Twelve percent of subjects with a normal BMI on recruitment became overweight, and 21.7% of overweight subjects became obese. On multivariate logistic regression analysis, a higher incidence of overweight was associated with low education level (in both the subject and his or her father) in both genders, and non-use of oral contraceptives and low level of physical activity in females. CONCLUSIONS: BMI appears to increase significantly during early adulthood. Intervention programs should be targeted specifically at subjects with low education or who started smoking before age 18, and physical activity (especially among females) should be encouraged.

Chronic pain: a population-based study.

BACKGROUND: The prevalence of chronic pain in the general population ranges from 10% to over 40%, depending on the definition and the population studied. No large study has been conducted in Israel. OBJECTIVES: To evaluate the prevalence of patients with chronic pain, and characterize them in a large community random sample. METHODS: We conducted a survey of Clalit Health Services members, interviewing them by phone. A random sample of 4063 Clalit members, 25 years or older and Hebrew speakers, were screened for chronic pain, defined as: any pain or discomfort that in the last 6 months has persisted continuously or intermittently for more than 3 months. RESULTS: Eight percent (n=325) refused to participate. Of the 3738 included in the study, 1722 (46%) reported chronic pain in at least one site. Most of the patients were over 50-years-old (62%) (mean age 56 +/- 16, range 27-97 years). Women suffered significantly more than men, as did those who were older, less educated and born in Israel and Eastern Europe. Prevalent painful sites were the back (32%), limbs (17%) and head (13%). More than a third reported severe pain and impaired life activities. Only 4.8% of the patients suffering from chronic pain were referred to pain specialists and 11% used complementary medicine. A logistic regression model showed that women and patients with a low education level were the only significant variables predicting higher life impact index and higher pain severity. CONCLUSIONS: We found a high prevalence of chronic pain in the study population. Chronic pain causes severe disturbance to quality of life. A low rate of referral to pain specialists and complementary medicine was observed.

Elevated cancer risk in Holocaust survivors residing in Israel: A retrospective cohort study.

BACKGROUND: The purpose of this study was to examine the incidence of malignant diseases among Holocaust survivors in Israel compared with European and American immigrants who did not experience the Holocaust. METHODS: Study subjects included Holocaust survivors born in European countries under Nazi occupation before 1945, who immigrated to Israel after 1945 and were alive as of the year 2000. Living survivors were identified based on recognition criteria in accordance with the Holocaust Survivor Benefits Law. The comparison group consisted of Clalit enrollees who were born before 1945 in European countries not under Nazi occupation and were alive in 2000 or were born in any European country or America, immigrated to Israel before 1939 and were alive in 2000. The incidence of malignant diseases was compared in univariate and Poisson regression models analyses, controlling for age, smoking, obesity, diabetes and place of residence. RESULTS: The study included 294,543 Holocaust survivors, and the mean age at the beginning of follow-up was 74 ± 8.7 years; 43% males. In multivariable analyses, the rate ratio (RR) values for males and females were 1.9 and 1.3 for colon cancer, 1.9 and 1.4 for lung cancer, 1.6 and 1.4 for bladder cancer and 1.2 and 1.3 for melanoma, respectively. For prostate cancer in males, the RR was 1.4, while for breast cancer in females, it was 1.2. CONCLUSIONS: The incidence of malignant diseases among Holocaust survivors residing in Israel was higher than that among non-Holocaust survivors. These associations remained statistically significant in a multivariable analysis and were stronger for males.

Cardiovascular Morbidity and Risk Factors in Holocaust Survivors in Israel.

OBJECTIVES: To compare the prevalence of cardiovascular diseases and risk factors in Holocaust survivors with that of Jewish immigrants from Europe and America. DESIGN: Population-based, cross-sectional study. SETTING: Clalit, a large Israeli healthcare provider. PARTICIPANTS: Holocaust survivors (n=83,971) and a comparison group of Jewish individuals born in North or South America or European countries not under Nazi occupation or who immigrated to Israel before 1939 (n=16,058) (mean age 84±7, 61% female) MEASUREMENTS: Univariate and multivariable logistic regression analyses of cardiovascular diseases and risk factors. Matching the comparison group to Holocaust Survivors on propensity scores for exposure. RESULTS: The prevalence of ischemic heart disease (38.7% vs 31.3%), congestive heart failure (10.9% vs 9.1%), past stroke (15.7% vs 13.4%), and peripheral vascular disease (9.5% vs 7.9%) was higher in Holocaust survivors (p<.001 for all comparisons). Similar results were found for cardiovascular risk factors (diabetes mellitus (14.4% vs 13.6%), hypertension (89.3% vs 86.4%), dyslipidemia (75.9% vs 74.0%) (p<.001 for all comparisons). In multivariable analysis, matched on propensity scores and controlled for confounders, odds ratios for men and women were higher for diabetes (1.23, 1.55), dyslipidemia (1.53, 1.51), hypertension (1.56 , 1.94), stroke (1.18, 1.17), and ischemic heart disease (1.18, 1,40), but not congestive heart failure (0.95, 1.02). A Positive association was noted for peripheral vascular disease in males (1.20) but not females (0.96). CONCLUSION: Prevalence of cardiovascular diseases and risk factors was higher in Holocaust survivors. These associations were stronger in women in most cases.

Primary care screening for childhood obesity: a population-based analysis.

BACKGROUND: The prevalence of obesity among children and adolescents in the western world has increased dramatically. OBJECTIVES: To assess the efficacy of routine childhood obesity screening by primary physicians in the pediatric population in Israel and the utilization of health services by overweight children. METHODS: The electronic medical records of children aged 60-83 months registered in 39 pediatric primary care centers between January 2001 and October 2004 (n=21,799) were reviewed. Those in whom height and weight were documented during a clinic visit (index visit) were classified as overweight, at risk of overweight, or normal weight according to body mass index percentiles. The number of visits to the pediatrician, laboratory tests and health care costs 12 months after the index visit were calculated. RESULTS: Anthropomorphic measurements were performed in 1556 of the 15,364 children (10.1%) who visited the clinic during the study period. Of these, 398 (25.6%) were overweight, 185 (11.9%) were at risk of overweight, and 973 (62.5%) were normal weight. Children in the first two groups visited the clinic slightly more often than the third group, but the differences were not statistically significant (P = 0.12), and they had significantly more laboratory tests than the rest of the children visiting the clinics (P = 0.053). Health care costs were 6.6% higher for the overweight than the normal-weight children. CONCLUSIONS: Electronic medical records are a useful tool for population-based health care assessments. Current screening for obesity in children during routine care in Israel is insufficient and additional education of community pediatricians in diagnosis and intervention is urgently needed.

[Trend in opioids use for chronic pain treatment at Clalit Health Services (2000-2004)].

BACKGROUND: Opioids are considered a cornerstone in the treatment of cancer and non-cancer pain. The World Health Organization considers a country's morphine consumption to be an important indicator of the quality of pain control. There is little or no use of opioids in nearly half of the countries in the world. OBJECTIVE: To assess the change in trends of opioids use for chronic pain treatment over a period of five years (2000-2004) among members of Clalit Health Services (CHS) in Israel. METHOD: Data on the consumption of opioid analgesic drugs that were authorized for use in Israel during the years 2000-2004 were obtained from the computerized data bases of CHS. In addition, patient's demographic details and cancer morbidity were also extracted. To make the patient's use of opioids comparable, we analyzed the data by translating all opioids consumption (fentanyl patch, oxycodone, methadone, hydromorphone) to oral morphine equivalents. RESULTS: An increase of 68% in total morphine consumption was found between the years 2000 and 2004 (from 56.4 Kg to 94.9 Kg) and in mg morphine per prescription from 15.7 to 25.3 mg. The total amount of morphine per prescription increased from 834.2 mg to 892.9 mg. The total number of patients who received an opioid prescription multiplied by 1.47 (from 18,551 to 27,302) while the growth in total number of CHS members was significantly smaller. No significant differences were found during the years in the characteristics of patients who received opioids; regarding gender (58% were woman) and age (about 80% were 65 years old and above). During the year 2004, a preliminary examination of opioids consumption, comparing cancer and non-cancer pain patients, showed that cancer pain patients used 2.74 times higher dosage than non-cancer pain patients (6110.8 vs. 2225.6 mg/patients/year). CONCLUSIONS: During the 5 year period evaluated, there is a growing trend in use of opioids at CHS in Israel. This trend may be an indication of the improvement in treatment of chronic pain.