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

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

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

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

The epidemiology and economic burden of hip fractures in Israel.

BACKGROUND: Hip fractures increase the risks of mortality and major morbidity in the elderly. Hip fractures are associated with chronic pain, reduced mobility, disability and increasing dependence. We evaluated the direct costs incurred to the Israeli healthcare system in 2013 as a result of hip fracture injuries in elderly patients. METHODS: Hip fractures costs evaluation consisted of first-year and long-term direct costs. Data on the incidence of hip fractures resulting in hospitalizations were retrieved from the Israeli Ministry of Health's (MOH) Central Database of Hospital Admissions. Hospitalization, rehabilitation and nursing utilization rates and costs were estimated based on the professional literature and according to the MOH's price list. RESULTS: During 2013, 6285 elderly patients were hospitalized in Israel due to hip fractures. Direct costs of hip fracture, comprising hospitalization, rehabilitation and nursing costs incurred during the first year after the injury, were estimated at 454 million New Israeli Shekels (NIS; 83,841 NIS per person). Long-term nursing care costs in 2013 were 265 million NIS, with an average cost of approximately 49,000 NIS for 1600 elderly persons receiving long-term nursing care as a result of a hip fracture. Overall, the total direct costs of hip fracture in the elderly population in Israel in 2013 were 719 million NIS. CONCLUSIONS: The direct costs of hip fractures in Israel among the elderly are approximately 719 million NIS per year. The majority of costs are associated with the first year following the injury. To reduce healthcare costs in Israel, changes in the country's healthcare policy on hip fractures are required. For example, there is a need for a program for detecting high- risk populations, and for early intervention following the injury.

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

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

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

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

Processes, contexts, and rationale for disinvestment: a protocol for a critical interpretive synthesis.

BACKGROUND: Practical solutions are needed to support the appropriate use of available health system resources as countries are continually pressured to 'do more with less' in health care. Increasingly, health systems and organizations are exploring the reassessment of possibly obsolete, inefficient, or ineffective health system resources and potentially redirecting funds to those that are more effective and efficient. Such processes are often referred to as 'disinvestment'. Our objective is to gain further understanding about: 1) whether how and under what conditions health systems decide to pursue disinvestment; 2) how health systems have chosen to undertake disinvestment; and 3) how health systems have implemented their disinvestment approach. METHODS/DESIGN: We will use a critical interpretive synthesis (CIS) approach, to develop a theoretical framework based on insights drawn from a range of relevant sources. We will conduct systematic searches of databases as well as purposive searches to identify literature to fill conceptual gaps that may emerge during our inductive process of synthesis and analysis. Two independent reviewers will assess search results for relevance and conceptually map included references. We will include all empirical and non-empirical articles that focus on disinvestment at a system level. We will then extract key findings from a purposive sample of articles using frameworks related to government agendas, policy development and implementation, and health system contextual factors and then synthesize and integrate the findings to develop a framework about our core areas of interest. Lastly, we will convene a stakeholder dialogue with Canadian and international policymakers and other stakeholders to solicit targeted feedback about the framework (e.g., by identifying any gaps in the literature that we may want to revisit before finalizing it) and deliberating about barriers for developing and implementing approaches to disinvestment, strategies to address these barriers and about next steps that could be taken by different constituencies. DISCUSSION: Disinvestment is an emerging field and there is a need for evidence to inform the prioritization, development, and implementation of strategies in different contexts. Our CIS and the framework developed through it will support the actions of those involved in the prioritization, development, and implementation of disinvestment initiatives. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014013204.

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

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

Continuation of statin therapy and primary prevention of nonfatal cardiovascular events.

Although the beneficial effect of statins in secondary prevention of cardiac events is well established, their effectiveness in primary prevention is questionable when most evidence derives from randomized controlled trials and not "real-life" data. To evaluate the association between persistent use of statins and risk of acute nonfatal cardiovascular events in primary prevention patients in community settings, we retrospectively analyzed a cohort of 171,535 adults 45 to 75 years old with no indication of cardiovascular disease who began statin therapy from 1998 to 2009 in a large health maintenance organization in Israel. Persistence with statins was measured by the proportion of days covered with dispensed prescriptions of statins during the follow-up period. Main outcome measurements were occurrence of myocardial infarction or performance of a cardiac revascularization procedure. Incidence of acute cardiovascular events during the follow-up period (993,519 person-years) was 10.22 per 1,000 person-years. Persistence with statins was associated with a lower risk of incident cardiac events (p for trend <0.01). The most persistent users (covered with statins for ≥80% of their follow-up time) had a hazard ratio of 0.58 (95% confidence interval 0.55 to 0.62) compared to nonpersistent users (proportion of days covered <20%). Similar results were found when analyses were limited to patients with >5 years of follow-up. Treatment with high efficacy statins was associated with a lower risk of cardiac events. In conclusion, our large and unselected community-based study supports the results of randomized controlled trials regarding the beneficial effect of statins in the primary prevention of acute cardiac events.

Quality of life and patient-perceived difficulties in the treatment of type 2 diabetes.

BACKGROUND: Clinical evidence points to patient-perceived difficulties and compliance problems in implementing early insulin therapy. Therefore, individual treatment aims are necessary to optimize diabetes therapy, as currently acknowledged by the new ADA/EASD guidelines. Better characterization of patient-perceived difficulties in the implementation of early insulin treatment may contribute to improved compliance and optimal tailoring of treatment regimens for the individual patient. OBJECTIVES: To assess differences in quality of life (QoL) and patient-perceived difficulties in health care with every addition of oral hypoglycemic agents (OHAs) and insulin therapy. METHODS: The analysis was conducted on a cross-sectional sample of 714 diabetic patients treated with OHAs or with insulin once or twice daily. Differences in diabetes-specific QoL, overall QoL, and perception of difficulties associated with specific diabetes treatment attributes were evaluated using trend analysis and comparisons between groups. The contribution of each diabetes treatment attribute to QoL measures and glycemic control was also assessed. RESULTS: No significant differences were found in QoL measures among patients treated exclusively with OHAs when these patients were assessed by the number of oral agents, irrespective of the degree of glycemic control. Better controlled patients treated with 2 OHAs, compared with poorly controlled patients treated with a single OHA, had a lower perception of difficulties associated with diabetes treatment attributes. Poorly controlled patients treated with 2 OHAs and better controlled patients treated with 3 OHAs had similar QoL and perceived difficulties with care. However, the insulin-based alternative was consistently associated with a significantly higher perception of pain and lower overall QoL when compared with the oral regimens. Multivariate models accounted for 52% and 32% of the variance in QoL measures. CONCLUSIONS: From the patients' perspective, oral therapy is the preferred strategy for attaining the treatment goals since the addition of OHAs was not associated with lower QoL or patient-perceived difficulties with care. If early insulin treatment is considered, physicians should address specific diabetes treatment characteristics, mainly the issue of pain, to promote improved QoL and disease control.

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

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

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

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

Optimism of health care workers during a disaster: a review of the literature.

Optimism has several orientations. One such outlook is a general tendency to regard the world as a positive place, accepting difficulties as mere challenges instead of impassable barriers. Among health care workers, optimism improves their level of functioning, their patients' satisfaction, and their therapeutic results. Optimistic staff members report feeling less pressure, use fewer avoidance strategies, focus on practical problem solutions, seek social support, and have more trust in people and organizations. The aim of this article is to provide a review of the literature concerning the role of optimism, both in daily life and in crisis situations. An attempt was made to find the linkage between optimism among health care workers during disasters and their active response, with special emphasis on the relationship between optimism and knowledge, feelings or behavior. Based on the literature, optimism was found to be helpful both in daily medical work and in cases of medical emergencies. Optimism was also revealed one of the key components of resilience and self-efficacy. Therefore, it is recommended to consider strengthening the optimism through initiative programs. Obtaining optimism can be included in toolkit preparedness for health care workers in order to confront the complications in the aftermath of disaster. These programs, together with appropriate information, social support, professional trust, and leaders modeling behavior, will raise the well-being and enhance coping skills of the health care workers during and aftermath of disaster scenarios.

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

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