Power Gaps Among Stakeholders in Israel's Primary Care and the Role of Primary Care Physicians' Relative Power in Their Intention to Use Video-Consultations with Patients.

Introduction: Although some correlates of primary care physicians (PCPs) telemedicine adoption have been studied, little is known about whether the intention to use video-consultations (VCs) relates to how PCPs view their power, relative to other stakeholder groups in primary care. The aim of this study was (1) to describe PCPs', patients', and policy makers' (PMs) views of their power and (2) to explore how PCPs views of power are associated with their intention to use VC. Methods: A convergent parallel mixed-methods design was used. Interviews were conducted with five focus groups that comprised 42 patients; five focus groups with 52 PCPs; and 24 individual interviews with PMs. A total of 508 patients, 311 PCPs, and 141 PMs completed the questionnaire, assessing intention to use VC and stakeholders' relative power. The qualitative data were analyzed using the thematic method; survey data were analyzed using quantitative methods. Results: All stakeholder groups rated PCPs' power as significantly lower, relative to that of patients and managers. PCPs' intention to use telemedicine was found to be significantly related to perceived power gaps between them and patients (r = -0.24, p < 0.001) and between them and managers (r = -0.45, p < 0.001). Themes revealed in the analysis describing how PCPs' low power influences their intention to use VC were as follows: PCPs' low-impact telemedicine-related decisions, increased work overload, "big brother" control, and Health Maintenance Organization demands for telemedicine mandatory usage. Conclusions: To successfully adopt VC, efforts should be made to increase PCPs' relative power, by strengthening their involvement in decision-making procedures and by increasing PCPs' control over their work environment.

Knowledge and attitudes about mental health among older immigrants from the former Soviet Union to Israel and their primary care physicians.

Previous studies have documented a high prevalence of psychological distress and mental illness among older immigrants from the former Soviet Union (FSU) in Israel. Yet, this population rarely seeks help from mental health providers. The present study aimed to identify beliefs and attitudes about depression and anxiety among older immigrants from the FSU treated in primary care, and among their primary care physicians, who were also FSU immigrants. The study used focus group (FG) interviews with primary care patients (n = 12) and physicians (n = 23). The interviews were transcribed and analyzed using open thematic coding. Three main themes were identified: a) avoidance of discussion of mental health and stigma regarding mental illness; b) expectations to control one's mental state; and c) limited opportunities to acquire knowledge about Western mental health. Primary care physicians recognized the barriers facing their older immigrant patients concerning mental health diagnosis and treatment. Yet, due to work overload, their ability to assist older immigrants was limited. The findings suggest that older immigrants from the FSU might benefit from mental health information and exchange of ideas about Western mental health.

Video or In-Clinic Consultation? Selection of Attributes as Preparation for a Discrete Choice Experiment Among Key Stakeholders.

INTRODUCTION: Video consultations (VCs) provide increased accessibility of primary care to remote areas and overall improved care for chronic patients. They also contribute to higher patient satisfaction and improved resource management. Despite these benefits, VC integration into the health system is complex and slow. Understanding the VC-related preferences of three key stakeholders-patients, primary care physicians (PCPs) and policy makers (PMs)-is crucial for achieving optimal implementation. OBJECTIVE: The aim of this study was to select relevant attributes and levels for a discrete choice experiment (DCE) of stakeholders' choice-VC or traditional in-clinic consultation (I-CC) in primary care. METHODS: Ten semi-structured focus group interviews and 24 semi-structured individual interviews were conducted. Data analysis was performed inductively, using a thematic content analysis method. An attribute-ranking exercise was then conducted based on the results gleaned from the interviews. RESULTS: The most important attributes when choosing either VC or I-CC, for both patients and PMs, were: (1) time to next available appointment; (2) time in line before consultation; (3) relationship to PCP; and (4) quality of consultation. For PCPs, the most important attributes were: (1) time in line before consultation; (2) patient's self-management ability; (3) consultation purpose; (4) quality of consultation. CONCLUSIONS: This qualitative study identified attributes and levels for a DCE quantitative stage among three key stakeholder groups. It adds to the literature of examples of developing DCE attributes, and to literature about the stakeholder benefits in the area of telemedicine in healthcare.

Using the capabilities approach to understand inequality in primary health-care services for people with severe mental illness.

BACKGROUND: Epidemiological studies show disparities in the provision of physical health-care for people with severe mental illness. This observation includes countries with universal health insurance. However, there is limited in-depth data regarding the barriers preventing equality of physical health-care provision for this population. This study applied the capabilities approach to examine the interface between general practitioners and patients with severe mental illness. The capabilities approach provides a framework for health status which conceptualizes the internal and external factors relating to the available options (capabilities) and subsequent health outcomes (functioning). METHODS: Semi-structured in-depth interviews were conducted with 10 general practitioners and 15 patients with severe mental illness, and then thematically analyzed. RESULTS: We identified factors manifesting across three levels: personal, relational-societal, and organizational. At the personal level, the utilization of physical health services was impaired by the exacerbation of psychiatric symptoms. At the relational level, both patients and physicians described the importance of a long-term and trusting relationship, and provided examples demonstrating the implications of relational ruptures. Finally, two structural-level impediments were described by the physicians: the absence of continuous monitoring of patients with severe mental illness, and the shortfall in psychosocial interventions. CONCLUSION: The capability approach facilitated the identification of barriers preventing equitable health-care provision for patients with severe mental illness. Based on our findings, we propose a number of practical suggestions to improve physical health-care for this population: 1. A proactive approach in monitoring patients' health status and utilization of services. 2. Acknowledgment of people with severe mental illness as a vulnerable population at risk, that need increased time for physician-patient consultations. 3. Training and support for general practitioners. 4. Increase collaboration between general practitioners and mental-health professionals. 5. Educational programs for health professionals to reduce prejudice against people with severe mental illness.

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

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

Direct and indirect health economic impact of hypoglycaemia in a global population of patients with insulin-treated diabetes.

AIMS: The Hypoglycaemia Assessment Tool (HAT) study investigated the health economic impact of hypoglycaemic events in 24 countries, including countries without previously published data on hypoglycaemia. METHODS: Self-assessment questionnaires and patient diaries (4-week prospective period) were completed by adults with type 1 (T1D) or type 2 diabetes (T2D) treated with insulin for more than 12 months (N = 27,585). RESULTS: Direct economic impacts of hypoglycaemia during the 4-week prospective period, included increased blood glucose monitoring (reported by 69.7% [T1D] and 60.9% [T2D] of patients), hospitalisation (T1D 2.1%; T2D 3.4% of patients) and medical contact (clinic or telephone; T1D 3.8%; T2D 6.8% of patients). Regional variation in medical contact and hospitalisation was found, with the highest usage in Russia (T1D 17.1%; T2D 17.3%), and Latin America (T1D 5.2%; T2D 6.8%) respectively. Indirect economic impacts following hypoglycaemia included loss of productivity due to absence from work or study; 3.9% (T1D) and 6.2% (T2D) of patients. Regional differences in work productivity were noted among patients with T2D, with a low prevalence in Northern Europe and Canada (0.9%) and high in Southeast Asia (14.6%). CONCLUSIONS: This study shows that hypoglycaemia has a significant but variable impact on the economics of diabetes healthcare globally.

Impact of hypoglycaemia on patient-reported outcomes from a global, 24-country study of 27,585 people with type 1 and insulin-treated type 2 diabetes.

AIMS: Data on the impact of hypoglycaemia on patients' daily lives and diabetes self-management, particularly in developing countries, are lacking. The aim of this study was to assess fear of, and responses to, hypoglycaemia experienced by patients globally. MATERIALS AND METHODS: This non-interventional, multicentre, 4-week prospective study using self-assessment questionnaires and patient diaries consisted of 27,585 patients, ≥18years, with type 1 diabetes (n=8022) or type 2 diabetes (n=19,563) treated with insulin for >12months, at 2004 sites in 24 countries worldwide. RESULTS: Increased blood glucose monitoring (69.7%) and seeking medical assistance (62.0%) were the most common responses in the 4weeks following hypoglycaemic events for patients with type 1 diabetes and type 2 diabetes, respectively. Approximately 44% of patients with type 1 diabetes or type 2 diabetes increased calorie intake in response to a hypoglycaemic episode. Following hypoglycaemia, 3.9% (type 1 diabetes) and 6.2% (type 2 diabetes) of patients took leave from work or study. Regional differences in fear of, and responses to, hypoglycaemia were evident - in particular, a lower level of hypoglycaemic fear and utilisation of healthcare resources in Northern Europe and Canada. CONCLUSIONS: Hypoglycaemia has a major impact on patients and their behaviour. These global data for the first time reveal regional variations in response to hypoglycaemia and highlight the importance of patient education and management strategies.

Time-Dependent Risk of Cancer After a Diabetes Diagnosis in a Cohort of 2.3 Million Adults.

Using a time-dependent approach, we investigated all-site and site-specific cancer incidence in a large population stratified by diabetes status. The study analyzed a closed cohort comprised of Israelis aged 21-89 years, enrolled in a health fund, and followed from 2002 to 2012. Adjusting for age, ethnicity, and socioeconomic status, we calculated hazard ratios for cancer incidence using Cox regression separately for participants with prevalent and incident diabetes; the latter was further divided by time since diabetes diagnosis. Of the 2,186,196 individuals included in the analysis, 159,104 were classified as having prevalent diabetes, 408,243 as having incident diabetes, and 1,618,849 as free of diabetes. In both men and women, diabetes posed an increased risk of cancers of the liver, pancreas, gallbladder, endometrium, stomach, kidney, brain (benign), brain (malignant), colon/rectum, lung (all, adenocarcinoma, and squamous cell carcinoma), ovary, and bladder, as well as leukemia, multiple myeloma, non-Hodgkin lymphoma, and breast cancer in postmenopausal women. No excess risk was observed for breast cancer in premenopausal women or for thyroid cancer. Diabetes was associated with a reduced risk of prostate cancer. Hazard ratios for all-site and site-specific cancers were particularly elevated during the first year following diabetes diagnosis. The findings of this large study with a time-dependent approach are consistent with those of previous studies that have observed associations between diabetes and cancer incidence.

Poor glycemic control as a reason for referral of diabetes patients to specialists in Israel.

AIMS/INTRODUCTION: Family physicians face the dilemma of when to refer patients with diabetes to specialists. This study examined attitudes of family physicians to referring patients with poor glucose control to diabetes specialists. MATERIALS AND METHODS: At continuous medical education courses, family physicians were asked to respond anonymously, as to whether they generally manage the diabetes of their patients, and specifically those with poor glycemic control (HbA1c>9.0%). RESULTS: Of 470 respondents, 426 (90%) reported that they generally manage their patients' diabetes; 202 (43%) reported that they manage the diabetes of patients with HbA1c>9.0%. Board certification in family medicine and affiliation to a health maintenance organization, but not sex, age, years of professional experience, or the proportion of patients with diabetes at their clinics, were associated with referral practices. CONCLUSIONS: Family medicine residency and organizational support appear to promote treatment by family physicians of patients with poorly controlled diabetes in the primary care setting.

The use of focus groups as a basis for planning and implementing culturally appropriate health promotion among people with diabetes in the Arab community.

OBJECTIVE: The main study objective was to identify perceived barriers to achieving glycemic control among the Arab population in Israel, by both members of the Arab community with type 2 diabetes and by primary care teams working with the Arab community. METHODS: A series of six focus groups using qualitative research methodology were conducted in two phases among people with diabetes and primary care professionals treating them. RESULTS: The perception of the disease among people with diabetes was one of low severity. Barriers to adopting a healthy lifestyle and to self-management included awareness of the need, financial considerations regarding medication, and traditional gender roles. Food preparation in family life was identified as a strong cultural determinant. The health literacy needs for more in-depth and accessible educational programs were identified. Primary care staff viewed the needs similarly, with the exception of the need for in-depth instructional materials. CONCLUSION AND PRACTICE IMPLICATIONS: The understanding of the significance of healthy lifestyles and self-management was essential for developing culturally appropriate implementation programs and policy. Consultation with, and involvement of patient groups in needs assessment and planning is essential and should be established in policy that promotes best practice and health promotion in chronic illness.

Barriers to the Treatment of Mental Illness in Primary Care Clinics in Israel.

The present study examined physicians' perceived barriers to the management of mental illness in primary care settings in Israel. Seven focus groups that included a total of 52 primary care Israeli physicians were conducted. Open coding analysis was employed, consisting of constant comparisons within and across interviews. Three major themes emerged: (a) barriers to the management of mental illness at the individual-level, (b) barriers to the management of mental illness at the system-level, and (c) the emotional ramifications that these barriers have on physicians. The findings highlight the parallelism between the experiences of primary care physicians and their patients. The findings also stress the need to attend to physicians' emotional reactions when working with patients who suffer from mental illness and to better structure mental health treatment in primary care.

How do integrative practices influence patient-centered care?: An exploratory study comparing diabetes and mental health care.

BACKGROUND: Integration between organizational units to achieve common goals has been of interest to health systems because of the potential to improve patient-centered care. However, the means by which integrative practices actually influence patient-centered care remain unclear. Whereas many studies claim a positive association between implementation of integrative practices and patient-centered care, others raise concerns that integrative practices may not necessarily improve patient-centered care. PURPOSE: The aim of this study was to explore the mechanism by which integrative practices influence patient-centered care and to suggest a systematic approach for effective integration. APPROACH: We conducted a qualitative study comparing diabetes and mental health services through focus groups with 60 staff members from one health maintenance organization. We developed quantitative indicators to support the suggested model. FINDINGS: We identified a five-category framework of integrative practices that each directly and distinctively influences patient-centered care. Moreover, our findings suggest that integrative practices influence patient-centered care indirectly through creation of interdependent treatment competence, which enables providers to repeatedly deliver interdependent treatment in a flexible and adaptive way. PRACTICAL IMPLICATIONS: Providers should carefully implement integrative practices considering patient and disease characteristics, as our findings suggest that more implementation of integrative practices is not necessarily better for patient-centered care. Specifically, optimal implementation refers to the collective implementation of different integrative practices and thus encompasses both the extent (i.e., the amount of currently implemented practices out of those considered important to implement) and the extensiveness (i.e., the amount relative to the implementation of other practices) that may lead to interdependent treatment competence and higher patient-centered care. We suggest a creative measurement method of comparing the relative implementation of integrative practices that may assist managers and policy makers in developing interdependent treatment competence.

Managing Diabetes Mellitus: A Survey of Attitudes and Practices Among Family Physicians.

Due to the increasing prevalence of diabetes and the shortage of endocrinologists, family physicians have an important role in diabetes management. The purpose of this study was to examine the sources of knowledge, attitudes and practices of family physicians regarding the management of type 2 diabetes. Attendees at continuous medical education (CME) programs in Israel were requested to respond anonymously to written questions about their sources of knowledge about diabetes, the methods of diabetes management they advise their patients, their knowledge of diabetes medication treatments, and their attitudes toward people with type 2 diabetes. Questionnaires were completed by 362 family physicians (79% response rate). Of them, 329 (91%) reported that they usually manage their patients' diabetes care, including that of patients with concomitant risk factors. Their most common recommendations for diabetes control were: to increase physical activity, decrease total calorie intake, consult with a dietitian and undergo weight loss counseling. Almost all physicians (97%) reported providing lifestyle change counseling. Sixty percent reported lacking knowledge about nutritional issues. Only 58% answered correctly regarding the effect of the anti-diabetic drug, GLP1 analog. Board certified family physicians and their residents exhibited more knowledge about diabetes practice than did non-board certified family physicians. The great majority of family physicians surveyed usually manage their patients' diabetes themselves, and do not refer them to diabetes specialists. The implementation of strategies that will enhance the competencies and confidence of family physicians in diabetes management are important for achieving successful treatment.

Between modern and traditional values: Informal mental health help-seeking attitudes according to Israeli Arab women, primary care patients and their providers.

BACKGROUND: Israeli Arab women under-utilize mental health services. OBJECTIVES: The present study evaluated the use of alternative services for dealing with depression and anxiety among Israeli Arab women and primary care providers. MATERIAL: Four focus groups with primary care patients and two focus groups with primary care providers were conducted. Constant comparisons were employed in order to identify major themes related to informal help-seeking behaviors. DISCUSSION: Three informal help-seeking behaviors were identified: (a) social support, divided into extended family and neighbors versus nuclear family and close friends; (b) religiosity, divided into inner, direct practices and beliefs versus externally mediated ones; and (c) self-help techniques, such as engagement in activities and distancing oneself from the situation. Both social support and religiosity were viewed with ambivalence by primary care patients and providers. CONCLUSION: The findings suggest that the Arab population in Israel might be lacking informal sources of support at times of mental health needs.

Psychometric properties of responses by clinicians and older adults to a 6-item Hebrew version of the Hamilton Depression Rating Scale (HAM-D6).

BACKGROUND: The Hamilton Depression Rating Scale (HAM-D) is commonly used as a screening instrument, as a continuous measure of change in depressive symptoms over time, and as a means to compare the relative efficacy of treatments. Among several abridged versions, the 6-item HAM-D6 is used most widely in large degree because of its good psychometric properties. The current study compares both self-report and clinician-rated versions of the Hebrew version of this scale. METHODS: A total of 153 Israelis 75 years of age on average participated in this study. The HAM-D(6) was examined using confirmatory factor analytic (CFA) models separately for both patient and clinician responses. RESULTS: Responses to the HAM-D(6) suggest that this instrument measures a unidimensional construct with each of the scales' six items contributing significantly to the measurement. Comparisons between self-report and clinician versions indicate that responses do not significantly differ for 4 of the 6 items. Moreover, 100% sensitivity (and 91% specificity) was found between patient HAM-D6 responses and clinician diagnoses of depression. CONCLUSION: These results indicate that the Hebrew HAM-D(6) can be used to measure and screen for depressive symptoms among elderly patients.

Patients' and physicians' characteristics associated with the purchase of benzodiazepines by older primary care patients in Israel.

This study evaluated patients' and physicians' characteristics associated with the purchase of benzodiazepines by older primary care patients in Israel. The analytic sample consists of those 6,421 patients age 65 and older. We used multi-level analysis with whether or not benzodiazepines were purchased at least once between June 2005 and 2007 as an outcome. We also evaluated patients' and physicians' characteristics associated with the purchase of benzodiazepines for 6 months or longer. Almost half the sample (41.5%) purchased benzodiazepines at least once during the study period and more than half (54.5%) of those purchasing benzodiazepines had a continued purchase for 6 months or longer. Physicians' characteristics explained only a small portion of the variance associated with purchasing, whereas patients' demographic and clinical characteristics were associated with purchasing. Any intervention to improve the use of benzodiazepines should be directed at both patients and physicians.

Cardiovascular risk management in patients with coronary heart disease in primary care: variation across countries and practices. An observational study based on quality indicators.

BACKGROUND: Primary care has an important role in cardiovascular risk management (CVRM) and a minimum size of scale of primary care practices may be needed for efficient delivery of CVRM . We examined CVRM in patients with coronary heart disease (CHD) in primary care and explored the impact of practice size. METHODS: In an observational study in 8 countries we sampled CHD patients in primary care practices and collected data from electronic patient records. Practice samples were stratified according to practice size and urbanisation; patients were selected using coded diagnoses when available. CVRM was measured on the basis of internationally validated quality indicators. In the analyses practice size was defined in terms of number of patients registered of visiting the practice. We performed multilevel regression analyses controlling for patient age and sex. RESULTS: We included 181 practices (63% of the number targeted). Two countries included a convenience sample of practices. Data from 2960 CHD patients were available. Some countries used methods supplemental to coded diagnoses or other inclusion methods introducing potential inclusion bias. We found substantial variation on all CVRM indicators across practices and countries. We computed aggregated practice scores as percentage of patients with a positive outcome. Rates of risk factor recording varied from 55% for physical activity as the mean practice score across all practices (sd 32%) to 94% (sd 10%) for blood pressure. Rates for reaching treatment targets for systolic blood pressure, diastolic blood pressure and LDL cholesterol were 46% (sd 21%), 86% (sd 12%) and 48% (sd 22%) respectively. Rates for providing recommended cholesterol lowering and antiplatelet drugs were around 80%, and 70% received influenza vaccination. Practice size was not associated to indicator scores with one exception: in Slovenia larger practices performed better. Variation was more related to differences between practices than between countries. CONCLUSIONS: CVRM measured by quality indicators showed wide variation within and between countries and possibly leaves room for improvement in all countries involved. Few associations of performance scores with practice size were found.

Diabetes, glucose control, glucose lowering medications, and cancer risk: a 10-year population-based historical cohort.

BACKGROUND: Both diabetes and glucose-lowering medications have been associated with an increased risk of cancer incidence. This study will compare cancer incidence rates in individuals with and without diabetes; and will investigate, in individuals with diabetes, an association between glucose control and cancer incidence; and between the use of specific glucose-lowering medications, as well as no drug exposure, and cancer incidence. METHODS/DESIGN: This is a population based historical cohort study of all individuals aged 21 years or older (about 2,300,000) who were insured by Clalit Health Services, the largest health maintenance organization in Israel during a ten-year study period. Four study groups will be established according to the status of diabetes and cancer at study entry, Jan 1, 2002: cancer free, diabetes free; cancer free, diabetes prevalent; cancer prevalent, diabetes free; and cancer prevalent, diabetes prevalent. Individuals without diabetes at study entry will be followed for diabetes incidence, and all four groups will be followed for specific cancer incidence, including second primary neoplasms. Glucose control will be assessed by HbA1c and by fasting plasma glucose levels. Time dependent regression models for cancer incidence will account for glucose-lowering medications as they are added and changed over the follow-up period. A large number of demographic and clinical variables will be considered, including: age, gender, BMI, smoking status, concomitant medications, glucose control (assessed by HbA1c and by fasting plasma glucose) and cancer screening tests. DISCUSSION: Strengths of this study include the large population; high quality comprehensive data; comparison to individuals without diabetes, and to those with diabetes but not treated with glucose-lowering medications; and the extensive range of variables available for analysis. The great increases in diabetes prevalence and in treatment options render this study particularly relevant and timely. The Israeli national healthcare system, characterized by high standard and uniform healthcare, offers an advantageous environment for its conduct.

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

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

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

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