A Nationwide Digital Multidisciplinary Intervention Aimed at Promoting Pneumococcal Vaccination in Immunocompromised Patients.

Immunocompromised patients (IPs) are at high risk for infections, some of which are vaccine-preventable. The Israeli Ministry of Health recommends pneumococcal conjugate vaccine 13 (PCV13) and pneumococcal polysaccharide vaccine 23 (PPSV23) for IP, but vaccine coverage is suboptimal. We assessed the project's effectiveness in improving the pneumococcal vaccination rate among IP. An automated population-based registry of IP was developed and validated at Maccabi Healthcare Services, an Israeli health maintenance organization serving over 2.6 million members. Included were transplant recipients, patients with asplenia, HIV or advanced kidney disease; or those receiving immunosuppressive therapy. A personalized electronic medical record alert was activated reminding clinicians to consider vaccination during IP encounters. Later, IP were invited to get vaccinated via their electronic patient health record. Pre- and post-intervention vaccination rates were compared. Between October 2019 and October 2021, overall PCV13 vaccination rates among 32,637 IP went up from 11.9% (n = 3882) to 52% (n = 16,955) (p < 0.0001). The PPSV23 vaccination rate went up from 39.4% (12,857) to 57.1% (18,652) (p < 0.0001). In conclusion, implementation of targeted automated patient- and clinician-facing alerts, a remarkable increase in pneumococcal vaccine uptake was observed among IP. The outlined approach may be applied to increase vaccination uptake in large health organizations.

Vaccination Coverage among Immunocompromised Patients in a Large Health Maintenance Organization: Findings from a Novel Computerized Registry.

Immune-compromised patients (IPs) are at high risk for infections, some of which are preventable by vaccines. Specific vaccines are recommended for IP; however, the vaccination rate is suboptimal. The aim of this study is to describe the development of an IP registry and to assess vaccination rates in this population. A population-based registry of IPs was developed using an automated extraction of patient electronic health-record data in Maccabi Healthcare Services (MHS), an Israeli health maintenance organization serving over 2.4 million members. Included in the registry were patients receiving immunosuppressive therapy (IT); patients living with HIV (PLWH); solid organ and bone marrow transplant recipients (TR); patients with advanced kidney disease (AKD), and asplenic patients. We evaluated the full schedule for each vaccine's uptake rates for influenza, pneumococcal, meningococcal, and hepatitis B. On 1 October 2019, 32,637 adult immune-compromised patients were identified by the registry. Of them, 1647 were PLWH; 2354 were asplenic; 5317 had AKD; 23,216 were on IT; and 1824 were TR. Their mean age was 57 and 52.4% were females. The crude rate of immune compromise among adult MHS members was 2%. Vaccine coverage rate was overall low for PCV13, with only 11.9% of all IPs in the registry having received one dose. Influenza and PPV23 vaccination rates were higher (45% and 39.4%, respectively). Only 5.3% of all IPs received all three vaccines. Overall, low vaccination coverage was found among IPs. Our registry can serve to identify target-patient populations for interventions and monitor their effectiveness.

The Association of Inflammatory Bowel Diseases with Autoimmune Disorders: A Report from the epi-IIRN.

BACKGROUND AND AIMS: There are conflicting data on the association between inflammatory bowel diseases [IBD] and autoimmunity disorders. The aim of this study was to explore this association including the effect of medications. METHODS: We utilized health administrative data collected by three of the four health maintenance organizations [HMOs] in Israel, covering 52% of the country's population. We explored the prevalence of the following autoimmune disorders: insulin-dependent diabetes mellitus [IDDM], psoriasis, Sjögren syndrome, coeliac disease, systemic lupus erythematosus [SLE], primary sclerosis cholangitis [PSC] and autoimmune thyroiditis, among all IBD patients vs non-IBD controls. Case ascertainment was determined according to validated computerized algorithms. RESULTS: In total, 12625 IBD patients were compared to 12625 controls. A total of 1395 [11.1%] IBD patients had at least one autoimmune disease compared with 740 [5.9%] of non-IBD controls (odds ratio [OR] = 1.99 [95% confidence interval 1.81-2.19]; p < 0.05); all autoimmune diseases, except for thyroiditis, were more prevalent among IBD patients. Adjusted for confounding variables, anti-tumour necrosis factor [anti-TNF] medications were associated with a higher prevalence of psoriasis (54 [5.7%] in IBD vs 177 [4.1%] in controls; OR = 1.50 [1.07-2.08]; p < 0.05) but lower prevalence of Sjögren (1 [0.1%] vs 39 [0.9%]; OR [95% CI] = 0.13 [0.02-0.94]; p < 0.05) and coeliac disease (11 [1.2%] vs 68 [1.6%]; OR [95% CI] = 0.51 [0.27-0.99]; p < 0.05). Thiopurines and 5-aminosalicylates were not associated with any autoimmune disorder. CONCLUSION: IBD is associated with all autoimmune diseases explored here except for thyroiditis. Anti-TNF users have a higher prevalence of psoriasis, and lower prevalence of Sjögren and coeliac disease.

[ESTABLISHING A REGISTRY FOR INFLAMMATORY BOWEL DISEASE PATIENTS IN MACCABI HEALTHCARE SERVICES - JOINT PROJECT BETWEEN HOSPITALS, EPI-IIRN GROUP AND COMMUNITY MEDICINE].

INTRODUCTION: Inflammatory bowel diseases (IBD) are becoming a significant cause for chronic long term complex morbidity, particularly among adolescents and young adults. IBD patients require multidisciplinary management and considerable health resources. Recent advances and developments in the diagnostics and therapeutic options require identification and tight monitoring of these patients at both hospital and community level for better management and care. AIMS: To establish at Maccabi Healthcare Services (MHS) a dedicated registry for inflammatory bowel disease patients for long term monitoring in order to optimize care, better use of health resources and to promote high quality research. METHODS: A national project, initiated and headed by a team from Shaare Zedek Medical Center aimed to resolve the complexity in identifying IBD patients at the community setting. The project included data from all Israeli HMOs and major hospitals, that was incorporated into various algorithms to determine prevalence and incidence and to distinguish between Crohn's disease and ulcerative colitis diagnoses. Eventually, an algorithm that includes the number of diagnoses, number of purchases and duration of IBD-related medications showed the best results for separating those that suffer from IBD and those that do not. This algorithm was further validated by chart review. RESULTS: According to the established registry criteria there were 14488 IBD patients in MHS, 13000 active. Additionally we have established an ongoing platform for ongoing monitoring of clinical, therapeutic, laboratory and imaging information. DISCUSSION: Establishing an IBD registry in MHS was enabled by a national project that combined deep professional knowledge of the disease by leading academic centers together with advanced informatics and community large data. We now move on to operate the registry in real life, together with live monitoring of various parameters in order to promote excellent care, communication with patients, management and control and to enable prospective high quality research.

Development and validation of novel algorithms to identify patients with inflammatory bowel diseases in Israel: an epi-IIRN group study.

BACKGROUND: Before embarking on administrative research, validated case ascertainment algorithms must be developed. We aimed at developing algorithms for identifying inflammatory bowel disease (IBD) patients, date of disease onset, and IBD type (Crohn's disease [CD] vs ulcerative colitis [UC]) in the databases of the four Israeli Health Maintenance Organizations (HMOs) covering 98% of the population. METHODS: Algorithms were developed on 5,131 IBD patients and 2,072 controls, following independent chart review (60% CD and 39% UC). We reviewed 942 different combinations of clinical parameters aided by mathematical modeling. The algorithms were validated on an independent cohort of 160,000 random subjects. RESULTS: The combination of the following variables achieved the highest diagnostic accuracy: IBD-related codes, alone if more than five to six codes or combined with purchases of IBD-related medications (at least three purchases or ≥3 months from the first to last purchase) (sensitivity 89%, specificity 99%, positive predictive value [PPV] 92%, negative predictive value [NPV] 99%). A look-back period of 2-5 years (depending on the HMO) without IBD-related codes or medications best determined the date of diagnosis (sensitivity 83%, specificity 68%, PPV 82%, NPV 70%). IBD type was determined by the majority of CD/UC codes of the three recent contacts or the most recent when less than three contacts were recorded (sensitivity 92%, specificity 97%, PPV 97%, NPV 92%). Applying these algorithms, a total of 38,291 IBD patients were residing in Israel, corresponding to a prevalence rate of 459/100,000 (0.46%). CONCLUSION: The application of the validated algorithms to Israel's administrative databases will now create a large and accurate ongoing population-based cohort of IBD patients for future administrative studies.

Family history intake: a challenge to personalized approaches in health promotion and disease prevention.

BACKGROUND: Family history is considered an essential, obligatory part of the primary physician's intake interview. Including coded FH in a unified medical file can save expensive genetic tests and detect the early onset of diseases in young people who are not recommended to be screened routinely. The objectives of this study are to explore the frequency and point in time of recording the coded family history (FH) as a first step to increasing awareness of the importance of such information. METHODS: All ICD-9 coded diagnoses of familial histories of disease (ICD-9 coded V16.0 - V19.8), including diseases related to gender, age, and indications of chronic diseases, were collected from the electronic medical records of patients ages 18 and above in Israel's Maccabi Health Care system. The study was carried out in 2012 on the basis of coded data for 1.9 million Maccabi members, which were collected from 2004 through 2011. RESULTS: Of the Maccabi members (the second biggest HMO in Israel covering 2 million people), only 10 % had FH coded documentation. FH was significantly more frequent for females than for males (13.5 % vise 10.1 %) and increased with age. About 10 % of the FH documentation occurred before any disease was diagnosed. The most frequent FH documentation was observed for cardiovascular disease, hypertension, and diabetes. In the case of cancer FH was more frequent in females, whereas in the case of males it was cardiovascular disease. DISCUSSION: Family history is an easy tool and need to be coded and implimented in most visits in order to get the best information of the potential health and disease of the patients. CONCLUSIONS: FH frequency is very low and varies with gender and age. The literature suggests that implementing it routinely in primary care will improve health care. Further research is needed to identify the factors that impede primary care givers from complying with FH guidelines.

[In-vitro fertilization cycles and outcomes in Maccabi Healthcare Services in Israel 2007-2010].

INTRODUCTION: While Israel is by far number one in the world of in-vitro fertilization (IVF) treatments per capita, detailed information about the outcome of these treatments is not available. OBJECTIVES: To describe IVF activity during the years 2007-2010 in Maccabi Healthcare Services, an independent health provider that reimburses IVF treatments. METHODS: Data on IVF cycles and live births were collected from the Maccabi Healthcare Services infertility registry and analyzed by year and age at cycle start. RESULTS: During the four years surveyed, the average patients' age rose from 35.12 to 36.19 years. The number of IVF treatments increased by 50%, while the "live birth" rate fell from 18.8% in 2007, to 14.8% in 2010. A drop in success rate was noted in patients >35 years of age, and more so in patients >40 years of age. Beyond 43 years of age, the success rate was in the low one digit range. The estimated cost of a single live birth in this age group is NIS 399,000. SUMMARY: The clinical results are not encouraging relative to IVF outcomes in Europe and the U.S.A. SurprisingLy, and contrary to worldwide trends, the success rate in Israel decreased during the surveyed years. We speculate that the main reason is that many IVF treatments are conducted in patients that a priori have a very low chance of success. A nationwide prospective IVF registry should be implemented.

A case-crossover study of infectious diseases and new diagnosis of type 1 diabetes.

BACKGROUND: Infectious diseases have been associated with increased risk of type 1 diabetes (T1D). The objective of this case-crossover was to quantify the role of infectious diseases as triggers for T1D, 1 and 2 yr preceding disease diagnosis. METHODS: All children aged 2-18 yr diagnosed with T1D between 2004 and 2009 among a two million member Israeli healthcare organization were identified (n = 368). For each patient, visits to physicians with symptomatic infectious diseases during 1 and 2 yr before T1D diagnosis were collected and compared. A similar analysis was conducted in a population of non-diabetic members matched on exact date of birth, sex and socioeconomic status (n = 307). RESULTS: The rate of systemic viral infections was significantly higher in the year before T1D onset, as compared to the prior year [27 vs. 7%, respectively, odds ratio (OR) = 4.7, 95% confidence intervals (CI): 2.9-8.2]. This difference was most significant among patients diagnosed with T1D at the age of 2 to 6 (5 vs. 46%, respectively, OR = 27.0, 95% CI: 4.5-1105.4). Among non-T1D patients of the same age group, no difference was found in the proportion of patients with viral diseases 1 and 2 yr prior to T1D diagnosis (44 vs. 49%, respectively, OR = 0.8, 95% CI: 0.4-1.6). This unique association was limited only to viral diseases and to patients diagnosed with T1D at young age. CONCLUSIONS: Our results indicate that T1D occurring in toddlers is characterized with a relatively low incidence of viral disease 2 yr prior to diagnosis and a much higher incidence in the subsequent year.

Epidemiology and comorbidity of severe mental illnesses in the community: findings from a computerized mental health registry in a large Israeli health organization.

PURPOSE: Maccabi Healthcare Services, a large health maintenance organization (HMO) operating in Israel, has recently constructed a computerized registry of patients with severe mental illnesses (SMI). In the present study, we aimed to use this registry to investigate the epidemiology of schizophrenia and bipolar affective disorder among adults, and to assess their comorbidity and mortality compared to the general population. METHODS: In this historical cohort study, we investigated the age- and sex-specific prevalence and incidence rates of HMO members diagnosed with schizophrenia or bipolar affective disorder between 2003 and 2009. We compared their medical comorbidity and mortality to the general HMO population. RESULTS: A total of 8,848 and 5,732 patients were diagnosed with bipolar (crude prevalence rate of 5 per 1,000) and schizophrenia (3 per 1,000), respectively. The annual incidence rates were 4.2 and 2.4 per 1,000 for schizophrenia and bipolar disorder, respectively. On average, schizophrenic men were diagnosed 4-5 years earlier than schizophrenic women. Compared to the general population, schizophrenia and bipolar disorder patients had a 12- and 9-year shorter life expectancy, respectively. They were also more likely to be diagnosed with diabetes mellitus (odds ratio of 1.9 and 1.6, respectively). CONCLUSIONS: The current study demonstrates the potential use of automated medical databases to characterize the epidemiology of SMI in the community. The increased comorbidity and mortality among these patients has important implication for health authorities for prevention and delivery of health-care services.

The use of an automated patient registry to manage and monitor cardiovascular conditions and related outcomes in a large health organization.

BACKGROUND: The present study describes a computerized registry of cardiovascular disease patients in a large health maintenance organization in Israel. The registry is aimed to be used by health professionals to identify cardiovascular disease patients and to follow the courses of their illnesses and risk factors. METHODS: In 1998, the registry was initiated using advanced information technology that integrated personal computerized community and hospital records, data from laboratory tests, dispensed medications, physiological signals, radiological images, and reports from investigations and procedures. RESULTS: Between 1998 and 2007, the number of patients with cardiovascular diseases that were identified by the registry has increased from 34,144 to 80,339. During this period, the age-adjusted prevalence rates have risen from 3.7% to 5.1% and from 1.9% to 2.6%, among men and women, respectively. The percentage of ischemic heart disease patients who reached target LDL was doubled, from 21% in 2000 to 50% in 2006. The average stay in hospital declined from 11.7 to 8.6 days. Primary myocardial infarction rates declined 33% and 54% in men aged 54-65 and women aged 65-74 years, respectively. CONCLUSIONS: The present study provides, for the first time in Israel, data on selected quality of care and clinical outcomes using a large, population-based registry of cardiovascular disease patients. It demonstrates a significant improvement in the adherence with LDL tests and achieving target LDL levels and a subsequent decline in incidence of myocardial infarction within ten years since its establishment.

Seasonality in birth weight in Israel: new evidence suggests several global patterns and different etiologies.

PURPOSE: To investigate the effect of season on birth weight and whether it is expressed also in fluctuations of proportions of extreme birth weights. METHODS: Information about 225,545 singletons born during 1998 to 2004 was obtained from a large health maintenance organization in Israel. We conducted a linear regression analysis of the weight with month and year of birth, sex, maternal age, diabetes, and several meteorological factors as independent variables, which were also incorporated into multivariate logistic regression models to examine the effect of season of birth on the frequency of low birth weight (LBW, <2500 g) or macrosomia (>4000 g). RESULTS: A significant (P < .001) seasonal pattern in birth weights was observed, with a peak in July and a trough in January. Babies born in summer had an OR of 1.12 (95% CI; 1.07 to 1.18) for macrosomia compared with those born in the winter. No such pattern was found for LBW. CONCLUSIONS: While in regions of mid-latitude, summer is associated with relatively lower birth weight, possibly because of exposure to cold temperature during early or mid-pregnancy, our data suggest that in Israel, the peak birth weight is in summer, possibly because of increased exposure to sunlight in the last weeks of the pregnancy.