Adherence to diabetes quality indicators in primary care and all-cause mortality: A nationwide population-based historical cohort study.

BACKGROUND: In the last three decades, much effort has been invested in measuring and improving the quality of diabetes care. We assessed the association between adherence to diabetes quality indicators and all-cause mortality in the primary care setting. METHODS: A nationwide, population-based, historical cohort study of all people aged 45-80 with pharmacologically-treated diabetes in 2005 (n = 222,235). Data on annual performance of quality indicators (including indicators for metabolic risk factor management and glycemic control) and vital status were retrieved from electronic medical records of the four Israeli health maintenance organizations. Cox proportional hazards and time-dependent models were used to estimate hazard ratios (HRs) for mortality by degree of adherence to quality indicators. RESULTS: During 2,000,052 person-years of follow-up, 35.8% of participants died. An inverse dose-response association between the degree of adherence and mortality was shown for most of the quality indicators. Participants who were not tested for proteinuria or did not visit an ophthalmologist during the first-5-years of follow-up had HRs of 2.60 (95%CI:2.49-2.69) and 2.09 (95%CI:2.01-2.16), respectively, compared with those who were fully adherent. In time-dependent analyses, not measuring LDL-cholesterol, blood pressure, HbA1c, or HbA1c>9% were similarly associated with mortality (HRs ≈1.5). The association of uncontrolled blood pressure with mortality was modified by age, with increased mortality shown for those with controlled blood pressure at older ages (≥65 years). CONCLUSIONS: Longitudinal adherence to diabetes quality indicators is associated with reduced all-cause mortality. Primary care professionals need to be supported by health care systems to perform quality indicators.

Timely childhood vaccination in Israel: a national retrospective study of ethnic and socioeconomic disparities.

A large proportion of children do not receive vaccines within the recommended timeframe. This study examined ethnic and socioeconomic differences in age-appropriate immunization of children in Israel, where immunization is freely available. Percent of children receiving MMR/V at 12-13 months, and four doses of DTP/IPV/Hib by 18 months were obtained from the National Programme for Quality Measures between 2015 and 2018. Ethnic group (Jewish vs Arab) (defined by proxy by the neighbourhood in which the clinic was located), neighbourhood socioeconomic status and peripherality were obtained. Rates of MMR vaccination were 61% in the Jewish and 82% in the Arab population; for DPT/IPV/Hib 75% in the Jewish, compared to 92% in the Arab population. These patterns were stable over time. Lowest rates occurred in the most peripheral areas for Arab children, and in urban areas for Jewish children. Differences between ethnic groups were significant at higher SES levels. Greater adherence to the vaccination schedule occurred in the Arab minority in contrast to studies showing lower vaccination in ethnic minorities elsewhere. Lower immunization rates among rural Arab children suggest a need for improved access to clinics. Efforts should be directed towards lower SES groups, while emphasizing the importance of timely vaccination in wealthier groups in order to achieve herd immunity.

What is important for people with type 2 diabetes? A focus group study to identify relevant aspects for Patient-Reported Outcome Measures in diabetes care.

BACKGROUND: Patient-Reported Outcome Measures (PROMs) aim to evaluate the quality of care based on the perspectives of patients rather than clinical indicators. Qualitative research is needed to identify these perspectives in people with type 2 diabetes. OBJECTIVE: To identify, for the first time in Israel, aspects valuable for people with type 2 diabetes that can be relevant for PROMs in diabetes care. METHODS: A qualitative study included three focus groups totalling 19 people with type 2 diabetes. Inclusion criteria were: (1)type 2 diabetes, (2)diabetes duration of at least six months, and (3)adults aged 45-80 years. Purposive sampling enabled recruitment of heterogeneous participants. Also, two experts' panels with healthcare providers involved in diabetes care (n = 23) were conducted to provide triangulation of information (more testimony about what is valuable for people with type 2 diabetes). Discussions were recorded, transcribed and thematically analysed. RESULTS: Four domains were deemed valuable for people with type 2 diabetes: (1)challenges of living with diabetes, including reduced physical function, healthy lifestyle struggles, sexual dysfunction, and financial burden, (2)mental health issues, including depression, distress, anxiety, frustration, and loneliness, (3)self-management ability, including management of lifestyle modifications and treatment, knowledge about the disease and treatment, and (4)patient-clinician relationships, including the devotion of clinicians, trust in clinicians and treatment, shared decision-making, and multidisciplinary care under one roof. Experts favour using PROMs in diabetes routine care and even acknowledged their necessity to improve the treatment process. However, only some of the domains raised by people with type 2 diabetes were identified by the experts. CONCLUSIONS: There are content gaps between perspectives of people with type 2 diabetes and their healthcare providers. PROMs are essential in addressing issues largely not addressed in routine diabetes care. We recommend that researchers and healthcare providers, who intend to utilize PROMs for diabetes care, consider the aforementioned domains.

Longitudinal Adherence to Diabetes Quality Indicators and Cardiac Disease: A Nationwide Population-Based Historical Cohort Study of Patients With Pharmacologically Treated Diabetes.

Background Evidence of the cardiovascular benefits of adherence to quality indicators in diabetes care over a period of years is lacking. Methods and Results We conducted a population-based, historical cohort study of 105 656 people aged 45 to 80 with pharmacologically treated diabetes and who were free of cardiac disease in 2010. Data were retrieved from electronic medical records of the 4 Israeli health maintenance organizations. The association between level of adherence to national quality indicators (2006-2010: adherence assessment) and incidence of cardiac outcome; ischemic heart disease or heart failure (2011-2016: outcome assessment) was estimated using Cox proportional hazards models. During 529 551 person-years of follow-up, 19 246 patients experienced cardiac disease. An inverse dose-response association between the level of adherence and risk of cardiac morbidity was shown for most of the quality indicators. The associations were modified by age, with stronger associations among younger patients (<65 years). Low adherence to low-density lipoprotein cholesterol testing (≤2 years) during the first 5 years was associated with 41% increased risk of cardiac morbidity among younger patients. Patients who had uncontrolled low-density lipoprotein cholesterol in all first 5 years had hazard ratios of 1.60 (95% CI, 1.49-1.72) and 1.23 (95% CI, 1.14-1.32), among patients aged <65 and ≥65 years, respectively, compared with those who achieved target level. Patients who failed to achieve target levels of glycated hemoglobin or blood pressure had an increased risk (hazard ratios, 1.50-1.69) for cardiac outcomes. Conclusions Longitudinal adherence to quality indicators in diabetes care is associated with reduced risk of cardiac morbidity. Implementation of programs that measure and enhance quality of care may improve the health outcomes of people with diabetes.

Developing a National Set of Health Equity Indicators Using a Consensus Building Process.

BACKGROUND: Considerable health inequities documented in Israel between communities, populations and regions, undermine the rights of all citizens to optimal health. The first step towards health equity is agreement on a set of national indicators, reflecting equity in healthcare provision and health outcomes, and allowing monitoring of the impact of interventions on the reduction of disparities. We describe the process of reaching a consensus on a defined set of national equity indicators. METHODS: The study was conducted between January 2019 and June 2020, in a multistage design: (A) Identifying appropriate and available inequity measures via interviews with stakeholders. (B) Agreement on the screening criteria (public health importance; gap characteristics; potential for change; public interest) and relative weighting. (C) Constructing the consultation framework as an online, 3-round Delphi technique, with a range of experts recruited from the health, welfare and education sectors. RESULTS: Participants were of diverse age, gender, geographic location, religion and ethnicity, and came from academia, healthcare provision, government ministries and patient representative groups. Thirty measures of inequity, presented to participants, represented the following domains: Health promotion (11 indicators), acute and chronic morbidity (11), life expectancy and mortality (2), health infrastructures and affordability of care (4), education and employment (2). Of the 77 individuals contacted, 75 (97%) expressed willingness to participate, and 55 (73%) completed all three scoring rounds. The leading ten indicators were: Diabetes care, childhood obesity, adult obesity, distribution of healthcare personnel, fatal childhood injuries, cigarette smoking, infant mortality, ability to afford care, access to psychotherapy and distribution of hospital beds. Agreement among raters, measured as intra-class correlation coefficient (ICC), was 0.75. CONCLUSION: A diverse range of consultants reached a consensus on the most important national equity indicators, including both clinical and system indicators. Results should be used to guide governmental decision-making and inter-sectoral strategies, furthering the pursuit of a more equitable healthcare system.

Effect of ethnicity, country of origin and workplace on health behaviors and health perception among nurses: Cross-sectional study.

PURPOSE: The study aimed to (1) examine health behaviors and perceived health among nurses; (2) analyze the effect of nurses' personal and work characteristics on these variables; and (3) explore the relationship between health behaviors and nurses' health perception. DESIGN AND METHODS: A cross-sectional study was conducted among nurses working in health care organizations (HCOs) across Israel. An email with the online questionnaire was sent to nurses working in 19 HCOs across Israel during September-December 2018. FINDINGS: Of 18,120 nurses employed, 3542 completed the survey. Mean age was 44.8 years, 91% were female), 64.6% were hospital nurses and 52.8% were clinical staff nurses. Two-thirds of nurses did not achieve the physical activity (PA) target; the majority reported unfavorable eating habits; 66% slept less than 7 h at night and 15% smoke. Hospital nurses working night shifts reported the least favorable health behaviors. Non-Jewish nurses had less eating habits compared with Jewish nurses. Nurses born in the Former Soviet Union perceived their health as significantly worse than that of the other respondents. Binomial logistic regression demonstrated that, age, Israeli origin, achieving the PA target, having food breaks during work, consuming a Mediterranean diet, sleeping at least 7 h, undergoing screening tests as recommended, and not smoking predicted better health perception among nurses. CONCLUSIONS: Nurses, particularly hospital-based, non-Jewish and immigrants from the Soviet Union, demonstrated unfavorable health behaviors that may negatively affect their wellbeing and health perception. CLINICAL RELEVANCE: Interventions aimed at improving the health promoting mindset of nurses have the potential to improve their health and wellbeing and to enable them to become role models and health educators for patients and their families.

Barriers to completing colonoscopy after a positive fecal occult blood test.

BACKGROUND: Colorectal cancer leads to significant morbidity and mortality. Early detection and treatment are essential. Screening using fecal occult blood tests has increased significantly, but adherence to colonoscopy follow-up is suboptimal, increasing CRC mortality risk. The aim of this study was to identify barriers to colonoscopy following a positive FOBT at the level of the patient, physician, organization and policymakers. METHODS: This mixed methods study was conducted at two health care organizations in Israel. The study included retrospective analyses of 45,281 50-74 year-old members with positive fecal immunochemical tests from 2010 to 2014, and a survey of 772 patients with a positive test during 2015, with and without follow-up. The qualitative part of the study included focus groups with primary physicians and gastroenterologists and in-depth interviews with opinion leaders in healthcare. RESULTS: Patient lack of comprehension regarding the test was the strongest predictor of non-adherence to follow-up. Older age, Arab ethnicity, and lower socio economic status significantly reduced adherence. We found no correlation with gender, marital status, patient activation, waiting time for appointments or distance from gastroenterology clinics. Primary care physicians underestimate non-adherence rates. They feel responsible for patient follow-up, but express lack of time and skills that will allow them to ensure adherence among their patients. Gastroenterologists do not consider fecal occult blood an effective tool for CRC detection, and believe that all patients should undergo colonoscopy. Opinion leaders in the healthcare field do not prioritize the issue of follow-up after a positive screening test for colorectal cancer, although they understand the importance. CONCLUSIONS: We identified important barriers that need to be addressed to improve the effectiveness of the screening program. Targeted interventions for populations at risk for non-adherence, specifically for those with low literacy levels, and better explanation of the need for follow-up as a routine need to be set in place. Lack of agreement between screening recommendations and gastroenterologist opinion, and lack of awareness among healthcare authority figures negatively impact the screening program need to be addressed at the organizational and national level. TRIAL REGISTRATION: This study was approved by the IRB in both participating organizations (Meuhedet Health Care Institutional Review Board #02-2-5-15, Maccabi Healthcare Institutional Review Board BBI-0025-16). Participant consent was waived by both IRB's.

Adherence to national guidelines for colorectal cancer screening in Israel: Comprehensive multi-year assessment based on electronic medical records.

OBJECTIVES: To assess time trends in colorectal cancer screening uptake, time-to-colonoscopy completion following a positive fecal occult blood test and associated patient factors, and the extent and predictors of longitudinal screening adherence in Israel. SETTING: Nation-wide population-based study using data collected from four health maintenance organizations for the Quality Indicators in Community Healthcare Program. METHODS: Screening uptake for the eligible population (aged 50-74) was recorded 2003-2018 using aggregate data. For a subcohort (2008-2012, N = 1,342,617), time-to-colonoscopy following a positive fecal occult blood test and longitudinal adherence to screening guidelines were measured using individual-level data, and associated factors assessed in multivariate models. RESULTS: The annual proportion screened rose for both sexes from 11 to 65%, increasing five-fold for age group 60-74 and >six-fold for 50-59 year olds, respectively. From 2008 to 2012, 67,314 adults had a positive fecal occult blood test, of whom 71% eventually performed a colonoscopy after a median interval of 122 (95% confidence interval 110.2-113.7) days. Factors associated with time-to-colonoscopy included age, socioeconomic status, and comorbidities. Only 25.5% of the population demonstrated full longitudinal screening adherence, mainly attributable to colonoscopy in the past 10 years rather than annual fecal occult blood test performance (83% versus 17%, respectively). Smoking, diabetes, lower socioeconomic status, cardiovascular disease, and hypertension were associated with decreased adherence. Performance of other cancer screening tests and frequent primary care visits were strongly associated with adherence. CONCLUSIONS: Despite substantial improvement in colorectal cancer screening uptake on a population level, individual-level data uncovered gaps in colonoscopy completion after a positive fecal occult blood test and in longitudinal adherence to screening, which should be addressed using focused interventions.

CRC Screening Results: Patient Comprehension and Follow-up.

BACKGROUND:: Fecal occult blood tests are recommended for colorectal cancer screening, but are only effective if colonoscopy follows positive results. Patients with positive results often do not complete follow-up. This study examined the association between patient comprehension and adherence to colonoscopy after positive FIT (Fecal Immunochemical Test). METHODS:: Five hundred twenty-two patients completed a telephone questionnaire regarding the FIT and its implications 120 days after a positive result. Patients were asked whether they had the test, received the results, and required follow-up. These questions were used to identify the degree to which patients understood medical information. A participant who answered "no" to any question was defined as having "low comprehension" regarding the FIT, and participants who answered "yes" to all 3 questions, as having "high comprehension". RESULTS:: Comprehension and colonoscopy adherence were significantly associated. Adherence to colonoscopy was significantly higher among participants with high comprehension, after adjusting for gender, age, education, ethnicity, and socio-economic status. CONCLUSIONS:: This study demonstrates a link between health comprehension and patient follow-up after positive FIT and contributes to understanding the implications of health comprehension in terms of health promotion. We recommend patients undergoing screening tests receive clear explanations regarding need for follow-up of positive results thus reducing health disparities associated with health comprehension.

Repeated Automated Mobile Text Messaging Reminders for Follow-Up of Positive Fecal Occult Blood Tests: Randomized Controlled Trial.

BACKGROUND: Fecal occult blood tests (FOBTs) are recommended by the US Preventive Services Task Force as a screening method for colorectal cancer (CRC), but they are only effective if positive results are followed by colonoscopy. Surprisingly, a large proportion of patients with a positive result do not follow this recommendation. OBJECTIVE: The objective of this study was to examine the effectiveness of text messaging (short message service, SMS) in increasing adherence to colonoscopy follow-up after a positive FOBT result. METHODS: This randomized controlled trial was conducted with patients who had positive CRC screening results. Randomization was stratified by residential district and socioeconomic status (SES). Subjects in the control group (n=238) received routine care that included an alert to the physician regarding the positive FOBT result. The intervention group (n=232) received routine care and 3 text messaging SMS reminders to visit their primary care physician. Adherence to colonoscopy was measured 120 days from the positive result. All patient information, including test results and colonoscopy completion, were obtained from their electronic medical records. Physicians of study patients completed an attitude survey regarding FOBT as a screening test for CRC. Intervention and control group variables (dependent and independent) were compared using chi-square test. Logistic regression was used to calculate odds ratios (ORs) and 95% CIs for performing colonoscopy within 120 days for the intervention group compared with the control group while adjusting for potential confounders including age, gender, SES, district, ethnicity, and physicians' attitude. RESULTS: Overall, 163 of the 232 patients in the intervention group and 112 of the 238 patients in the control group underwent colonoscopy within 120 days of the positive FOBT results (70.3% vs 47.1%; OR 2.17, 95% CI 1.49-3.17; P<.001); this association remained significant after adjusting for potential confounders (P=.001). CONCLUSIONS: A text message (SMS) reminder is an effective, simple, and inexpensive method for improving adherence among patients with positive colorectal screening results. This type of intervention could also be evaluated for other types of screening tests. TRIAL REGISTRATION: ClinicalTrials.gov NCT03642652; https://clinicaltrials.gov/ct2/show/NCT03642652 (Archived by WebCite at http://www.webcitation.org/74TlICijl).

Is the patient activation measure associated with adherence to colonoscopy after a positive fecal occult blood test result?

BACKGROUND: Colorectal cancer (CRC) is a major cause of morbidity and mortality worldwide, but these can be reduced significantly with population screening using annual fecal occult blood tests (FOBT)A positive FOBT requires timely follow-up with colonoscopy to maximize screening benefits.. Several barriers to follow-up have been identified, with patient health behaviors and choices comprising a significant part of these. The Patient Activation Measure (PAM) assesses knowledge, skills, beliefs, and confidence in managing health. Increased patient activation is related to positive health outcomes. The aim of this study is to examine the association between patient empowerment, as reflected in the PAM, and follow-up colonoscopy within 90 days of a positive FOBT result. METHODS: This case-control study included 429 patients with a positive FOBT, 174 who had a colonoscopy within 90 days, and 255 who did not.. Participants completed a PAM telephone questionnaire (Cronbach's α = 0.785). We used both univariate and multivariate analyses to examine the effect of the PAM score as on the likelihood of undergoing colonoscopy, after adjusting for the independent variables. RESULTS: In this study we did not find a significant association between PAM and adherence to colonoscopy, using both univariate and multivariate analyses (p = .334 and p = .697, whether PAM was defined as a continuous or as categorical, respectively). CONCLUSIONS: This study was the first to examine the association between patient empowerment, as reflected in the patient activation measure, and adherence to colonoscopy after a positive FOBT. The findings did not support such an association. Further examination is required to clarify the relation between patient empowerment and activation and personal healthcare in general, and in the Israeli population in particular. Future policy should include specific, technical interventions to improve FOBT follow-up among all groups, until the patient-related barriers are better understood. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02534142 https://clinicaltrials.gov/ct2/show/NCT02534142.

An intensive family intervention clinic for reducing childhood obesity.

BACKGROUND: Childhood and adolescent obesity constitute a significant public health concern. Family health care settings with multidisciplinary teams provide an opportunity for weight loss treatment. The objective of this study was to examine the effect of intensive treatment designed to reduce weight using a parent-child lifestyle modification intervention in a family health care clinic for obese and overweight children who had failed previous treatment attempts. METHODS: This was a practice-based 6-month intervention at Maccabi Health Care Services, an Israeli health maintenance organization, consisting of parental education, individual child consultation, and physical activity classes. We included in the intervention 100 obese or overweight children aged 5 to 14 years and their parents and 943 comparison children and their parents. Changes in body mass index z-scores, adjusted for socioeconomic status, were analyzed, with a follow-up at 14 months and a delayed follow-up at an average of 46.7 months. RESULTS: The mean z-score after the intervention was lower in the intervention group compared to the comparison group (1.74 and 1.95, respectively; P = .019). The intervention group sustained the reduction in z-score after an average of 46.7 months (P < .001). Of the overweight or obese children, 13% became normal weight after the intervention, compared with 4% of the comparison children. CONCLUSION: This multidisciplinary team treatment of children and their parents in family health care clinics positively affected measures of childhood obesity. Additional randomized trials are required to verify these findings.

Reducing resistance to treatment, through group intervention, improves clinical measurements in patients with type 2 diabetes.

BACKGROUND: Studies have shown that group Therapeutic Patient Education (TPE) may empower patients with type 2 diabetes to better manage their disease. The mechanism of these interventions is not fully understood. A reduction in resistance to treatment may explain the mechanism by which TPE empowers participants to improve self-management. The Objective of this study was to examine the effectiveness of diabetes groups in reducing resistance to treatment and the association between reduced resistance and better management of the disease. METHODS: In a program evaluation study, we administered validated questionnaires to measure resistance to treatment (RTQ) in 3 time periods: before the intervention (T1), immediately after the intervention (T2) and six months later (T3). Clinical measures (HbA1C, blood pressure, HDL, LDL and total cholesterol, Triglycerides and BMI) were retrieved from Maccabi Healthcare Services computerized systems, for T1;T2 and a year post intervention (T3). Linear mixed models were used adjusting for age, gender, social support and family status. RESULTS: 157; 156 and 106 TPE participants completed the RTQ in T1; T2 and T3 respectively. HbA1C and systolic and diastolic blood pressure were significantly reduced in the group which achieved a reduction in three out of the five RTQ components. For the other clinical measurements no significant changes were observed. CONCLUSION: Our findings suggest that reducing resistance to treatment, through an educational program for patients with diabetes, is associated with a better disease control. Identifying patients with higher resistance to treatment, and including components that reduce resistance in patient education programs, have the potential to increase the effectiveness of these programs.

A structured intentions and action-planning intervention improves weight loss outcomes in a group weight loss program.

PURPOSE: To assess whether forming general behavioral intentions and implementing intentions through action plans promotes weight loss and is moderated by weight loss goals and self-efficacy. DESIGN: A quasi-experimental study comparing change in body mass index (BMI) for 15 months between a behavioral intentions condition (BIC), an implementation intentions condition (IIC), and a comparison condition (CC). SETTING: Ten-week weight loss program delivered in weekly group meetings at community medical centers. SUBJECTS: Six hundred thirty-two attendants at the weight loss program (80% of program attendants participated in the study). INTERVENTION: Weight loss program focused on lifestyle changes, augmented by two experimental conditions (vs. a comparison condition): BIC, intended use of weight loss techniques; IIC, intended use and detailed plans for two techniques. Phone follow-up was conducted 3 and 12 months later. MAIN OUTCOME: BMI during the program (computed on the basis of weight and height measured on a mechanical medical scale). Experimental manipulations included exposure to list of techniques (BIC/IIC) and structured planning form (IIC); independent variables were assessed with questionnaires (eating self-efficacy, weight loss goal, demographics). ANALYSIS: Linear mixed models estimating changes in BMI and their interactions with the planning interventions, goals, and self-efficacy. RESULTS: Participants in the BIC and IIC lost 40% more weight during the 10-week program than those in the CC (1.10 and 1.11 BMI points compared with .79; ts < -2.76, ps < .01). Weight loss goals interacted with implementation intentions (t = 2.98, p < .01). Self-efficacy was unrelated to weight loss. No differences were found between conditions at 3 and 12 months after the program. CONCLUSION: Findings revealed that forming implementation intentions promotes weight loss within a weekly program at a field setting and that its effectiveness depends on initial high goals.

Disparities in pneumococcal and influenza immunization among older adults in Israel: a cross-sectional analysis of socio-demographic barriers to vaccination.

OBJECTIVE: Vaccinations against influenza and pneumonia reduce morbidity and mortality among older adults. We examined vaccination rates among Israel's diverse geriatric population to determine socio-demographic barriers to vaccination. METHODS: This study is a quantitative data analysis with a cross-sectional design, comprising 136,944 patients aged 65 and older enrolled during 2008-2009 in the Maccabi Healthcare Services, one of Israel's four sick funds (preferred provider organizations). We conducted multivariable logistic regression analyses to determine the association between vaccination status and socio-demographic characteristics, including age, gender, rural residency, socio-economic status, region of origin, immigrant status, and Holocaust survivorship. We controlled for potential confounders, including comorbidities, primary care visits and hospitalizations, as well as the physician's gender and region of origin. RESULTS: Overall, vaccination rates were 72% for pneumonia and 59% for influenza. The strongest socio-demographic barriers to vaccination included female gender, rural residency, low socio-economic status, recent immigration, and being from or having a physician from the Former Soviet Union. CONCLUSION: Efforts to further explore barriers to influenza and pneumococcal vaccination and interventions to reduce disparities in vaccination rates should focus on the sub-groups identified in this paper, with careful thought being given as to how to overcome these barriers.

The impact of the Yom Kippur fast on emergency room visits among people with diabetes.

This retrospective review of an Israeli computerized medical data base assessed visits to emergency departments in the 48h following the commencement of the Jewish Yom Kippur fast in the years 1999-2009, and showed that fasting does not seem to be associated with an increased rate of visits.

Perceptions of hypertension treatment among patients with and without diabetes.

BACKGROUND: Despite the availability of a wide selection of effective antihypertensive treatments and the existence of clear treatment guidelines, many patients with hypertension do not have controlled blood pressure. We conducted a qualitative study to explore beliefs and perceptions regarding hypertension and gain an understanding of barriers to treatment among patients with and without diabetes. METHODS: Ten focus groups were held for patients with hypertension in three age ranges, with and without diabetes. The topic guides for the groups were: What will determine your future health status? What do you understand by "raised blood pressure"? How should one go about treating raised blood pressure? RESULTS: People with hypertension tend to see hypertension not as a disease but as a risk factor for myocardial infarction or stroke. They do not view it as a continuous, degenerative process of damage to the vascular system, but rather as a binary risk process, within which you can either be a winner (not become ill) or a loser. This makes non-adherence to treatment a gamble with a potential positive outcome. Patients with diabetes are more likely to accept hypertension as a chronic illness with minor impact on their routine, and less important than their diabetes. Most participants overestimated the effect of stress as a causative factor believing that a reduction in levels of stress is the most important treatment modality. Many believe they "know their bodies" and are able to control their blood pressure. Patients without diabetes were most likely to adopt a treatment which is a compromise between their physician's suggestions and their own understanding of hypertension. CONCLUSION: Patient denial and non-adherence to hypertension treatment is a prevalent phenomenon reflecting a conscious choice made by the patient, based on his knowledge and perceptions regarding the medical condition and its treatment. There is a need to change perception of hypertension from a gamble to a disease process. Changing the message from the existing one of "silent killer" to one that depicts hypertension as a manageable disease process may have the potential to significantly increase adherence rates.

Differences between soldiers, with and without emotional distress, in number of primary care medical visits and type of presenting complaints.

BACKGROUND: In 2003 a total of 43 soldiers in the Israel Defense Forces committed suicide; only 20% of them were known to the IDF mental health services. Somatic symptoms are often the only presentation of emotional distress during the primary care visit and may be the key to early identification and treatment. OBJECTIVES: To examine whether the information in the medical records of soldiers can be used to identify those suffering from anxiety, affective or somatoform disorder. METHODS: We conducted a case-control study using the information in the electronic medical records of soldiers who during their 3 year service developed affective disorder, anxiety, or somatoform disorder. A control group was matched for recruitment date, type of unit and occupation in the service, and the Performance Prediction Score. The number and reasons for physician visits were collated. RESULTS: The files of 285 soldiers were examined: 155 cases and 130 controls. The numbers of visits (mean +/- SD) during the 3 and 6 month periods in the case and control groups were 4.7 +/- 3.3 and 7.1 +/- 5.0, and 4.1 +/- 2.9 and 5.9 +/- 4.6 respectively. The difference was statistically significant only for the 6 month period (P < 0.05). The variables that remained significant, after stepwise multivariate regression were the Performance Prediction Score and the presenting complaints of back pain and diarrhea. CONCLUSIONS: These findings may spur the development of a computer-generated warning for the primary care physician who will then be able to interview his or her patient appropriately and identify mental distress earlier.

Do regular check ups and preventive drug use reduce asthma severity in school children?

OBJECTIVE: To investigate whether regular check ups and preventive drug use reduce asthma symptoms in school children. METHODS: Cross sectional retrospective questionnaire responses obtained from 2193 children aged 6-7 years in 34 primary schools, and 3650 children aged 13-14 years in nine secondary schools, selected at random by cluster sampling. MAIN OUTCOME MEASURES: Asthma severity in the past 12 months as measured by the number of attacks of wheezing, visits to a doctor, visits to a hospital emergency department, and hospital admissions, all for wheezing or asthma. ANALYSIS: Multivariate ordinal logistic regression. RESULTS: Regular general practitioner check ups were associated with reduced asthma severity. Regular use of prophylactic and bronchodilator medications was associated with reduced symptoms. Asthma action plans and peak flow meter usage were associated with reduced hospital admissions. DISCUSSION: If these associations are causal, then regular GP check ups are effective in reducing the health consequences of asthma in children.