Real-World Effectiveness of Single-Inhaler Triple Therapy for COPD: Impact of Diabetes Comorbidity.

Type 2 diabetes is a frequent comorbidity in chronic obstructive pulmonary disease (COPD) patients, with the GOLD treatment recommendations asserting that the presence of diabetes be disregarded in the choice of treatment.In a cohort of COPD patients with frequent exacerbations, initiators of single-inhaler triple therapy or dual bronchodilators were compared on the incidence of COPD exacerbation and pneumonia over one year, adjusted by propensity score weighting and stratified by type 2 diabetes.The COPD cohort included 1,114 initiators of triple inhalers and 4,233 of dual bronchodilators (28% with type 2 diabetes). The adjusted hazard ratio (HR) of exacerbation with triple therapy was 1.04 (95% CI: 0.86-1.25) among COPD patients with type 2 diabetes and 0.74 (0.65-0.85) in those without. The incidence of severe pneumonia was elevated with triple therapy among patients with type 2 diabetes (HR 1.77; 1.14-2.75).Triple therapy in COPD is effective among those without, but not those with, type 2 diabetes. Future therapeutic trials in COPD should consider diabetes comorbidity.

Triple therapy for frequent COPD exacerbators is effective in patients without type 2 diabetes but not in those with type 2 diabetes. The impact of comorbidities should be considered in future COPD therapeutic trials.

Breast Cancer in Arab and Jewish Women in Northern Israel: A Retrospective Database Study.

BACKGROUND: In Israel, breast cancer prevalence is lower among Arab than Jewish women, but incidence is increasing among Arab women at a younger age. OBJECTIVES: To explore differences between Arab and Jewish women with breast cancer with respect to age at diagnosis, associated risk factors, and use of hormonal medications. METHODS: We conducted a retrospective database study comparing Arab and Jewish women with breast cancer focusing on age at diagnosis, smoking history, obesity, and previous hormonal medication usage, including oral combined contraceptive pills (OCCP), progestogens, hormonal medications for treatment of infertility, and hormone replacement therapy (HRT). RESULTS: The study included 2494 women who were diagnosed with breast cancer during 2004-2015. Age at diagnosis was lower among Arab women (50.7 ± 13.1 years vs. 55.4 ± 12.6 years, P < 0.0001). The rate of smoking was higher among Jewish women (16.0% vs. 4.3%, P < 0.0001). The rate of obesity was higher in Arab women older than 50 years at diagnosis (59.0% vs. 42.4%, P < 0.0001). Arab women demonstrated a lower overall chance of previous use of all types of hormonal medications (odds ratio [OR] 0.6, 95% confidence interval [95%CI] 0.6-0.8) compared to Jewish women. Arab women were more likely to have used progestogens (OR 1.7, 95%CI 1.4-2.2) and medications for treatment of infertility (OR 2.3, 95%CI 1.5-3.4) and less likely OCCP (OR 0.4, 95%CI 0.3-0.6) and HRT (OR 0.4, 95%CI 0.3-0.5). CONCLUSIONS: Previous use of hormonal medications may contribute to incidence of breast cancer in Arab women.

Community-acquired pneumonia - use of chest x-rays for diagnosis in family practice.

BACKGROUND: According to guidelines, the diagnosis of pneumonia should be confirmed by chest x-ray, ensuring appropriate management and wise use of antibiotics. Our study aimed to describe use of x-rays by family doctors and patients following diagnosis of pneumonia in primary care practices in the north of Israel. METHODS: This was a retrospective database study including adults diagnosed with pneumonia, assessing rates of referral and actual use of chest x-rays. We examined rates of referral for chest x-rays and rates of adherence to the referral, according to age, gender, smoking status, comorbidities and distance of residence from the radiology facility. RESULTS: During one year there were 4,230 diagnosed cases of pneumonia in the practice, of which 2,503 were referred for chest x-rays, and 1,920 adhered to the referral (45% of those diagnosed with pneumonia). The rate of referral was higher when the radiology facility was located in the same city as the family doctor compared to outside the city (69.7% and 53.2%, p < 0.001). Patients aged 40-64 were referred more than patients aged 18-39 or 65+ (61.5% vs. 56.5% and 58.3%, p = 0.03). Actual use of chest x-rays (considering both referral and adherence) was more likely when the radiology facility was in the same health centre or city than when it was outside the city [OR = 2.4; 95% CI: 2.1-2.8]; patients aged 65 + or 40-64 were more likely to adhere to the referral for x-ray than those aged 18-39 [OR = 1.3; 95% CI: 1.1-1.6, OR = 1.2; 95% CI: 1.0-1.4, respectively]. CONCLUSION: Accessibility of radiology facilities seems to be an important factor associated with both doctors' decisions and patients' adherence to the referral for chest x-rays.

Detection of Hepatitis D Virus: Performance in the Community.

BACKGROUND: Hepatitis D virus may cause a disease at various severities in the presence of hepatitis B virus, using hepatitis B surface antigen (HBsAg) on the external envelope in its replication process. Thus, people identified with HBsAg in blood tests should also be tested for hepatitis D virus. OBJECTIVES: To describe the situation of performance of blood tests for detection of hepatitis D virus in patients positive for hepatitis surface antigen during 9 years in a population with heterogeneous origins in the north region of Israel. METHODS: We conducted a retrospective study using the database of Clalit Health Services. RESULTS: We found 3367 people were positive for HBsAg during the study period; 613 (18%) were tested for hepatitis D. People who tested for hepatitis D were younger (47.3 ± 15 years vs. 50.5) and showed a higher rate of visiting the gastroenterology clinic (80.6% vs. 41%). The rate of positive blood tests for hepatitis D was too small for analysis, but it still demonstrated tendency for higher rates in the Ethiopian Jewish group. CONCLUSIONS: The recommendation for performance of blood test for hepatitis D virus was followed to a small extent. Considering the ethnic diversity of the population in Israel, activities to raise rates of performance should be considered.

Medical student lifestyle counselling for non-communicable disease: impact on students' competence and patients' health behaviors.

BACKGROUND: Promoting healthy lifestyle is key to tackling lifestyle-induced diseases, yet many doctors feel unskilled and medical schools lack its inclusion in their curricula. The impact of a novel elective lifestyle course is described, where students provided 3 months' coaching to at-risk patients. METHODS: Students' attitudes, competence and lifestyle were assessed pre- and post the 18-month course. Patients' health measures and behaviors were measured. Student and patient views were ascertained. RESULTS: Nineteen students, 13 controls, and 29 patients participated. Perception of physicians' importance as lifestyle consultants increased in coaching students (mean ± SD 3.7 ± 0.4 vs. 3.2 ± 0.5; p = 0.05). Self-perceived competence remained high in coaching students (6.7 ± 1.8 vs. 6.7 ± 1.2; p = 0.66). Controls' competence increased but did not attain coaching students' levels (3.6 ± 2.1 vs. 5.5 ± 1.9; p = 0.009). Focus groups of students confirmed self-perceived acquisition of skills. More patients exercised (38% vs. 82.7%; p = 0.001); spent more time in physical activity (median mins/week + IQR) 25 + [0.180] vs. 120 + [45,300]; p = 0.039), and avoided less desirable foods, such as unhealthy snacks, sweets and drinks. LDL cholesterol showed declining trend. Patients highlighted students' empathy and attentiveness; satisfaction was extremely high. CONCLUSIONS: The course successfully enhanced students' counselling skills, with beneficial effects for patients. This model for teaching experience-based lifestyle medicine has potential policy implications in terms of promoting effective lifestyle counselling by future physicians.

Prescribing Analgesics for Low Back Pain: Is There a Gender Difference?

Background: Gender differences have been described in many fields of pain. However, research is inconclusive as to gender difference in pain management. Our study aimed to investigate gender differences in prescribing analgesics for low back pain. Methods: We designed a cross-sectional study based on data originated from computerized health records. We retrieved data on low back pain diagnosis, among patients aged 18-64 years during 2016. Visits due to trauma and fracture were excluded, as were visits of patients with known neoplasm, or neurological or congenital defects. Data included demographics and the analgesics prescribed. Results: The cohort comprised 45,479 patients; of them, 55% were women. The mean age was 42.9 ± 12.6 years. Analgesics were prescribed to 49% of the men and 47% of the women (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.03-1.11). The distribution of analgesics was similar between the genders: overall, 73% nonsteroidal anti-inflammatory drugs, 23% opioids, 4% other analgesics, mainly paracetamol and dipyrone. A higher proportion of men were prescribed strong opioids than women: 17% versus 8% (OR 2.36, 95% CI 2.03-2.75). Conclusion: Men and women were similarly prescribed analgesics for low back pain. Men were more likely than women to be prescribed strong opioids. Further research is needed to evaluate the outcomes of this differential treatment.

Occurrence of comorbidities in newly diagnosed type 2 diabetes patients and their impact after 11 years' follow-up.

The burden of type 2 diabetes is growing, not only through increased incidence, but also through its comorbidities. Concordant comorbidities for type 2 diabetes, such as cardiovascular diseases, are considered expected outcomes of the disease or disease complications, while discordant comorbidities are not considered to be directly related to type 2 diabetes and are less extensively addressed under diabetes management. Here we show that the combination of concordant and discordant comorbidities appears frequently in persons with diabetes (75%). Persons with combined comorbidities visited family physicians more than persons with discordant, concordant or no comorbidity (17.3 ± 10.2, 11.6 ± 6.5, 8.7 ± 6.8, 6.3 ± 6.6 visits/person/year respectively, p < 0.0001). The risk of death during the study period was highest in persons with combined comorbidities and discordant only comorbidities (HR = 33.4; 95% CI 12.5-89.2 and HR = 33.5; 95% CI 11.7-95.8), emphasizing the contribution of discordant comorbidities to the outcome. Our study is unique as a long-term follow-up of an 11-year cohort of 9725 persons with new-onset type 2 diabetes. The findings highlight the contribution of discordant comorbidity to the burden of the disease. The high prevalence of the combination of both concordant and discordant comorbidities, and their appearance before the onset of type 2 diabetes, indicates a continuum of morbidity.

Uptake of pneumococcal vaccination in older people in northern Israel.

The 23-valent pneumococcal vaccine is recommended for people aged 65 years and over, to prevent pneumonia, a leading cause of infectious morbidity in older people. This study assessed pneumococcal vaccination in people aged 65-74 years living in northern Israel who were eligible for the pneumococcal vaccine since introduction free of charge. This retrospective study used the database of Clalit Health Services, the largest health maintenance organization in Israel. We fitted a Cox regression model to assess associations of vaccine uptake with sociodemographic and clinical characteristics, and a Wilcoxon rank-sum test and Chi-square test to assess associations of vaccine uptake with the performance of other health-related activities. The analysis included 20,591 people. People aged 65-70 were more likely to take the vaccine than people aged 71-74 [HR = 1.8; CI: 1.6-1.9]. Jews were more likely to take it than Arabs [HR = 1.1; CI: 1.0-1.2], and men were more likely to take it than women [HR = 1.1; CI: 1.0-1.2]. In women who took the vaccine, the rate of performance of mammography was higher (61.9 % ± 45.3 vs 50.3% ± 44.5, p < 0.0001). A similar trend was found for men and women with respect to occult blood tests (36.3% ± 31.5 vs 31.7% ± 30, p < 0.0001). Frequency of visits to family medicine clinics was negatively associated with vaccination. Uptake of the pneumococcal vaccine was associated with some parameters indicative of self-care but not with the level of exposure to the primary health care staff. After-hours health promotion activities by trained personnel may be an effective way to cope with the gap in performance.

Randomized trial results of alerting primary clinicians to severe weight loss among older adults in the Low Indexes of Metabolism Intervention Trial part A.

AIM: To test whether alerting clinicians to severe weight loss in older patients leads to higher dietitian visit rates, to higher body mass index (BMI) levels and, mainly, to lower annual death risk. METHODS: The randomized controlled trial included patients aged ≥75 years, with BMI ≤23 kg/m2 that decreased ≥2 kg/m2 during the previous 2 years. All participants received usual care. Additionally, an email alert was sent only to clinicians of participants assigned to the email alert group. The follow-up period was 12 months. RESULTS: Among 706 participants (mean age 83 ± 6 years; mean baseline BMI 20.5 kg/m2 ), the BMI record was updated in 541 (77%) participants, and 123 participants died. Dietitian visits were reported for 22 patients (6%) in the email group (n = 362) and 14 patients (4%) in the control group (n = 344; OR 1.5, 95% CI 0.8-2.9; P = 0.24). Measured BMI were raised by a mean of 0.69 (95% CI 0.43-0.95) kg/m2 versus 0.79 (95% CI 0.48-1.1) kg/m2 (P = 0.63). A total of 77 patients (21%) died in the intervention group versus 47 (14%) in the control group (P = 0.008; number needed to harm = 13; 95% CI 7-43). CONCLUSIONS: In this trial, alerting clinical staff to severe weight loss in patients aged ≥75 years was not associated with higher visit rates to a dietitian or change in BMI, but was associated with a significantly higher death rate than usual clinical care. Geriatr Gerontol Int 2020; 20: 329-335.

A Randomized Trial of Alerting to Hypocholesterolemia Results of the Low Indexes of Metabolism Intervention Trial-C (LIMIT-C).

OBJECTIVES: The benefit of alerting clinical staff to drug-induced hypocholesterolemia in patients aged 75 years and older remains uncertain. DESIGN, SETTING, AND PARTICIPANTS: The study included 1791 patients with serum cholesterol <160 mg/dL and on cholesterol-lowering drugs who were assigned to have an e-mail alert sent to their physician, and 1804 patients who were assigned to receive usual clinical care (control group). The primary outcome of the trial was annual death rate. Secondary outcomes included cholesterol-lowering drug dose reduction and emergency department (ED) visits. RESULTS: At 1 year, 58 patients (3.2%) in the intervention group and 61 (3.4%) in the control group had died [relative risk 0.94, 95% confidence interval (CI) 0.66-1.34; P = .74]. Quarter-averaged cholesterol-lowering drug defined daily doses were reduced by -13.5 ± 47.0 (-17% ± 60%) in the intervention group and by -5.1 ± 42.2 (-6%±54%) in the control group (difference -8.5 ± 1.5, 95% CI -5.5 to -11.4; P < .0001). Annual ED visit rates per 1000 patients were 291 in the intervention group and 336 in the control group (45 fewer visits per 1000 patients in the intervention group, 95% CI -1 to -89; P = .04). CONCLUSIONS AND IMPLICATIONS: In this trial, alerting clinical staff to hypocholesterolemia in patients aged 75 years and older being treated with cholesterol-lowering drugs was associated with mildly reduced cholesterol-lowering drugs doses and marginally reduced ED visit rates. This e-mail alert intervention was not associated with a significant difference in 1-year survival rate compared with usual clinical care.

A Randomized Trial of Alerting to Low Glycated Hemoglobin Level in Older Adults: Results of the Low Indexes of Metabolism Intervention Trial B (LIMIT-B).

OBJECTIVES: The benefit of alerting clinical staff to low plasma glycated hemoglobin (HbA1c) in patients aged 75 years and older who receive antidiabetic drugs remains uncertain. DESIGN, SETTING, AND PARTICIPANTS: In a randomized controlled trial, 1684 patients with HbA1c ≤ 6.5% who received antidiabetic drugs were assigned to have an e-mail alert sent to their physician, and 1643 were assigned to have no such alert (control group). The primary outcome of the trial was annual death. Secondary outcomes included antidiabetic drug dose reduction and HbA1c change. RESULTS: In the first quarter, antidiabetic drug-defined daily doses were reduced on average by 10.4 ± 35.8 (16% ± 55%) in the intervention group and by 6.4 ± 36.1 (10% ± 56%) in the control group (difference -4.1 ± 1.2, 95% confidence interval [CI] -6.5 to -1.6; P = .001). Measured HbA1c levels were raised by a mean (± standard deviation) of 0.28 ± 0.77 in the intervention group and by 0.18 ± 0.57 in the control group (difference 0.10 ± 0.02, 95% CI -0.15 to -0.059, P < .001). One year after the alerts, 121 patients (7.2%) died in the intervention group and 107 patients (6.5%) died in the control group (relative risk 1.1, 95% CI 0.86-1.42; P = .44). CONCLUSIONS AND IMPLICATIONS: In this trial, alerting clinical staff to low HbA1c in patients aged 75 years and older treated with antidiabetic medicines was associated with mildly reduced antidiabetic doses and increased HbA1c but was not associated with a significant difference in survival rate compared with usual clinical care.

Statin Use Over 65 Years of Age and All-Cause Mortality: A 10-Year Follow-Up of 19 518 People.

OBJECTIVES: As life expectancy continues to rise, the burden of cardiovascular disease among older people is expected to increase, making cardiovascular prevention in older people an issue of growing interest and public health importance. We aimed to explore the long-term effects of adherence to statins on mortality and cardiovascular morbidity among older adults. DESIGN: A historical population-based cohort study using routinely collected data. SETTING: Clalit Health Services Northern District. PARTICIPANTS: We followed members of Clalit Health Services aged 65 years or older who were eligible for primary cardiovascular prevention for a period of 10 years. MEASUREMENTS: We fitted Cox regression models to assess the association between the adherence to statin therapy and all-cause mortality and cardiovascular morbidity, adjusting for cardiovascular risk factors and associated morbidity as time-updated variables. RESULTS: The analysis included 19 518 older adults followed during 10 years (median = 9.7 y). All-cause mortality rates were 34% lower among those who had adhered to statin treatment, compared with those who had not (hazard ratio [HR] = .66; 95% confidence interval [CI] = .56-.79). Adherence to statins was also associated with fewer atherosclerotic cardiovascular disease events (HR = .80; 95% CI = .71-.81). The benefit of statin use did not diminish among beyond age 75 and was evident for both women and men. CONCLUSION: Adherence to statins may be associated with reduced mortality and cardiovascular morbidity among older adults, regardless of age and sex. J Am Geriatr Soc 67:2038-2044, 2019.

The low indexes of metabolism intervention trial (LIMIT): design and baseline data of a randomized controlled clinical trial to evaluate how alerting primary care teams to low metabolic values, could affect the health of patients aged 75 or older.

BACKGROUND: Too-low body mass index (BMI), HbA1c% or cholesterol levels predicts poor survival. This study investigates whether e-mails about these low values, improve health of people older than 75 years. METHODS: LIMIT - an open label randomized trial - compares usual care to the addition of an e-mail which alerts the family physicians and nurses to low metabolic indexes of a specific patient and advises on nutritional and medical changes. PARTICIPANTS: Clalit Health Services (CHS) patients in the Northern and Southern Districts, aged ≥75 years with any of the following inclusion criteria: a. Significant weight loss: BMI < 23 kg/m2 with BMI drop of ≥2 kg/m2 during previous two years and without dietitian counseling during previous year. b. Tight diabetic control: HbA1c% ≤ 6.5% and received anti-diabetic medicines during previous 2 months. c. Drug associated hypocholesterolemia: total cholesterol <160 mg/dL and received cholesterol-lowering medicines during previous 2 months. Excluded from criterion c, were patients diagnosed with either ischemic heart disease, transient ischemic attack or stroke. The primary outcome was death from any cause, within one year. In a population of 48,623 people over the age of 75 years, 8584 (17.7%) patients were identified with low metabolic indices and were randomized to intervention or control groups. E-mails were sent on November 2015 to physicians and nurses at 383 clinics. DISCUSSION: Low metabolic reserve is common in people in Israel's peripheral districts aged ≥75 years. LIMIT may show whether alerting primary care staff is beneficial. TRIAL REGISTRATION: ClinicalTrials.gov NCT02476578 . Registered on June 11, 2015.

[THE SCHIZOPHRENIC PATIENT IN THE DEPARTMENT OF MEDICINE IN THE 21ST CENTURY: IS THERE ANYTHING NEW UNDER THE SUN?]

INTRODUCTION: A retrospective analysis of information from the computerized data of the Emek Medical Center (EMC) and Clalit Community Healthcare Services (CCHS) was conducted. Two hundred and seventy-five SPs and four hundred and twenty eight NPPs were enrolled in the study. AIMS: Patients returning to the emergency room, and re-hospitalizations in the internal medicine wards. BACKGROUND: Schizophrenic patients (SPs) are at risk for organic co-morbidities and tend to be excessively hospitalized in medical departments. It is important to understand the pattern of SP re-admissions to emergency rooms and medical departments in order to avoid re-hospitalizations. OBJECTIVES: To compare re-admissions to medical emergency rooms and medical departments between SP and non-psychiatric patients (NPPs) and to assess the changes that took place during the years 2001-2011. RESULTS: The likelihood that SPs would be referred to the ER during the first 6 months after discharge was 1.51 (95% CI 1.10-2.07), higher than in NPPs. The likelihood of being re-hospitalized in medical departments during the first 6 months after discharge was higher in SPs but did not reach statistical significance (26.18% among SPs vs.20.09% among NPPs (P = 0.059). The time from the index hospitalization to re-hospitalization during the first year was shorter in the SPs when compared with NPPs (P=0.0032). CONCLUSIONS: Medical patients with schizophrenia tend to be referred to the medical emergency room and to be re-hospitalized after their index hospitalization. The integration of medical and psychiatric systems may improve their medical care and reduce their re-admission rates.

Evaluation of telehealth service for patients with congestive heart failure in the north of Israel.

AIMS: This research was conducted to evaluate the impact of a telehealth service on re-hospitalization of patients with congestive heart failure at New York Heart Association II-IV. METHODS AND RESULTS: The telehealth service for congestive heart failure patients was designed to follow the patients after their daily weighing and to provide a response in cases of non-compliance or deviation from baseline weight. A weighing scale was installed in the patient's house together with a communication module connected to the telemedicine control centre through a telephone line. The control centre is staffed by skilled nurses whose responses to patients are guided by programmed algorithm. Over a year, we evaluated the changes in the frequency of hospital admission and of primary care visits, and quality of life of 141 individuals who were eligible for the telehealth service for congestive heart failure. A decline was noted in the average number of hospitalizations per patient (from 4.7 to 2.6, p < 0.001). Scores of parameters of quality of life were improved (average score for first through fourth quarterly administration: 64, 50, 16, 16, p < 0.001 by the Minnesota Living with Heart Failure Questionnaire). CONCLUSIONS: During the year of use in telehealth service for congestive heart failure parameters of hospitalization were improved, together with parameters of quality of life.

Teaching internal medicine in the community.

BACKGROUND: Teaching Internal Medicine is mainly hospital-based. Chronic diseases are treated mostly in community-based ambulatory care. This study describes our experience during the first year of teaching Internal Medicine in the community, with a focus on chronic disease management. METHODS: This was an observational study describing the content of clinical exposure and the feedback from students after a two-week clerkship in community health centers. RESULTS: Over a period of three months, 54 students spent two weeks in health centers singly or in pairs. The disciplines covered were: Endocrinology, Gastroenterology, Pulmonology, Rheumatology and Geriatrics. In their feedback, the students most frequently noted knowledge acquired in the management of diabetes, infectious diseases and cardiology. The teaching content was determined by the case-mix of patients. The spectrum of conditions was wide. Students who were used to more structured hospital-based study found it difficult to cope with this mode of learning by discovery. DISCUSSION: Future research should concentrate on the transition between the different modes of learning as students move from the hospital to the community setting.

Management of kidney disease in patients with diabetes in the primary care setting.

AIMS: To evaluate the performance of general practitioners (GPs) in the care of diabetic patients in areas represented or unrepresented by quality indicators. METHODS: An observational study in primary care practices. The study population was comprised of GPs who cared for 1799 patients with diabetes mellitus co-existing with stage 3 chronic kidney disease, hypertension, and cardiovascular disease. The performance of GPs was monitored twice during a 6-month interval using a regional computerized clinical data base according to the measurement and treatment of blood pressure, LDL-cholesterol level, proteinuria, hematuria, and anemia. RESULTS: Those parameters which were familiar to the GPs for several years as part of the Quality Indicators Program (QIP) were measured and treated at a high rate compared to parameters not included in the QIP. For example, measurement of blood pressure and testing for glycosylated hemoglobin were 99% and 98% respectively at the end point. In contrast the rate of performance of specific kidney disease-focused activities, such as referral of patients with proteinuria to nephrologic consultation was 36% at the end point. CONCLUSION: Good performance in areas monitored by Quality Indicators does not imply good quality of care in other areas for the same patients. Attention should be paid to initiating activities to raise the awareness of GPs with respect to important health parameters which are not included in the Quality Indicators Program.

Knowledge and health literacy are not associated with osteoporotic medication adherence, however income is, in Arab postmenopausal women.

OBJECTIVE: To investigate the association between adherence with oral bisphosphonate treatment, income, health literacy, knowledge, and receiving instructions from a pharmacist or doctor, among Arab postmenopausal women diagnosed with osteoporosis in Israel. METHODS: Arab osteoporotic women treated with oral bisphosphonates were interviewed (303 women). The questionnaire included socio-demographic characteristics, knowledge about osteoporosis and health literacy. Adherence was measured by the Medication Possession Ratio (MPR) according to the number of prescription refills registered in the database of Clalit Health Services. RESULTS: Forty-one percent of the women were adherent according to the MPR. The main predictor of adherence in a multivariate logistic regression was income. Health literacy and knowledge were not associated with adherence after adjustment for income. Neither was the health care provider's counseling regarding the medication. CONCLUSIONS: Lower income seems to be a barrier to adherence with osteoporotic medication, over and above other known barriers. Policy makers should take into account that medication funding may be a barrier to treatment. Practical implications Income may be a major barrier to adherance with osteoporosis medication and calls for attention of practiciner.

Patients' perceptions of radical prostatectomy for localized prostate cancer: a qualitative study.

BACKGROUND: Radical prostatectomy is one option for treating localized prostate cancer, but it can cause functional impairment of the urogenital system. OBJECTIVES: To describe the outcomes of radical prostatectomy as perceived by the patients, and their ways of coping with them. METHODS: We conducted a qualitative study of 22 men with localized prostatic cancer 1 year after surgery. The key questions related to the effect of the disease and the surgery on their lives and their view on the value of the surgery. RESULTS: The surgery was perceived as a necessary solution for the diagnosed cancer. All the participants suffered from varying degrees of urinary incontinence and erectile dysfunction. Urinary incontinence caused severe suffering. The impaired sexual ability affected relations with partners and led to feelings of shame and guilt and a decreased sense of self-esteem. In retrospect, the participants still viewed the surgery as a life-saving procedure. Faith in the surgeon contributed to their affirmation of the decision to undergo surgery despite the difficulties. CONCLUSIONS: Patients were prepared to suffer the inevitable physical and psychological sequelae of radical prostatectomy because they believed the surgery to be a definitive solution for cancer. Surgeons advising patients with localized prostatic cancer on treatment options should address these difficult issues and provide psychological support, either themselves or in collaboration with professionals.