Determinants of physical activity habit formation: a theory-based qualitative study among young adults.

PURPOSE: Engagement in physical activity significantly contributes to reducing the onset and severity of chronic diseases. Nonetheless, establishing habits around this behaviour remains a persistent challenge. This research endeavours to discern the determinants influencing the formation of physical activity habit among young adults in Israel, drawing upon a socio-ecological model. METHODS: A qualitative approach with phenomenological-hermeneutical method was used. In-depth interviews were carried to cover four levels of the socio-ecological model. RESULTS: Interviewees were categorized into three subgroups according to their physical activity habit strength: Habitually physically active (n = 8), Variably physically active (n = 11), and physically inactive (n = 6). The content analysis yielded four overarching themes associated with physical activity habit formation. Intrapersonal determinants encompassed personal traits, perceptions and attitudes, perceived benefits, and emotional responses related to physical activity. Interpersonal determinants encompassed social support, modelling support, and peer pressure. Community determinants pertained to social norms, resource availability, and accessibility. Finally, public policy considerations encompassed educational policies as well as workplace policies and cultural influences. CONCLUSIONS: This study highlights the unique determinants contributing to the formation of physical activity habit. As intrapersonal and interpersonal factors are significant determinants, interventions should focus on these elements in order to promote this behaviour among young adults.

Unique patterns of healthcare utilization following the opening of the Samson Assuta Ashdod University Hospital.

Our aim was to examine the influence of the market entry of Samson Assuta Ashdod University Hospital on community and hospital-based healthcare utilization (HCU). A retrospective study was conducted among Maccabi Health Services enrollees in the regions of Ashdod (n = 94,575) and Netanya (control group, n = 80,200) before and after this market entry. Based on difference-in-differences framework, we examined the change in HCU of Ashdod region's enrollees compared to the control group and following the market entry using multivariable generalized estimating equations models. Our results revealed that, as hypothesized, after the market entry and compared to the control group, there was a 4% increase in specialists visits not requiring referral (RR = 1.04, 95% CI 1.03-1.06, p < 0.001), a 4% increase in MRI and CT scans (RR = 1.04, 95% CI 1.01-1.08, p = 0.022), and a 33% increase in emergency room visits (RR = 1.33, 95% CI 1.29-1.38, p < 0.001). Unexpectedly, no changes were observed in the number of hospital admissions (RR = 1.05, 95% CI 0.97-1.14, p = 0.250), and hospitalization days (RR = 0.99, 95% CI 0.94-1.04, p = 0.668). Moreover, and unexpectedly, there was a 1% decrease in primary care physician visits (RR = 0.99, 95% CI 0.98-1.00, p = 0.002), a 11% decrease in specialists visits requiring a referral (RR = 0.89, 95% CI 0.86-0.91, p < 0.001), and a 42% decrease in elective surgeries (RR = 0.58, 95% CI 0.55-0.60, p < 0.001). We conclude that this market entry was not translated to an increase in utilization of all services. The unique model of maintaining the continuity of care that was adopted by the hospital and patients' loyalty may led to the unique inter-relationship between the hospital and community care.

Context-Specific Estimation of Future Unrelated Medical Costs and Their Impact on Cost-Effectiveness Analyses.

OBJECTIVES: This study constructed and applied procedures for the estimation of unrelated future medical costs (UFMC) of women with breast cancer in Israel (as a case study) and examined the influence of including UFMC in cost-effectiveness analyses (CEAs). METHODS: Part I consisted of a retrospective cohort study based on patient-level claims data of both patients with breast cancer and matched controls during 14 years of follow-up. UFMC were estimated as (a) the annual average all-cause healthcare costs of the control subjects, and (b) as predicted values based on a generalized linear model (GLM) adjusted to patients' characteristics. Part II consisted of a CEA performed using a Markov simulation model comparing regimens of chemotherapy with/without trastuzumab, both excluding and including UFMC and for each of the UFMC estimates separately. All costs were adjusted to 2019 prices. Costs and QALYs were discounted at a yearly rate of 3%. RESULTS: The average annual healthcare costs in the control group were $2328 (± $5662). The corresponding incremental cost-effectiveness ratio (ICER) was $53,411/QALY and $55,903/QALY, when UFMC were excluded or included, respectively. Hence, trastuzumab was not considered cost-effective compared with a threshold of willingness-to-pay of $37,000 per QALY, regardless of the inclusion of UFMC. When UFMC were estimated on the basis of the prediction model, the ICERs were $37,968/QALY and $39,033/QALY, when UFMC were excluded or included, respectively. Thus, in this simulation, trastuzumab was not considered cost-effective, independent of the inclusion of UFMC. CONCLUSION: Our case study revealed that the inclusion of UFMC had modest effect on the ICERs, and thus did not alter the conclusion. Thus, we should estimate context-specific UFMC if they are expected to change the ICERs significantly, and transparently report the corresponding assumptions to uphold the integrity and reliability of the economic evaluation.

The association between normal 50-g glucose challenge test results and risk for future metabolic morbidities: A retrospective cohort study.

OBJECTIVE: To study the association between normal glucose challenge test (GCT) results during pregnancy and the incidence of future maternal metabolic morbidities. METHOD: This was a population-based retrospective cohort study conducted between the years 2005 and 2020. The study included all women aged 17-55 years who underwent GCT as part of the routine prenatal care at the Central District of Clalit Health Services, Israel. The highest GCT result per woman was categorized into five study groups: <120 (reference), 120-129, 130-139, 140-149, and ≥150 mg/dL. Adjusted hazard ratios of the study groups for metabolic morbidities were calculated with Cox proportional survival analysis models. RESULTS: Among a total of 77 568 women participants, 53%, 12.3%, and 10.3% had normal GCT results of <120, 120-129, and 130-139 mg/dL, respectively. During the study period of 6.07 ± 4.35 years, 13 151 (17.0%) cases of metabolic morbidities were documented. High-normal GCT results of 120-129 and 130-139 mg/dL were significantly associated with increased risk for future metabolic morbidity compared with <120 mg/dL (adjusted hazard ratio [aHR] 1.15, 95% confidence interval [CI] 1.08-1.22 and aHR 1.32, 95% CI 1.24-1.41, respectively). CONCLUSION: Although GCT is only recommended as a screening tool for gestational diabetes mellitus, high results, even within the normal range, may point to maternal increased risk for future metabolic morbidity.

Incremental Costs and Diners' Satisfaction Associated with Improvement in Nutritional Value of Catering Dishes.

Eating in catering systems has been identified as a driver of poor diet quality. Interventions within catering systems increase the nutrient density of dishes. Little is known about the incremental costs associated with this strategy. One part of the NEKST (Nutrition Environmental Kibbutzim Study) intervention was nutritional improvement of recipes (decreasing the amount of energy, sodium, and saturated fat). We evaluated the nutritional content of dishes per 100 g and the incremental costs associated with these changes from the catering system's perspective, as well as diners' satisfaction with the catering system before and after the intervention. Our results revealed that as energy and saturated fat decreased, the associated incremental cost increased (rs = −0.593, p = 0.010 and rs = −0.748, p < 0.001, respectively). However, the decrease in sodium was not associated with increased costs (rs = 0.099, p = 0.696). While diners' satisfaction decreased in the control group, it did not change in the intervention group following the intervention (p = 0.018). We concluded that recipe modification improved the nutritional value of dishes without increasing cost. This intervention was not associated with decreased diner satisfaction. This evidence encourages the implementation of policies to improve the nutritional quality of food served by caterers without jeopardizing sales and with the potential to improve public health.

Factors Involved in the Food Choices of Diners in a Kibbutz Communal Dining Room Buffet: A Qualitative Study.

Improving nutrition improves health outcomes. Eating in a catering system may provide an environment for promoting healthy dietary choices. To map the factors that shape the food choices of diners who routinely eat in catering systems, we collected and analyzed qualitative data about diners' perceptions of their food choices in communal dining rooms in three kibbutzim in Israel. From May to July 2014, we conducted in-depth, semi-structured, face-to-face interviews with 13 diners who ate at least three lunches per week in the kibbutz's dining room. Data analysis followed thematic analysis principles. Two categories of themes emerged from the interviews. In the personal context category, the themes identified were eating as a task and attempts to control one's eating. In the contextual aspects of eating in the catering system category, themes identified were eating in the dining room as a default, the characteristics of the food served, routine, and personal versus public aspects. The sub-theme of the diners' freedom of choice emerged in the two categories of themes. Diners' wishes of maintaining their freedom of choice may be an important contribution to the debate of whether catering systems should provide only healthy foods, which may jeopardize diners' freedom of choice.

The impact of a community-based heart failure multidisciplinary team clinic on healthcare utilization and costs.

AIMS: Multidisciplinary team (MDT) management in heart failure (HF) is recommended to reduce mortality and HF hospitalization. We investigated whether an MDT in a community-based HF unit (HFU) impacted patients' healthcare utilization (HCU) and costs. METHODS AND RESULTS: A retrospective cohort study was conducted among HF patients who visited at least once in a regional community-based HFU, established for ambulatory specialist care for New York Heart Association Functional Classes III and IV, between January 2012 and August 2019. HCU data were obtained from the health maintenance organization's claims data for 12 months before and after first HFU visit. Multivariable generalized estimating equation models were specified for the annual average change in total healthcare utilization and hospitalization costs. Our cohort consisted of 962 patients, of whom 843 (87.6%) completed at least 12 months of follow-up (Group A) and 119 (12.4%) died within 12 months following their first visit (Group B). Both groups were comparable regarding sex, socio-economic status, Charlson Comorbidity Index, ischaemic heart disease, and/or carotid artery disease. Those who died within 12 months were older and had more hypertension, diabetes, chronic renal disease, and malignancy. There was a significant reduction in the total average annual HCU costs of the entire study population 12 months after the first HFU visit [$12 675 (±17 210) after vs. $13 188 (±15 011) before, P = 0.014]. This was driven by a reduction in costs among patients who completed 12 months of follow-up [$11 955 (±17 352) after vs. $13 112 (±15 268) before, P < 0.001], whereas an increase in these costs was observed among patients who died during follow-up [$17 774 (±15 292) after vs. $13 728 (±13 093) before, P = 0.015]. These opposite trends stem mainly from a decrease [$3540 (±8991) after vs. $4941 (±6806) before, P < 0.001] vs. increase [$10 932 (±11 660) after vs. $6733 (±7215) before, P = 0.002] in hospitalization costs of these groups, respectively. The multivariable models revealed that patients who died within 12 months following the first visit to the HFU demonstrated a significant increase of 57% in hospitalization costs following their first visit [relative risk (RR) = 1.57, 95% confidence interval (CI): 1.20-2.05, P = 0.001], whereas there was a decrease of 34% in the hospitalization costs of patients who completed 12 months of follow-up after their first visit (RR = 0.66, 95% CI: 0.54-0.81, P < 0.001). The entire cohort demonstrated 27% decrease in hospitalization costs following their first HFU visit (RR = 0.73, 95% CI: 0.62-0.87, P < 0.001). CONCLUSIONS: Intensification of therapy by a dedicated MDT significantly reduced healthcare utilization and costs, predominantly due to a decrease in hospitalizations.

Overuse of reliever inhalers and associated healthcare utilization of asthma patients.

Global Initiative for Asthma 2019 guidelines recommend to avoid strengthening patients' reliance on relievers since they increase exacerbation risk. Our aim was to examine the association between reliever inhalers overuse and all-cause healthcare utilization (HCU). A retrospective study among Clalit Health Services (CHS) adult enrollees (n = 977) for 2012-2017. Reliever inhalers overuse was defined as consistent prescription refills of ≥ 3 canisters annually. Adherence to controllers was calculated using the proportion of days covered. HCU included: hospitalizations, diagnostic and surgical procedures, medications, emergency room (ER) visits, and clinic visits. 27% of the study population (n = 264) consistently refilled ≥ 3 relievers prescriptions annually, and had higher adherence to controllers (0.38 vs. 0.24, p < 0.001). Their total 6-year HCU costs were not higher than that of others ($5,550 vs. $5,562, p = 0.107). Most HCU components [including hospitalization (p = 0.405) and ER visits (p = 0.884)] were comparable; however, medication costs were higher ($1734 vs. $1504, p < 0.001). A multivariable ordered-logit model revealed that frequent and regular use of relievers was not associated with higher HCU costs (OR = 0.82, 95% CI 0.62-1.09, p = 0.175). Higher adherence to maintenance and reliever therapy (OR = 2.18, 95% CI 1.44-3.28, p < 0.001), other controllers (OR = 3.30, 95% CI 2.11-5.16, p < 0.001), and nebulized SABAs and SAMAs (OR = 1.08, 95% CI 1.02-1.14, p = 0.007) was associated with higher costs. Overuse of reliever inhalers was prevalent and associated with higher adherence to controllers, yet not associated with higher all-cause HCU. This highlights the need to examine the sources of elevated usage in order to develop intervention strategies to optimize pharmaceutical therapy of asthma patients.

Improvement in Healthy Meal Index, Lunch Quality, and Diversity Scores Following an Integrated Nutritional Intervention in a Communal Dining Room: The NEKST Study.

The objective of the NEKST (Nutrition Environmental Kibbutzim Study), a nonrandomized interventional study, was to evaluate the effect of an integrated intervention program on participants' lunch quality and diversity in two communal dining rooms (intervention n = 58 vs. control n = 54). The intervention included recipe modification, environmental changes, and an education program. The outcomes included simple healthy meal index (SHMI), lunch quality (LQS), and diversity scores (LDS) calculated based on photographs of lunch trays. A nutrition questionnaire assessed the changes in fruit and vegetable intake at baseline and 3 months following the intervention. The mean SHMI, LQS, and LDS increased in the intervention group (0.51, p < 0.001; 0.27, p = 0.045; 0.95, p < 0.001, respectively) but not in the control group (p = 0.865; p = 0.339; p = 0.354, respectively). Multivariable linear models demonstrate an increase in the SHMI (ß = 0.26, 95% CI [0.12-0.76], p = 0.015), LQS (ß = 0.23, 95% CI [0.06-0.83], p = 0.024), and LDS (ß = 0.34, 95% CI [0.41-1.39], p < 0.001) of the participants in the intervention group. More participants in the intervention group raised their daily fruit intake compared with the control. We conclude that this integrated intervention program was effective in improving lunch healthy meal index, quality, and diversity in a communal dining room, with a modest halo effect of the intervention throughout the day.

The effect of regulatory focus and time preference on the dual process of physical activity: A cross-sectional study among nurses.

AIMS: To examine the dual process of physical activity adoption among nurses and its relationships with two personal orientations-regulatory focus-the tendency to focus on promotion (vs. prevention) goals and time preference as measured by delay discounting: the tendency to overvalue immediate rewards over long-term ones. BACKGROUND: The dual process theory suggests that both conscious and non-conscious processes influence the adoption of physical activity. However, the role of regulatory focus and time preference in this process was not yet examined. DESIGN: A cross-sectional online survey among 143 nurses during August-November 2017. METHODS: Validated measures were used to estimate physical activity habit strength (a non-conscious process) and intention, planning and behaviour control (conscious processes), physical activity level, regulatory focus and time preference. Multivariable ordered logit and logistic models were specified to examine determinants of both processes. RESULTS: Promotion focus was positively associated with having a strong habit of physical activity among nurses with moderate-to-low activity levels, but it was negatively associated with habit for active nurses. As for time preference, higher delay discounting was negatively associated with nurses' conscious intention to adopt physical activity and with their action planning. CONCLUSION: Promotion focus and time preference are associated with both conscious and non-conscious processes of physical activity adoption among nurses and should be considered in future health promotion interventions targeted to this population. IMPACT: Promotion focus and time preference have a significant role in this dual process. Enhancing physical activity of health providers by adjusting the intervention to personal orientations may improve public health.

Healthcare utilization of breast cancer patients following telephone-based consultations of oncology nurse navigator via telemedical care.

OBJECTIVES: To characterize breast cancer patients who received telephone-based consultations of oncology nurse navigator via telemedical care (TMC patients) and analyze their healthcare utilization (HCU) one year before and after receiving this service. METHODS: A retrospective study among Maccabi Healthcare Services enrollees that were newly diagnosed during 2016 (n = 1035). HCU, demographic characteristics and comorbidities were obtained from computerized database. Multivariable ordered logit model was specified for the determinants of HCU by quarters. Independent variables included: annual number of telephone-based consultations, gap between diagnosis and first consultation, age, socio-economic status, eligibility for disability and income security benefits, and comorbidities. RESULTS: Twenty-two percent of our cohort were TMC patients. Compared to others, these patients were younger and had a lower prevalence of hypertension. A higher proportion of these patients received disability benefits, and a lower proportion received income security benefits. The total average annual HCU of TMC patients (n = 107) before first consultation was $8857 and increased to $44130 in the first year following it (p<0.001), predominantly due to a significant increase in outpatient visits ($20380 vs. $3502, p<0.001) and medication costs ($19339 vs. $1758, p<0.001). The multivariable model revealed that each additional telephone-based consultation decreased the likelihood to be in the lowest quarter of the HCU distribution by 1.1 percentage points (p = 0.015), and increased the likelihood to be in the upper quarter of the HCU distribution by 1.1 percentage points (p = 0.016). CONCLUSIONS: There was a significant increase in outpatient care and medications usage following first consultation. Moreover, a more intense use of this service was associated with elevated HCU. This result may stem from the proactive nature of the telemedical care.

Adherence of patients with type 2 diabetes mellitus to medications: the role of risk preferences.

OBJECTIVE: To examine whether risk tolerance is associated with adherence to oral hypoglycemic agents (OHAs). METHODS: We performed a cross-sectional study among adult patients with type 2 diabetes mellitus (n = 308) presenting for routine out-patient visits, using validated questionnaires to estimate: risk preferences (risk-seeking, risk averse, risk neutral), motivation, self-efficacy, impulsivity, perception of the disease and of the interpersonal process of care, demographic and socioeconomic characteristics; computerized patient medical records to estimate disease severity and a computerized database for retrieval of medication adherence, 1 year before the interview. Adherence was estimated using prescription-based measures of proportion of days covered (PDC). Concurrent adherence was calculated as: PDC with ≥1 OHAs; average PDC; PDC of ≥80% for all OHAs. RESULTS: Multivariable ordered logit model revealed that compared to others, risk-seeking patients had lower PDC with ≥1 OHAs (ß = -0.50, p ≤ .1). Specifically, risk-seeking patients were 11.2 percentage points less likely to have ≥80% of the follow-up period covered with ≥1 OHAs available (p ≤ .1). In addition, risk-seeking patients had lower average PDC (ß = -0.85, p ≤ .05). Specifically, these patients were 19.5 percentage points less likely to have an average PDC of ≥80% (p ≤ .05). Multivariable logistic model revealed that risk-seeking was associated with lower probability of having PDC ≥80% for all OHAs in the follow-up period (OR; 90% CI: 0.59; 0.35-0.97). CONCLUSIONS: Risk-seeking patients are less adherent to OHA medications. Identifying these patients may enable practitioners to proactively tailor strategies to improve their adherence and health outcomes.

Adherence to Self-Care Behaviors among Patients with Type 2 Diabetes-The Role of Risk Preferences.

OBJECTIVES: To examine whether the degree of risk aversion is associated with adherence to disease self-management among adults with type 2 diabetes. METHODS: This was a cross-sectional study of patients with type 2 diabetes (n = 408) aged 21 to 70 years who presented for routine visits in the diabetes clinic at a university medical center in Beer-Sheva, Israel. The authors used validated questionnaires to estimate adherence, risk preferences, motivation, self-efficacy, impulsivity, perceptions about the disease and the interpersonal process of care, and demographic and socioeconomic characteristics, in addition to retrieving data from computerized patient medical records of clinical indicators of disease severity. Multivariable linear and ordered-logit models examined predictors of adherence to each self-care behavior. RESULTS: Multivariable analyses revealed that, compared with others, risk-seeking patients reported lower general adherence (ß = -0.32; P ≤ 0.05), and specifically, lower adherence to healthful eating plan (ß = -0.48; P ≤ 0.1), consumption of low-fat food (ß = -0.47; P ≤ 0.1), exercise (ß = -0.73; P ≤ 0.05), blood glucose monitoring (ß = -0.69; P ≤ 0.05), and foot care (ß = -0.36; P ≤ 0.1). Risk-seeking patients did not report lower consumption of fruits and vegetables (ß = -0.19; P > 0.1). Because 96% of the study population reported optimal adherence to medication, determinants of this behavior could not be analyzed. CONCLUSIONS: Risk preference is associated with adherence to self-care behaviors. Identifying risk seekers may enable practitioners to target these patients with tailored strategies to improve adherence, thus more efficiently allocating scarce health care resources.

The influence of healthcare workers' occupation on Health Promoting Lifestyle Profile.

To compare the adoption of healthy lifestyle behaviors, including: spiritual growth, nutrition, physical activity, interpersonal relations, health responsibility, and stress management, of healthcare workers with workers of other professions. Cross-sectional observational study among a convenience sample of 285 healthcare workers and 137 of other professions. The Health-Promoting Lifestyle Profile-II (HPLP-II), a 52-item measure regarding the six components of healthy lifestyle. Demographic characteristics, education, income, work duration and self-rated health were also collected. Multivariable linear models were specified for each of the components of healthy lifestyle. Both groups were comparable in their age, family status, income and self-rated health. Results of multivariable linear models revealed that healthcare workers adopt better nutrition (ß=0.228, p<0.001), more physical activity (ß=0.133, p=0.049), and greater health responsibility (ß=0.131, p=0.016), compared to other professions. Such differences were not found with regard to spiritual growth (ß=0.097, p=0.121), interpersonal relations (ß=0.039, p=0.444), or stress management (ß=0.053, p=0.299). Healthcare workers adopt better healthy lifestyle only in components that may be perceived to have direct influence on health outcomes, namely nutrition, physical activity, and health responsibility. Further research that will explore the reasons for the observed differences may enable designing health-improving interventions.

Cost-effectiveness of adherence-enhancing interventions: a systematic review.

Low patient adherence to health-related interventions is a major barrier to achieving healthcare goals and is associated with very high avoidable costs. Although several studies suggest that adherence-enhancing interventions can improve health outcomes, economic evaluations of these interventions are scarce. Systematic reviews published to date are limited to interventions to enhance adherence to pharmaceuticals or to specific diseases and interventions. The authors' objective was to examine the evidence regarding the cost-effectiveness of adherence-enhancing interventions in healthcare and what conclusion could be drawn about these interventions. The present systematic review included 43 original studies and assessed the current evidence regarding the cost-effectiveness of a broad array of interventions aimed at enhancing adherence to medications, medical devices, screening tests and lifestyle behaviors. The authors found that although the majority of adherence-enhancing interventions were cost-effective or cost-saving, variation exists within different intervention types. Further research on the sustainability of adherence improvements is needed in order to accurately evaluate interventions' long-term benefits.

Regulatory focus and adherence to self-care behaviors among adults with type 2 diabetes.

The aims of this study were, first, to test the association between regulatory focus of adults with type 2 diabetes and their adherence to two types of self-care behaviors - lifestyle change (e.g. physical activity and diet) and medical care regimens (blood-glucose monitoring, foot care and medication usage). Second, to explore whether a fit between the message framing and patients' regulatory focus would improve their intentions to adhere specifically when the type of behavior fits the patients' regulatory focus as well. A cross-sectional study was conducted among 130 adults with type 2 diabetes who were hospitalized in an academic medical center. The patients completed a set of questionnaires that included their diabetes self-care activities, regulatory focus, self-esteem and demographic, socioeconomic and clinical data. In addition, participants were exposed to either a gain-framed or a loss-framed message, and were then asked to indicate their intention to improve adherence to self-care behaviors. A multivariable linear regression model revealed that promoters reported higher adherence to lifestyle change behaviors than preventers did (B = .60, p = .028). However, no effect of regulatory focus on adherence to medical care regimens was found (B = .46, p = .114). In addition, preventers reported higher intentions to adhere to medical care behaviors when the message framing was congruent with prevention focus (B = 1.16, p = .023). However, promoters did not report higher intentions to adhere to lifestyle behaviors when the message framing was congruent with promotion focus (B = -.16, p = .765). These findings justify the need to develop tailor-made interventions that are adjusted to both patients' regulatory focus and type of health behavior.

The association between adherence to cardiovascular medications and healthcare utilization.

BACKGROUND: Poor adherence to medications for cardiovascular disease (CVD) is associated with adverse health outcomes, but little is known about its association with healthcare utilization (HCU). OBJECTIVE: To examine whether adherence is associated with a long-term decrease in HCU. METHODS: This is a retrospective cohort study of 1582 patients with CVD who enrolled in Maccabi Healthcare Services in Israel, initiating CVD medication therapy in 2006. Adherence was assessed by the proportion of days covered (PDC) with medications. Patients were defined as: non-adherent (PDC <0.4), partially adherent (0.4 ≤ PDC < 0.8), and fully adherent (PDC ≥0.8). HCU was estimated for 4 years following treatment initiation. Multivariable GEE models were used to analyze predictors of HCU. Model I included total adherence during the entire follow-up period as well as the interaction between this measure and the follow-up year. Model II included previous and current year's adherence as well as previous year's HCU cost. Both models were adjusted for potential confounders including: patient's age, gender, socioeconomic status, ownership of voluntary supplementary health insurance, and comorbidities. RESULTS: The median age of patients was 63 (69 % males). Fifty-four percent of patients (n = 860) were defined as adherent, 24 % as partially adherent and 22 % as non-adherent. Model I: the annual HCU costs of adherent patients decreased by 10 % following treatment initiation [rate ratio (RR) = 0.90, 95 % confidence interval (CI) 0.86-0.94, P < 0.001]. This decrease stemmed predominantly from reduction in hospitalization costs. No significant changes in annual costs following treatment initiation were observed among partially adherent (RR = 1.00, 95 % CI 0.90-1.10, P = 0.935) and non-adherent (RR = 0.98, 95 % CI 0.87-1.10, P = 0.681) patients. Model II: no temporal association was found between adherence and HCU. CONCLUSIONS: Adherence to CVD medications is relatively low. Adherence is associated with long-term decrease in healthcare expenditure. Exploring reasons for the high non-adherence and ways to improve adherence may optimize utilization of health systems' scarce resources.

The Price of a Neglected Zoonosis: Case-Control Study to Estimate Healthcare Utilization Costs of Human Brucellosis.

Human brucellosis has reemerged as a serious public health threat to the Bedouin population of southern Israel in recent years. Little is known about its economic implications derived from elevated healthcare utilization (HCU). Our objective was to estimate the HCU costs associated with human brucellosis from the insurer perspective. A case-control retrospective study was conducted among Clalit Health Services (CHS) enrollees. Brucellosis cases were defined as individuals that were diagnosed with brucellosis at the Clinical Microbiology Laboratory of Soroka University Medical Center in the 2010-2012 period (n = 470). Control subjects were randomly selected and matched 1:3 by age, sex, clinic, and primary physician (n = 1,410). HCU data, demographic characteristics and comorbidities were obtained from CHS computerized database. Mean±SD age of the brucellosis cases was 26.6±17.6 years. 63% were male and 85% were Bedouins. No significant difference in Charlson comorbidity index was found between brucellosis cases and controls (0.41 vs. 0.45, respectively, P = 0.391). Before diagnosis (baseline), the average total annual HCU cost of brucellosis cases was slightly yet significantly higher than that of the control group ($439 vs. $382, P<0.05), however, no significant differences were found at baseline in the predominant components of HCU, i.e. hospitalizations, diagnostic procedures, and medications. At the year following diagnosis, the average total annual HCU costs of brucellosis cases was significantly higher than that of controls ($1,327 vs. $380, respectively, P<0.001). Most of the difference stems from 7.9 times higher hospitalization costs (p<0.001). Additional elevated costs were 3.6 times higher laboratory tests (P<0.001), 2.8 times higher emergency room visits (P<0.001), 1.8 times higher medication (P<0.001) and 1.3 times higher diagnostic procedures (P<0.001). We conclude that human brucellosis is associated with elevated HCU costs. Considering these results in cost-effective analyses may be crucial for both reducing health inequities and optimal allocation of health systems' scarce resources.

Medical loss ratio as a potential regulatory tool in the Israeli healthcare system.

BACKGROUND: The growth of the private health insurance sector in Western countries, which is characterized by information deficiencies and limited competition, necessitates the implementation of effective regulatory tools. One measure which is widely used is the medical loss ratio (MLR). Our objective was to analyze how MLR is applied as a regulatory measure in the Israeli voluntary health insurance (VHI) market in order to promote the protection of beneficiaries. The study will examine MLR values and the use of this tool by regulators of VHI in Israel. METHODS: Descriptive analysis using 2005-2012 data from public reports of the Ministry of Health and the Ministry of Finance on VHI plans in three market segments: nonprofit health plans, group (collective) policies offered by commercial insurance companies and individual policies offered by commercial insurance companies. RESULTS: In 2012, 74% of the Israeli population owned VHI provided by nonprofit health plans and 43% owned VHI offered by for-profit commercial companies. At that time the MLRs of three nonprofit health plans were significantly lower than 80%, mostly in the upper layers of coverage. The MLR in the individual commercial segment was consistently low (38% in 2012). The use of MLR as a regulation tool was, and continues to be, relatively limited in all segments. CONCLUSION: The VHI in Israel covers several essential services that are not covered by the statutory benefits package as a result of budget constraints. Thus, due to the high penetration rate of VHI in Israel compared to European countries and the lower levels of MLR, in order to assure the protection of beneficiaries it may be warranted to increase the extent of regulation and adjust it to the nature of the services covered. This may include distinguishing between essential and nonessential coverages and implementation of the most suitable regulatory measures (such as an MLR threshold, limitation of services covered and adjusting the actuarial models to the beneficiaries' behavior), rather than focusing only on assuring solvency.

Tiotropium as part of inhaled polytherapy: adherence and associated health-care utilization.

BACKGROUND AND OBJECTIVE: Previous studies had demonstrated association between Tiotropium therapy (once-daily inhaled anticholinergic) and reductions of exacerbations, improvements in dyspnoea and quality of life in chronic obstructive pulmonary disease (COPD) patients. Little is known about the influence of adherence to Tiotropium on health-care utilization. Our objective was to examine whether adherence to Tiotropium is associated with decreased health-care utilization. METHODS: A computerized medical database was used to identify patients with COPD registered in an academic pulmonology institute who began therapy of Tiotropium 18 mg between 2008 and 2011 (n = 193). Adherence was assessed by calculating the proportion of days covered and defined as coverage of at least 80% of the follow-up period. Adherence to long-acting beta-agonists and/or inhaled corticosteroids (LABA and/or ICS) and health-care utilization were analysed 1 year before and 2 years after initiation of Tiotropium. A multivariate regression model was applied to examine determinants of change in health-care utilization. RESULTS: The median age of study population was 67 (80% male). Forty-one percent of study population (n = 79) adhered to Tiotropium. Hospitalization costs decreased 1 year following treatment initiation only among adherent patient when their adherence to LABA and/or ICS improved (ß = -463.6, P = 0.033). This cost did not change significantly in the consecutive second year (ß = 206.3, P = 0.583). CONCLUSIONS: Adherence to Tiotropium was associated with decreased hospitalizations only among patients who improved their adherence to LABA and/or ICS as well. Exploring reasons for high non-adherence and ways to improve adherence may optimize utilization of the scarce hospital resources.