Depressive symptoms and use of health services among older adults in Israel.

OBJECTIVES: Depressive symptoms are often undetected, particularly among older adults. The purpose of this study is to provide information on the prevalence, characteristics, and patterns of depressive symptoms among older adults residing in the community in Israel, and their health-care utilization. METHODS: A cross-sectional survey was conducted among a random sample of 2502 members of one HMO in Israel, aged 65+. They were interviewed by telephone with the GDS-15 scale, which serves as the gold standard for depressive symptoms. Data from the computerized medical records of the HMO were added to the interview file, including the diagnosis of depression, purchase of antidepressant medication and use of services. RESULTS: The average age of respondents was 73; 54% were women. They tended to be older, living alone, suffering from falls and from sleep disorders, and to have poor subjective health status. 24% scored 6+ on the GDS scale. A significant association was found between a GDS score of 6+ and increased hospitalizations, visits to the emergency room and/or to family physicians and specialists. CONCLUSION: We found a high prevalence of depression. Its negative effects on the individual and increased costs to the health system, supports the screening and treatment of the disease in the older population. This problem should be a national priority, with screening and treatment becoming part of the national quality of care indicators which would then be implemented by the HMOs as part of an integrated disease management program for the elderly.

Adapting and Evaluating a Health System Intervention From Kaiser Permanente to Improve Hypertension Management and Control in a Large Network of Safety-Net Clinics.

BACKGROUND: Nearly half of Americans with diagnosed hypertension have uncontrolled blood pressure (BP) while some integrated healthcare systems, such as Kaiser Permanente Northern California, have achieved control rates upwards 90%. METHODS AND RESULTS: We adapted Kaiser Permanente's evidence-based treatment protocols in a racially and ethnically diverse population at 12 safety-net clinics in the San Francisco Health Network. The intervention consisted of 4 elements: a hypertension registry, a simplified treatment intensification protocol that included fixed-dose combination medications containing diuretics, standardized BP measurement protocol, and BP check visits led by registered nurse and pharmacist staff. The study population comprised patients with hypertension who made ≥1 primary care visits within the past 24 months (n=15 917) and had a recorded BP measurement within the past 12 months. We conducted a postintervention time series analysis from August 2014 to August 2016 to assess the effect of the intervention on BP control for 24 months for the pilot site and for 15 months for 11 other San Francisco Health Network clinics combined. Secondary outcomes were changes in use of guideline-recommended medication prescribing. Rates of BP control increased at the pilot site (68%-74%; P<0.01) and the 11 other San Francisco Health Network clinic sites (69%-74%; P<0.01). Statistically significant improvements in BP control rates (P<0.01) at the 11 San Francisco Health Network clinic sites occurred in all racial and ethnic groups (blacks, 60%-66%; whites, 69%-75%; Latinos, 67%-72%; Asians, 78%-82%). Use of fixed-dose combination medications increased from 10% to 13% (P<0.01), and the percentage of angiotensin-converting enzyme inhibitor prescriptions dispensed in combination with a thiazide diuretic increased from 36% to 40% (P<0.01). CONCLUSIONS: Evidence-based system approaches to improving BP control can be implemented in safety-net settings and could play a pivotal role in achieving improved population BP control and reducing hypertension disparities.

Harvard Pilgrim's Patrick Cahill Tries To Make Sense of It All.

The 40-year-old vice president of regional markets for eastern Massachusetts wants enrollees and, especially, employers to know that there will continue to be a lot of public policy change as the ACA evolves. His course? Keep strengthening ties with providers.

A Hospital Is Not Just a Factory, but a Complex Adaptive System-Implications for Perioperative Care.

Many methods used to improve hospital and perioperative services productivity and quality of care have assumed that the hospital is essentially a factory, and therefore, that industrial engineering and manufacturing-derived redesign approaches such as Six Sigma and Lean can be applied to hospitals and perioperative services just as they have been applied in factories. However, a hospital is not merely a factory but also a complex adaptive system (CAS). The hospital CAS has many subsystems, with perioperative care being an important one for which concepts of factory redesign are frequently advocated. In this article, we argue that applying only factory approaches such as lean methodologies or process standardization to complex systems such as perioperative care could account for difficulties and/or failures in improving performance in care delivery. Within perioperative services, only noncomplex/low-variance surgical episodes are amenable to manufacturing-based redesign. On the other hand, complex surgery/high-variance cases and preoperative segmentation (the process of distinguishing between normal and complex cases) can be viewed as CAS-like. These systems tend to self-organize, often resist or react unpredictably to attempts at control, and therefore require application of CAS principles to modify system behavior. We describe 2 examples of perioperative redesign to illustrate the concepts outlined above. These examples present complementary and contrasting cases from 2 leading delivery systems. The Mayo Clinic example illustrates the application of manufacturing-based redesign principles to a factory-like (high-volume, low-risk, and mature practice) clinical program, while the Kaiser Permanente example illustrates the application of both manufacturing-based and self-organization-based approaches to programs and processes that are not factory-like but CAS-like. In this article, we describe how factory-like processes and CAS can coexist within a hospital and how self-organization-based approaches can be used to improve care delivery in many situations where manufacturing-based approaches may not be appropriate.

Policy entrepreneurship and policy networks in healthcare systems - the case of Israel's pediatric dentistry reform.

BACKGROUND: Can the entry of a policy entrepreneur challenge the equilibrium of a policy network and promote changes that might clash with the goals of powerful civil-servants and/or interest groups and, if so, why and how? Our goal is to examine two sides of the same coin: how does an in-depth analysis of Israel's dental care reform enrich our understanding of policy networks and policy entrepreneurship? Second, how does the literature on policy networks and policy entrepreneurship help us understand this reform? Based on a theoretical framework that appears in the literature of policy entrepreneurship and policy networks, we analyze the motivations, goals and strategies of the main actors involved in the process of reforming pediatric dental care in Israel. We demonstrate how a policy entrepreneur navigated within a policy network and managed to promote a reform that, until his appearance, no one else in that network had succeeded in enacting. METHODS: Our goals are advanced through a case study of a reform in pediatric dentistry implemented in Israel in 2010. It rests on textual analyses of the literature, reports, committee minutes, parliamentary proceedings, print and online media, and updates in relevant legislation and case law between 2009 and 2015. In addition, the case study draws on the insights of one of the authors (TH), who played a role in the reform process. RESULTS: Historical circumstances and the Israeli public's longstanding lack of interest in changing the existing model as well as interest groups that preferred the dominance of the private sector in the dental healthcare system kept that area out of the services supplied, universally, under the National Health Insurance Law. This situation changed significantly following the publication in 2007 of a policy analysis that contributed to shifts in the motivations and balance of power within the policy network, which in turn prepared the ground for a policy change. In this environment a determined policy entrepreneur, who identified a window of opportunity, took the lead and instituted an innovative and far-reaching reform. CONCLUSIONS: A policy entrepreneur can leverage external factors as well as the previous activities of a policy network that has already matured to create a policy change. Such entrepreneurial activity includes maneuvering around opponents and overcoming resistance from various stakeholders.

Extracting and analyzing ejection fraction values from electronic echocardiography reports in a large health maintenance organization.

The left ventricular ejection fraction value is an important prognostic indicator of cardiovascular outcomes including morbidity and mortality and is often used clinically to indicate severity of heart disease. However, it is usually reported in free-text echocardiography reports. We developed and validated a computerized algorithm to extract ejection fraction values from echocardiography reports and applied the algorithm to a large volume of unstructured echocardiography reports between 1995 and 2011 in a large health maintenance organization. A total of 621,856 echocardiography reports with a description of ejection fraction values or systolic functions were identified, of which 70 percent contained numeric ejection fraction values and the rest (30%) were text descriptions explicitly indicating the systolic left ventricular function. The 12.1 percent (16.0% for male and 8.4% for female) of these extracted ejection fraction values are <45 percent. Validation conducted based on a random sample of 200 reports yielded 95.0 percent sensitivity and 96.9 percent positive predictive value.

Who is Using Telehealth in Primary Care? Safety Net Clinics and Health Maintenance Organizations (HMOs).

Despite rapid advancements in telehealth services, only 15% of family physicians in a 2014 survey reported using telehealth; use varied widely according to the physician's practice setting or designation. Users were significantly more likely than nonusers to work in federally designated "safety net" clinics and health maintenance organizations (HMOs) but not more likely than nonusers to report working in a patient-centered medical home (PCMH) or accountable care organization.

Investing in Obesity Treatment: Kaiser Permanente's Approach to Chronic Disease Management.

Kaiser Permanente, an integrated health care delivery system in the USA, takes a "whole systems" approach to the chronic disease of obesity that begins with efforts to prevent it by modifying the environment in communities and schools. Aggressive case-finding and substantial investment in intensive lifestyle modification programs target individuals at high risk of diabetes and other weight-related conditions. Kaiser Permanente regions are increasingly standardizing their approach when patients with obesity require treatment intensification using medically supervised diets, prescription medication to treat obesity, or weight loss surgery.

Reporting on the Strategies Needed to Implement Proven Interventions: An Example From a "Real-World" Cross-Setting Implementation Study.

UNLABELLED: The objective of this study was to empirically demonstrate the use of a new framework for describing the strategies used to implement quality improvement interventions and provide an example that others may follow. Implementation strategies are the specific approaches, methods, structures, and resources used to introduce and encourage uptake of a given intervention's components. Such strategies have not been regularly reported in descriptions of interventions' effectiveness, or in assessments of how proven interventions are implemented in new settings. This lack of reporting may hinder efforts to successfully translate effective interventions into "real-world" practice. A recently published framework was designed to standardize reporting on implementation strategies in the implementation science literature. We applied this framework to describe the strategies used to implement a single intervention in its original commercial care setting, and when implemented in community health centers from September 2010 through May 2015. Per this framework, the target (clinic staff) and outcome (prescribing rates) remained the same across settings; the actor, action, temporality, and dose were adapted to fit local context. The framework proved helpful in articulating which of the implementation strategies were kept constant and which were tailored to fit diverse settings, and simplified our reporting of their effects. Researchers should consider consistently reporting this information, which could be crucial to the success or failure of implementing proven interventions effectively across diverse care settings. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02299791.

Do Health Care Delivery System Reforms Improve Value? The Jury Is Still Out.

BACKGROUND: Widespread restructuring of health delivery systems is underway in the United States to reduce costs and improve the quality of health care. OBJECTIVE: To describe studies evaluating the impact of system-level interventions (incentives and delivery structures) on the value of US health care, defined as the balance between quality and cost. RESEARCH DESIGN: We identified articles in PubMed (2003 to July 2014) using keywords identified through an iterative process, with reference and author tracking. We searched tables of contents of relevant journals from August 2014 through 11 August 2015 to update our sample. SUBJECTS: We included prospective or retrospective studies of system-level changes, with a control, reporting both quality and either cost or utilization of resources. MEASURES: Data about study design, study quality, and outcomes was extracted by one reviewer and checked by a second. RESULTS: Thirty reports of 28 interventions were included. Interventions included patient-centered medical home implementations (n=12), pay-for-performance programs (n=10), and mixed interventions (n=6); no other intervention types were identified. Most reports (n=19) described both cost and utilization outcomes. Quality, cost, and utilization outcomes varied widely; many improvements were small and process outcomes predominated. Improved value (improved quality with stable or lower cost/utilization or stable quality with lower cost/utilization) was seen in 23 reports; 1 showed decreased value, and 6 showed unchanged, unclear, or mixed results.Study limitations included variability among specific endpoints reported, inconsistent methodologies, and lack of full adjustment in some observational trials. Lack of standardized MeSH terms was also a challenge in the search. CONCLUSIONS: On balance, the literature suggests that health system reforms can improve value. However, this finding is tempered by the varying outcomes evaluated across studies with little documented improvement in outcome quality measures. Standardized measures of value would facilitate assessment of the impact of interventions across studies and better estimates of the broad impact of system change.

Looking at Graduate Medical Education Through a Different Lens: A Health Care System's Perspective.

In the era of the accountable care organization, U.S. models of physician practice are shifting from the solo, independent practitioner to the physician who is part of a multispecialty group practice or is employed by a health care institution, and from paper-based small offices to practice settings that emphasize technology-enabled, team-based systems of care. In this light, Kaiser Permanente's (KP's) long experience as an integrated, population-based health care delivery system makes it an increasingly relevant model in which to consider how graduate medical education (GME) can best prepare physicians for 21st-century health care. KP's multiple perspectives-as a GME setting, a health care delivery system, a health research enterprise, a community benefit organization, and the nation's largest private, multispecialty group practice of physicians-provide a multifaceted opportunity to consider GME in the context of health care transformation. The authors suggest that all participants in medical education have a role to play in preparing physicians for this future. They recommend that partnerships between universities and health care delivery systems serve as a highly effective model for education; that to better serve the needs of society, medical education institutions must adopt a broad community benefit mindset; and that, when medical groups and other institutions that employ physicians take the baton from GME, they need to commit to ongoing development and lifelong learning to enable their new physicians to reach their full potential.

[Declared dead? Recommendations regarding integrated care from the perspective of German statutory health insurance]. / Totgesagte leben länger : Empfehlungen zur Integrierten Versorgung aus Sicht der gesetzlichen Krankenkassen.

The traditional separation of health care into sectors in Germany causes communication problems that hinder continuous, patient-oriented care. This is most evident in the transition from inpatient to outpatient care. That said, there are also breaks in the flow of information, a lack of supply, or even incorrect information flowing within same-sector care. The transition from a division of functions into sectors to a patient-oriented process represents a change in the paradigm of health care that can only be successfully completed with considerable effort. Germany's statutory health insurance (SHI) funds play a key role here, as they are the contracting parties as well as the financiers of integrated care, and are strategically located at the center of the development process.The objective of this article is to explore how Germany's SHI funds view integrated care, what they regard as being the drivers of and barriers to transitioning to such a system, and what recommendations they can provide with regard to the further development of integrated care. For this purpose semi-structured interviews with board members and those responsible for implementing integrated care into the operations of ten SHI funds representing more than half of Germany's SHI-insured population were conducted. According to the interviewees, a better framework for integrated care urgently needs to be developed and rendered more receptive to innovation.Only in this way will the widespread stagnation of the past several years be overcome. The deregulation of § 140a-d SGB V and the establishment of a uniform basis for new forms of care in terms of a new innovation clause are among the central recommendations of this article. The German federal government's innovation fund was met with great hope, but also implied risks. Nonetheless, the new law designed to strengthen health care overall generated high expectations.

[Health care networks in Germany: status quo and key success factors]. / Den Kinderschuhen entwachsen - Arztnetze in Deutschland leisten wertvollen Beitrag zur Optimierung der lokalen Versorgungssituation.

One third of all practicing physicians are currently working in one of the 400 German health care networks. These physicians' networks bring together GPs and specialists and cooperate with different partners, for example, nursing homes, hospitals, and self-help groups. To increase the quality and the efficiency of care and patient satisfaction by improving the collaboration and communication between physicians and other health care providers.The example of the accountable care organization "Gesundheitsnetz Qualität und Effizienz" (QuE; Health Quality and Efficiency Network) in Nuremberg is used to show that it is possible to achieve an increase in efficiency while providing above-average quality of care and achieving high patient satisfaction. Additionally, the article deals with the status quo, the core objectives, and the key activities of previous generations of health care networks. Quality indicators, satisfaction surveys, and economic parameters are the basis for measuring and representing the above-average performance of physicians' networks. Regional health care networks offer an entire range of patient care, from outpatients and inpatients to the complementary sector, and thereby have excellent prospects for playing an even more important role in the German health care system. The key success factors are: the consideration of specific regional characteristics, their proximity to the patient, and consistent patient orientation.

[Pursuing the triple aim: evaluation of the integrated care system Gesundes Kinzigtal: population health, patient experience and cost-effectiveness]. / Triple Aim - Evaluation in der Integrierten Versorgung Gesundes Kinzigtal - Gesundheitszustand, Versorgungserleben und Wirtschaftlichkeit.

BACKGROUND: The integrated care system Gesundes Kinzigtal (ICSGK), one of the most comprehensive population-based ICS in Germany, started its work nearly 9 years ago. The ICSGK is pursuing the Triple Aim: improving the health of the population, improving the individual's experience of care, and at the same time reducing the per capita costs of care. OBJECTIVES: To evaluate the impact of the ICSGK on the Triple Aim. MATERIALS AND METHODS: The ICSGK is being evaluated externally and internally via a mix of diverse quantitative and qualitative methods. This paper presents selected results for each Triple Aim dimension. RESULTS AND CONCLUSIONS: Regarding population health, most of the quality indicators examined by the external scientific evaluation show positive development. For example, the prevalence of patients with fractures among all insurants with osteoporosis is presented. In 2011, this prevalence was approximately 26 % in the "Kinzigtal" population (aged ≥ 20 years old) in comparison to 33 % in the control group. As far as patient experience is concerned, to the question "Would you recommend becoming a member of Gesundes Kinzigtal to your friends or relatives?" 92.1 % of those questioned answered "Yes, for sure" or "Yes, probably." Twenty-four percent of those questioned further stated that they would now live "more healthy" than before enrolment in the ICSGK. In the subgroup of questioned insurants who had objective agreements with their doctors 45.4 % answered in this way. On the subject of cost-effectiveness, for both participating socil health insurance schemes, cost savings relative to the costs normally expected for the ICSGK population concerned are observed every year. In the seventh intervention year (2012) the total is 4.56 million Euros for the AOK Baden-Württemberg (BW), which is a contribution margin of 146 Euros per insurant for the 31.156 insurants concerned (LKK BW = 322 Euros per insurant relative to cost savings). The results presented in this paper indicate positive effects in all three Triple Aim dimensions. Further longitudinal studies are recommended to validate those first results together with a detailed analysis to obtain in-depth insights into the specific influence of subcomponents of the total intervention.

[Rationale and dissemination of "GP centered health care" ("HzV") in Germany]. / Rationale und Stand der hausarztzentrierten Versorgung in Deutschland.

BACKGROUND: In the face of demographic changes, the aging of the population, and the increase in chronic morbidity and complexity, efficient primary care is needed to ensure comprehensive and high-quality health care. The general practitioner (GP) can only cope with this task, if certain preconditions are met. OBJECTIVES: To strengthen primary health care, the German legislator added § 73b, "GP-centered health care" ("Hausarztzentrierte Versorgung", HzV) to the Social Code Book V. This article seeks to illustrate the rationale and general set-up of the HzV and to report on its dissemination. We discuss whether or not the HzV can promote the preconditions required. MATERIALS AND METHODS: Literature search, querying participants. RESULTS: Several elements of the HzV, such as lump-sum reimbursement, obligatory participation in structured quality circles, continuing education, and the qualification of non-medical health care assistants help to promote an environment that enables GPs to fulfill their new role. Considering all assured people and the Federal Republic as a whole, the distribution of the HzV is poor. However, a growing number of contracts (currently: 79) and participants (currently > 3.6 million) is expected. CONCLUSIONS: The establishment of efficient primary care is heavily promoted by the HzV. In future, ways must be found to overcome the inflexible borders between sectors and to integrate community-based health care, which truly focuses on the patients needs. The HzV can be seen as a starting point.

[The integration of telemedicine concepts in the regional care of rural areas: Possibilities, limitations, perspectives]. / Telemedizinische Versorgungskonzepte in der regionalen Versorgung ländlicher Gebiete : Möglichkeiten, Einschränkungen, Perspektiven.

In rural areas with a low population density and (imminent) gaps in regional health care, telemedicine concepts can be a promising option in supporting the supply of medical care.Telemedicine connections can be established between different health care providers (e.g., hospitals) or directly between health care providers and patients.Different scenarios for the implementation of telemedicine have been developed, from the monitoring of chronically ill patients to the support of acute care. Examples of frequently applied telemedicine concepts are teleradiology, telemedicine stroke networks, and the telemedicine monitoring of patients with heart failure. The development of concepts for other indications and patient groups is apparently difficult in Germany; one reason could be that research institutions are involved in only a small number of projects. However, the participation of research institutes would be of importance in creating more scientific evidence. The development of appropriate evaluation designs for analyzing the effectiveness of telemedicine concepts and economic effects is an important task and challenge for the future. Mandatory evaluation criteria should be developed to provide a basis for the translation of positively evaluated telemedicine concepts into routine care.

[Integrated stroke care]. / Integrierte Versorgung bei Schlaganfall.

The structures and processes of stroke care provision in the acute and chronic phases, during rehabilitation and societal integration, the needs of patients, and the means of meeting those needs are described and analyzed. Deficits mainly involve local multidisciplinary professional aid, focusing on participation under the supervision of a neurologist experienced in rehabilitation. Deficits are mainly caused by a lack of funding from statutory and private health insurance.