Intra-articular and soft-tissue corticosteroid injections and risk of infections: Population-based self-controlled-risk-interval design.

PURPOSE: Chronic and short-term treatment with oral corticosteroids is associated with an increased risk of infection. However, the potential risk of infection that may be associated with intra-articular and soft-tissue injections of corticosteroids has not been reported. The aim of this study was to assess the risk for infection following intra-articular or soft-tissue corticosteroid injections. METHODS: Self-controlled-risk-interval study with 15 732 adults who were treated with intra-articular or soft-tissue corticosteroid injections during 2015-2018. The study was conducted in a large Israeli Health Maintenance Organization. We self-matched the participants and analyzed the incidence of infection over three periods: an exposure-period of 90 days following the injection, and two 90-day control periods. We identified the occurrence of several common infections in the patient's electronic medical record and analyzed the incidence rates of all infections (composite end-point) as well as each infection separately. RESULTS: The incidence of any infection was higher during postexposure period compared with the control periods (46.5 vs. 42.1 events per 1000 persons), number needed to harm was 227 persons. Self-matching analysis showed increased incidence-rate-ratio (IRR) for the combined incidence of infections in the post-exposure period compared with the control periods (IRR = 1.10, 95% confidence interval [CI] 1.01-1.21). A sensitivity analysis showed that the highest IRR was during the first 30 days (IRR = 1.19, 95% CI 1.03-1.38), with higher IRR for patients aged 65 years and older (IRR = 1.37, 95% CI 1.08-1.73). CONCLUSIONS: Intra-articular and soft-tissue corticosteroids injections may be associated with an increased risk of infections; however, the absolute risk increase is low.

Continuity of care after attempted suicide: the primary care physicians' role.

BACKGROUND: Suicide prevention is an important public health concern, and primary care physicians (PCPs) often serve as the first point of contact for individuals at risk. Few interventions in the primary care setting have been linked to reduced suicide attempt (SA) rates. The Continuity of Care (COC) protocol was developed to improve the primary care treatment of high-risk suicidal patients. OBJECTIVES: This study examined PCPs' awareness of the COC protocol, its perceived effectiveness, and PCPs' attitudes towards post-SA-discharge visits. METHODS: A survey was administered to 64 PCPs who had a recent office visit with a patient who had attempted suicide. Data were collected between May and July 2021 and analyzed anonymously. RESULTS: Thirty of the 64 PCPs answered the questionnaires, giving a response rate of 47%. Most were unaware of the COC protocol. Seventeen physicians (57%) felt that the visit strengthened their physician-patient relationship, and while nearly half of the physicians (47%, n = 14) agreed they had the knowledge and tools to manage a post-SA-discharge visit, 43% of them (n = 13) preferred that the visit would have been handled by a mental health professional rather than a PCP. Analysis of open-ended questions uncovered three themes: knowledge gap, system limitation, and the PCP's role in maintaining the COC. CONCLUSION: The findings of this study highlighted the important role PCPs can play to prevent future SAs, as well as exposed gaps in the knowledge and system constraints that impede them from carrying out this role as effectively as possible.

Primary care physicians (PCPs) are often the first point of contact for individuals at risk of suicide and can play a critical role in suicide prevention. Our study examined the perceptions and attitudes of PCPs towards the Continuity of Care (COC) protocol, an intervention designed to improve primary care treatment of high-risk suicidal patients. The study surveyed 64 PCPs who had recently seen a patient who had attempted suicide, and 47% of them responded to the survey. While the study revealed areas for improvement, it also highlighted the perceived importance of the physician­patient relationship in preventing future suicide attempts. The study also revealed that many PCPs felt they had the knowledge and tools to manage a post-attempt discharge visit and that the visit strengthened their physician­patient relationship. However, the study also identified gaps in knowledge and system limitations that can impede PCPs from carrying out their role effectively. It is important to continue to improve training and support for PCPs in order to better equip them to handle high-risk suicidal patients and prevent future suicide attempts.

Primary care physicians' attitudes and knowledge regarding medical cannabis and willingness to prescribe it: the Israeli experience.

BACKGROUND: Use of medical cannabis (MC) in Israel has increased since its regulatory approval in 2016. Currently, more than 1% of Israeli adults are treated with MC; this requires primary care physicians (PCPs) to be familiar with this treatment option. OBJECTIVES: We assessed the attitudes and knowledge of Israeli PCPs toward MC and evaluated their willingness to prescribe it for different medical conditions. METHODS: A cross-sectional survey which was distributed to PCPs in Israel. Physicians were asked about their opinions, knowledge, and willingness to prescribe MC. RESULTS: Two hundred and one PCPs answered the questionnaire. Their average age was 47 years (±11.2), 71% were specialists. 51% of the respondents thought that MC is an effective treatment. 63% replied that they had little knowledge and 75% indicated that they would like to deepen it. 61% of the respondents were willing to initiate an MC treatment for a dying patient, while less than 50% were willing to initiate MC treatment for various other conditions. Most respondents indicated that they were willing to renew a prescription for any approved medical condition. Willingness to prescribe MC increased for physicians who agreed that MC was effective (odds ratio [OR] 21.9, 95% confidence interval [CI] 2.40-200.85), for physicians who strongly agreed with the statement that they had sufficient knowledge (OR 5.0, 95% CI 1.58-15.83) and for residents compared with specialists (OR 4.0, 95% CI 1.52-10.73). CONCLUSIONS: Our survey revealed PCPs' differing opinions and insufficient knowledge regarding treatment with MC. These findings suggest that continuing medical education regarding MC is needed.

Use of medical cannabis (MC) in Israel has increased substantially since its regulatory approval in 2016. Currently, more than 1% of Israeli adult population receive MC; this requires primary care physicians (PCPs) to be familiar with this treatment option. We assessed the attitudes and knowledge of Israeli PCPs toward MC and evaluated their willingness to prescribe it for different medical indications. Two hundred and one PCPs answered our questionnaire. 51% of the respondents thought that MC was an effective treatment. 63% of physicians stated that they had little knowledge regarding MC and 75% indicated that they would like to deepen it. 61% of the respondents were willing to initiate MC treatment for a dying patient, while less than 50% were willing to initiate MC treatment for other conditions. Willingness to initiate treatment with MC was low for most indications, while renewal was more acceptable. Our survey revealed PCPs' different opinions and insufficient knowledge regarding the utilization of MC in primary care. These findings emphasize the necessity for continuous medical education regarding MC.

Comparing assessment of diabetes-related quality of life between patients and their physicians.

BACKGROUND: Health-related quality of life (QoL) is a comprehensive, multidimensional construct encompassing physical and psychosocial wellbeing. Physicians frequently assess QoL as part of their decision making process without specifically asking their patients. This study examined the degree and predictors of concordance between physician and patient assessments of QoL among patients with diabetes in primary care and in multi-disciplinary diabetes clinics. METHODS: Patients completed a questionnaire regarding overall and diabetes-specific QoL before entering their physician's office. After the visit, the physician completed the same questionnaire in order to evaluate how he/she perceived that patient's QoL. In addition, medical data relating to the patient's health status were collected from the medical records. The concordance between patient-reported QoL and physician-estimated QoL was evaluated. Stepwise regression analysis was conducted to determine which factors contributed to the difference between physicians' and patients' assessment of QoL. RESULTS: A total of 136 patients and 39 treating physicians were surveyed. Patients' response rate was 95%. A strong concordance was found between patients' and physicians' ratings of current health status (r = 0.79, p < 0. 01); however, physicians perceived their patients' QoL as worse than the QoL assessed by the patients themselves. Primary care physicians were better at assessing their patients' overall wellbeing while diabetes-specialists were better at assessing their patients' diabetes-specific QoL. In addition, the longer the duration of diabetes, the more difficult is was for the physicians to accurately assess QoL. When entered in the regression analysis, familiarity did not explain physicians' ability to assess health-related QoL or diabetes-specific QoL. CONCLUSIONS: Physicians make reasonable assessments of their patients' QoL, however as the patients' disease progresses, it becomes harder for physicians to assess QoL. Primary care physicians are better at assessing overall well-being whereas diabetes specialists are better at assessing diabetes-specific QoL. TRIAL REGISTRATION NUMBER: Not registered. Assuta Medical Center institutional review board approval number 2009103.

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

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

The critical factors for COVID-19 vaccination uptake are perceived vaccine effectiveness and the desire to protect others.

The proportion of the population vaccinated in Israel against COVID-19 in 2021 was significantly higher than that of the annual uptake rates of the influenza vaccine over time. Understanding the reasons behind the high vaccination rate may facilitate maintaining these rates if annual COVID-19 vaccination is required. Using a mixed-methods design, we characterized the individuals who were vaccinated and studied their attitudes toward vaccines and motivators for the COVID-19 vaccine. The first part was a cross-sectional study of adults aged 65 and over who were vaccinated against COVID-19. We stratified them according to their annual influenza vaccination patterns, and compared variables such as age, gender, health status, and timing of COVID-19 vaccination. The second part consisted of a questionnaire administered to a subsample of the above population, inquiring about vaccine hesitancy, motivators for vaccination, and intention to be vaccinated in the future. We found that motivating factors for COVID-19 vaccination are similar between those who regularly vaccinate against influenza and those who don't. Internal motivators such as perceived vaccine effectiveness and the desire to protect others were stronger than external rewards or sanctions. High adherence to annual influenza vaccine recommendations was associated with earlier COVID-19 vaccine uptake. Respondents with lower adherence to influenza vaccines were more likely to demonstrate higher levels of vaccine hesitancy. These factors should be addressed in future vaccination campaigns.

The effect of the COVID-19 pandemic on primary care physicians in Israel, with comparison to an international cohort: a cross-sectional study.

BACKGROUND: The COVID-19 pandemic had a major impact on primary care and primary care physicians (PCPs) in Israel and around the world. There is paucity of information regarding treatment of patients with COVID-19 in the community, since most research was performed in hospitals. The aim of this study was to describe the Israeli PCPs' experience. METHODS: This study is a part of an international cross-sectional study, the PRICOV-19. A translated version of the questionnaire was distributed among Israeli PCPs from December 2020 to July 2021. In this study, we describe the Israeli results and compare them to the international results. RESULTS: 5,961 respondents from 29 countries answered the questionnaire, 94 from Israel, with an Israeli response rate of 16%. Israeli PCPs reported an increase in use of telemedicine from 11 to 49% during the COVID epidemic. PCPs also reported a decline in their wellbeing; absence of secured time slots for keeping updated; perception that the Ministry of Health guidelines were a threat to the staff wellbeing and organization of practice and delays in the examination of non-COVID urgent cases. CONCLUSIONS: The findings of this study raise concerns regarding the PCPs experience and may form the basis for an improved process of care. Guidelines for proper usage of telemedicine, substitutes for the physical examination and procedures for minimizing delayed patient examination for urgent conditions should be developed. Government directives and clinical guidelines should be communicated in a timely manner, with secured timeslots for physicians' self-learning or updating. Ensuring physicians' well-being in general should be an organization priority.

Real-world safety data for the Pfizer BNT162b2 SARS-CoV-2 vaccine: historical cohort study.

OBJECTIVE: The Pfizer BNT162b2 vaccine showed a reassuring safety profile in clinical trials, but real-world data are scarce. Bell's palsy, herpes zoster, Guillain-Barré syndrome (GBS) and other neurological complaints in proximity to vaccination have received special public attention. We compared their rates among vaccinated and unvaccinated individuals. METHODS: Individuals ≥16 years vaccinated with at least one dose of BNT162b2 were eligible for this historical cohort study in a health maintenance organization insuring 1.2 million citizens. Each vaccinee was matched to a non-vaccinated control by sex, age, population sector (general Jewish, Arab, ultra-orthodox Jewish) and comorbidities. Diagnosis of Covid-19 before or after vaccination was an exclusion criterion. The outcome was a diagnosis of Bell's palsy, GBS, herpes zoster or symptoms of numbness or tingling, coded in the visit diagnosis field using ICD-9 codes. Diagnoses of Bell's palsy and GBS were verified by individual file review. RESULTS: Of 406 148 individuals vaccinated during the study period, 394 609 (97.2%) were eligible (11 539 excluded). A total of 233 159 (59.1%) were matched with unvaccinated controls. Mean follow was 43 ± 15.14 days. In vaccinated and unvaccinated individuals there were 23 versus 24 cases of Bell's palsy (RR 0.96, CI 0.54-1.70), one versus zero cases of GBS, 151 versus 141 cases of herpes zoster (RR 1.07, CI 0.85-1.35) and 605 versus 497 cases of numbness or tingling (RR 1.22, CI 1.08-1.37), respectively. DISCUSSION: No association was found between vaccination, Bell's palsy, herpes zoster or GBS. Symptoms of numbness or tingling were more common among vaccinees. This study adds reassuring data regarding the safety of the BNT162b2 vaccine.

Gestational diabetes and risk of incident primary cancer: a large historical cohort study in Israel.

PURPOSE: Gestational diabetes mellitus (GDM), a state of glucose intolerance associated with pregnancy, is increasing in prevalence. Data regarding the cancer risk associated with GDM are sparse and limited to cancers of the breast and pancreas. This study was conducted to examine the risk of incident overall and site-specific malignancies associated with prior GDM in a historical cohort of women in a large health maintenance organization in Israel. METHODS: All pregnant women aged 15-50 years who underwent 50-g glucose challenge tests between 13 March 1995 and 27 May 2009, without history of malignancy, diabetes, and infertility, were included. Clinical and demographic parameters at index date including age, socioeconomic level, BMI, and parity were collected. Diagnosis of gestational diabetes was based on the 100-g oral glucose tolerance test using Carpenter and Coustan criteria. Cancer diagnoses were obtained from the Israel Cancer Register through linkage data. RESULTS: Among the 185,315 women who had undergone glucose challenge during the study period, 11,264 (6.1%) were diagnosed with GDM. During a total follow-up period of 1.05 million person-years (mean = 5.19 ± 3.9, median = 4.3), 2,034 incident cases of cancer were identified. GDM was associated with a hazard ratio (HR) of 7.06 (95% CI: 1.69-29.45) for pancreatic cancer (nine cases) and a HR of 1.70 (95% CI: 0.97-2.99) for hematological malignancies (177 cases). The association between GDM and hematological malignancies was limited to women with 5 or more years of follow-up (HR = 4.53; 95% CI: 1.81-11.31). CONCLUSION: GDM is associated with an increased risk of pancreatic cancer and hematologic malignancies.

Factors associated with hypertensive patients' compliance with recommended lifestyle behaviors.

BACKGROUND: A crucial element in controlling blood pressure is non-pharmaceutical treatment. However, only a few studies specifically address the question of hypertensive patients' compliance with physicians' recommendations for a healthy lifestyle. OBJECTIVES: To explore factors associated with hypertensive patients' compliance with lifestyle recommendations regarding physical activity, smoking cessation and proper diet. METHODS: We performed a secondary data analysis of a representative sample of 1125 hypertensive patients in Israel's two largest health funds. Data were collected in 2002-2003 by telephone interviews using structured questionnaires. The response rate was 77%. Bivariate and multivariate analysis was conducted. RESULTS: About half of the hypertensive patients reported doing regular exercise and adhering to a special diet; 13% were smokers. About half reported receiving counseling on smoking cessation and diet and a third on physical exercise. A quarter reported receiving explanations regarding self-measurement of blood pressure and signs of deterioration. Multivariate analysis revealed that patients' beliefs about hypertension management, their knowledge on hypertension and its management, and physician counseling on a healthy lifestyle and self-care, have an independent effect on compliance with recommended lifestyle behaviors. CONCLUSIONS: The low counseling rates suggest that there may be a need to improve physicians' counseling skills so that they will be more confident and effective in delivering this service to their patients. A model based on educating both physicians and patients may contribute to improving the care of hypertensive patients.

Glycemic Control and Risk of Cellulitis.

OBJECTIVE: We know that diabetes predisposes to common infections, such as cellulitis and pneumonia. However, the correlation between the level of glycemic control and the rate of infection is unknown. RESEARCH DESIGN AND METHODS: We examined the association between glycemic control in patients with diabetes and the incidence of infection in the entire population of patients with diabetes in a large HMO. During the study period, we first selected an HbA1c test for each patient and then searched for an infection diagnosis in the 60 days that followed the test. A multivariate logistic regression analysis was performed to determine the independent effect of HbA1c on the likelihood of being diagnosed with an infection. We were able to control for many confounders, such as other chronic illness, time since the diagnosis of diabetes, and use of steroids before the infection. RESULTS: We identified 407 cases of cellulitis. Multivariate logistic regressions for cellulitis showed a 1.4-fold increased risk among patients with HbA1c >7.5% (58 mmol/mol). Factors such as obesity, Parkinson's disease, peripheral vascular disease, and prior treatment with prednisone predisposed to cellulitis. There was an increase of 12% in the odds of cellulitis for every 1% (11 mmol/mol) elevation in HbA1c (odds ratio [OR] 1.12; CI 1.05-1.19). A similar analysis showed a trend toward an increased risk of pneumonia in patients with HbA1c >7.5% (58 mmol/mol) (OR 1.1; CI 0.9-1.4). CONCLUSIONS: Poor glycemic control was associated in this study with the development of cellulitis. The study also suggests that exposure to oral prednisolone increases the risk of cellulitis, pneumonia, and upper respiratory infection.

BNT162b2 Vaccine Effectiveness in Preventing Asymptomatic Infection With SARS-CoV-2 Virus: A Nationwide Historical Cohort Study.

BACKGROUND: There is strong evidence regarding the efficacy and effectiveness of the BNT162b2 vaccine in preventing symptomatic infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). There is a relative paucity of data regarding its effectiveness in the prevention of asymptomatic infection. METHODS: In this real-world observational study, we identified a subpopulation of individuals in a large health maintenance organization who were repeatedly tested for SARS-CoV-2 infection by polymerase chain reaction (PCR). We included these individuals in the study cohort and compared those who were vaccinated with BNT162b2 mRNA vaccine to unvaccinated individuals. A positive SARS-CoV-2 PCR test result was used as the outcome. The follow-up period was from January 1, 2021, until February 11, 2021. RESULTS: A total of 6286 individuals were included in the cohort. Seven days after the second vaccine dose, a rate of 6 positive PCR tests per 10 000 person-days was recorded, compared with a rate of 53 positive tests per 10 000 person-days for the unvaccinated group. The estimated vaccine effectiveness against infection with SARS-CoV-2 virus after 2 vaccine doses was 89% (95% CI, 82%-94%). The estimated effectiveness 2 weeks after the first vaccine dose was 61% (95% CI, 49%-71%). CONCLUSIONS: In this study, vaccination with BNT162b2 reduced infection rates among individuals who underwent screening by frequent SARS-CoV-2 PCR testing. Using a cohort of frequently tested individuals reduced the indication bias for the PCR testing, which enabled estimation of infection rates.

Persistence with statins and onset of rheumatoid arthritis: a population-based cohort study.

BACKGROUND: The beneficial effects of statins in rheumatoid arthritis (RA) have been suggested previously, but it is unclear whether statins may prevent its development. The aim of this retrospective cohort study was to explore whether persistent use of statins is associated with onset of RA. METHODS AND FINDINGS: The computerized medical databases of a large health organization in Israel were used to identify diagnosed RA cases among adults who began statin therapy between 1998 and 2007. Persistence with statins was assessed by calculating the mean proportion of follow-up days covered (PDC) with statins for every study participant. To assess the possible effects of healthy user bias, we also examined the risk of osteoarthritis (OA), a common degenerative joint disease that is unlikely to be affected by use of statins. A total of 211,627 and 193,770 individuals were eligible for the RA and OA cohort analyses, respectively. During the study follow-up period, there were 2,578 incident RA cases (3.07 per 1,000 person-years) and 17,878 incident OA cases (24.34 per 1,000 person-years). The crude incidence density rate of RA among nonpersistent patients (PDC level of <20%) was 51% higher (3.89 per 1,000 person-years) compared to highly persistent patients who were covered with statins for at least 80% of the follow-up period. After adjustment for potential confounders, highly persistent patients had a hazard ratio of 0.58 (95% confidence interval 0.52-0.65) for RA compared with nonpersistent patients. Larger differences were observed in younger patients and in patients initiating treatment with high efficacy statins. In the OA cohort analysis, high persistence with statins was associated only with a modest decrement in risk ratio (hazard ratio = 0.85; 0.81-0.88) compared to nonadherent patients. CONCLUSIONS: The present study demonstrates an association between persistence with statin therapy and reduced risk of developing RA. The relationship between continuation of statin use and OA onset was weak and limited to patients with short-term follow-up.

Diabetes and risk of incident cancer: a large population-based cohort study in Israel.

Type 2 diabetes mellitus has been associated with an increased risk of a variety of cancers in observational studies, but few have reported the relationship between diabetes and cancer risk in men and women separately. The main goal of this retrospective cohort study was to evaluate the sex-specific risk of incident overall and site-specific cancer among people with DM compared with those without, who had no reported history of cancer at the start of the follow-up in January 2000. During an average of 8 years of follow-up (SD = 2.5), we documented 1,639 and 7,945 incident cases of cancer among 16,721 people with DM and 83,874 free of DM, respectively. In women, DM was associated with an adjusted hazard ratio of 1.96 (95% CI: 1.53-2.50) and 1.41 (95% CI: 1.20-1.66) for cancers of genital organs and digestive organs, respectively. A significantly reduced HR was observed for skin cancer (0.38; 95% CI: 0.22-0.66). In men with DM, there was no significant increase in overall risk of cancer. DM was related with a 47% reduction in the risk of prostate cancer. These findings suggest that the nature of the association between DM and cancer depends on sex and specific cancer site.

The perceived performance, barriers and solutions for the good preventive care of elderly people in Israel.

BACKGROUND: Many elderly people, who experience functional and cognitive deterioration, visit their family physician or general practitioner (GP) who is well placed to administer preventive care; however, this provision is often suboptimal. AIM: To examine barriers to preventive care among the elderly and examine self-perceived skills and knowledge among Israeli physicians. DESIGN: Quantitative and qualitative research methods involving focus groups were used. SETTING: Two Israeli primary care preferred provider organisations. METHODS: Eighty-five physicians participated in 12 focus group discussions on preventive medicine for the elderly. The discussions were analysed using Atlas. ti software. Before each discussion, the physicians answered a self-report questionnaire which addressed his or her perceived skills in these areas. RESULTS: Family physicians felt less skilled in identifying cognitive deterioration, detecting signs of depression or treating urinary incontinence than in dealing with visual decline, and reported fewer skills than geriatricians. Most of the GPs felt that preventive medicine in the elderly was worthwhile but that they lacked the time and skills to undertake this task. Proposed solutions included the need for educational and training programmes, protected time, incentives and the involvement of nurses. CONCLUSION: Although the issue of 'lack of time' is usually considered a major barrier to successful implementation of preventive care, lack of family physician knowledge and skills, and organisational barriers should also be addressed.

Distinct trajectories in HbA1c are associated with different all-cause mortality and morbidity in newly diagnosed patients with type 2 diabetes.

AIMS: To identify trajectories of long-term HbA1c levels and examine associations with subsequent risk for morbidity and mortality. METHODS: We conducted a longitudinal follow-up among 27,724 patients, newly diagnosed with type 2 diabetes, in a large healthcare organization. We identified trajectories of long-term HbA1c levels during the first 5 years post diabetes onset to examine associations with subsequent risk for morbidity and all-cause mortality. RESULTS: We identified two HbA1c trajectories; the "Steady-plateau HbA1c trajectory" in 93% of patients and a "Sharp-incline HbA1c trajectory" in 7% of patients. When compared to the steady-plateau group, patients in the sharp-incline group were younger, male, from a lower socio-economic background, and higher levels of HbA1c at baseline. Patients in the sharp-incline trajectory had a HR = 1.83 (95%CI: 1.58-2.12) for all-cause mortality, HR = 1.99 (95%CI: 1.74-2.27) for cardiovascular disease, and HR = 1.68 (95%CI: 1.51-1.86) for renal disease, compared to patients in the steady-plateau trajectory. CONCLUSIONS: Patients in the sharp-incline trajectory had a higher risk for all-cause mortality, cardiovascular disease, and renal disease, compared to patients in the steady-plateau trajectory. Estimation of HbA1c variability in the first years of diagnosis may be a useful indicator of those patients at high risk for diabetes related complications.

Long-term persistence with statin treatment in a not-for-profit health maintenance organization: a population-based retrospective cohort study in Israel.

BACKGROUND: Although discontinuing lipid-lowering treatment can cause preventable morbidity, previously published reports have indicated considerable variability in persistence with statin use. In general, such reports have been limited by short follow-up periods and modest study populations. OBJECTIVES: The aims of this study were to assess long-term persistence with statins and to identify the sociodemographic, clinical, and pharmacotherapy-related factors associated with long-term persistence with statin treatment in first-time users in Israel. METHODS: This retrospective cohort study used data from adult enrollees of a not-for-profit health maintenance organization and from death certificates in Israel. Eligible patients initiated statin treatment between 1998 and 2006. Persistence was assessed separately in patients with no indication of a cardiovascular disease (primary prevention) or coronary artery disease (secondary prevention). Treatment persistence and proportion of days covered (PDC) were measured using the interval between the date of the first prescription dispensation (index date) and the point of discontinuation. RESULTS: Data from 229,918 patients were included (primary prevention, 136,052; secondary prevention, 93,866). The PDC was significantly higher in the secondary-prevention group compared with the primary-prevention group (59% vs 45%; P < 0.001). In both cohorts, persistence continually diminished from the index date through follow-up, with > or = 75% of patients discontinuing statin therapy by 2 years. Baseline predictors of discontinuation of statin treatment included younger age, female sex, lower socioeconomic status (SES), absence of diabetes or hypertension, no concurrent use of beta-blockers or angiotensin-converting enzyme inhibitors, and less health service utilization. New immigrants and patients in the primary-prevention group who had a baseline low-density lipoprotein cholesterol concentration <130 mg/dL were at increased risk for treatment discontinuation. CONCLUSION: In this study in these patients receiving first-time statin treatment in Israel, we found poor persistence with statins among both the primary- and secondary-prevention cohorts, especially among new immigrants and patients with low SES despite low out-of-pocket prescription costs and free access to health services.

Adherence to quality of care measurements among 58,182 patients with new onset diabetes and its association with mortality.

OBJECTIVES: Disease registry for diabetes care encourages transparency and benchmarking of quality of care (QoC) measurements for all service providers and seems to improve diabetes care. This study evaluate changes over time in QoC measurement performance in a large diabetes registry among newly diagnosed diabetics and it association with mortality. METHODS: Retrospective cohort study of patients in a large health maintenance organization diabetes registry from years 2000 to 2013. We identified 58,182 patients diagnosed with diabetes from 2000-2008 and examined the level of performance for seven QoC measurements (HbA1c, LDL, albumin-creatinine-ratio, fundus/foot examinations, BMI and Blood-pressure) at diagnosis year. We also searched data regarding visits to dietitians or endocrinologists, and purchase of diabetes and statin medications. We used Mantel-Haenszel's χ2 test to assess QoC performance and mortality rate by calendar year of entry into the registry, and Cox regression to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality up to 5 years from diagnosis adjusted for age, gender, socio-economic status and comorbidities. RESULTS: The total QoC measurements improved from a mean of 2.71 tests performed in 2000 to 5.69 in 2008 (p<0.001). The mortality rate dropped from 7.7% in 2000 to 5.7% in 2008 (p<0.001). Patients with more QoC measurements performance who visited a dietitian and purchased statin medications had a lower mortality risk (HRs (95% CIs) 0.89 (0.87-0.92), 0.83 (0.76-0.91) and 0.70(0.65-0.75) respectively). Visits to endocrinologists and purchases of oral diabetes medication and insulin were associated with a higher risk of mortality (HRs (95% CIs) 1.20(1.07-1.35), 1.35(1.26-1.46) and 3.36(2.92-3.87) respectively). CONCLUSION: Performance of QoC measurements including visiting a dietitian and purchase of statin medications were associated with lower mortality in patients with diabetes. It may be that the early active involvement of the patients in their care plays a protective role in long term mortality.

In a population-based cohort of diabetes patients, men and women had similar risks for all-cause mortality.

OBJECTIVES: To compare death rates of diabetic men and women relative to the general population and to identify sex-specific risk factors for all-cause mortality. STUDY DESIGN AND SETTINGS: In the current historical prospective cohort study, standardized mortality ratios (SMRs) were calculated for 19,657 men and women with diabetes in a large Israeli health care organization compared to the mortality in the general population from 1999 to 2003. In addition, sex-specific survival analyses were performed for men and women separately using baseline data obtained between 1995 and 1999. RESULTS: During the study follow-up (90,899 person-years), 2,924 deaths were identified. The SMR for diabetic women (1.40; 95% confidence interval [CI]: 1.33, 1.47) was significantly (P<0.01) higher than for diabetic men (1.20; 95% CI: 1.14, 1.26). Age, glycated hemoglobin, serum creatinine, low-density lipoprotein, high-density lipoprotein, dialysis, use of angiotensin-converting enzyme inhibitors, and insulin were similarly associated with mortality in both sexes. Residing in the south of Israel was related with higher risk among men but with decreased risk among women. CONCLUSIONS: The study indicates that diabetes seems to eliminate the relative protection against death usually seen in women. It also suggests that most risk factors are comparable between the sexes, underlining the importance of similarly intensive disease management in diabetic women and in diabetic men.

Pemphigus variant associated with penicillin use: a case-cohort study of 363 patients from Israel.

OBJECTIVE: To determine whether medication use is associated with the development of a pemphigus variant. DESIGN: Population-based case-cohort study. SETTING: Health maintenance organization in Israel. METHODS: All incident pemphigus variant cases diagnosed from January 1, 1997, through December 31, 2001, among 1.5 million members were identified. A cohort of 150,000 was randomly selected from the health maintenance organization population as the control group. Data on case patients and control subjects, including all medication purchased during the 6 months before the diagnosis, were obtained using the health maintenance organization's central database. RESULTS: We identified a total of 363 case patients diagnosed as having pemphigus during the 5-year study (6,961,853 person-years of follow-up). The mean age at diagnosis was 49.8 (SD, 22.7) years, and 53% of the cases were women. Results of a multivariate analysis showed that increased risk for pemphigus was associated with purchasing penicillin during the 6 months before the diagnosis (odds ratio, 2.03; 95% confidence interval, 1.56-2.64). Compared with individuals with no penicillin purchases, we calculated increased risks of 1.84 (95% CI, 1.36-2.49) and 3.02 (95% CI, 1.41-6.49) in those with 1 and 3 or more purchases, respectively. None of the other examined medications, including cephalosporins, angiotensin-converting enzyme inhibitors, dipyrone, anticonvulsants, and nonsteroidal anti-inflammatory drugs, showed similar risks. CONCLUSIONS: To our knowledge, the present research is one of the largest published epidemiological studies on pemphigus variant. The use of computerized medical and administrative databases allowed the detection of case patients in the community, resulting in a higher calculated incidence rate than previously reported. The findings suggest a relationship between the use of penicillin and pemphigus variant. Further studies to assess the nature of this statistical association are warranted.