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Nationwide Evaluation of Quality of Care Indicators for Individuals with Severe Mental Illness and Diabetes Mellitus, Following Israel's Mental Health ReformDeborah Barasche-BerdahEliana Ein-MorRonit Calderon-MargalitAdam J RoseMichal KriegerShuli Brammli-GreenbergArye Ben-Yehuda , Orly ManorArnon D Cohen , Edna Bar-Ratson , Ronen Bareket , Eran Matz , Ora Paltiel 

Diabetes Mellitus (DM) is more common among individuals with severe mental illness (SMI). We aimed to assess quality-of-care-indicators in individuals with SMI following the 2015 Israel's Mental-Health-reform. We analyzed yearly changes in 2015-2019 of quality-of-care-measures and intermediate-DM-outcomes, with adjustment for gender, age-group, and socioeconomic status (SES) and compared individuals with SMI to the general adult population. Adults with SMI had higher prevalences of DM (odds ratio (OR) = 1.64; 95% confidence intervals (CI): 1.61-1.67) and obesity (OR = 2.11; 95% CI: 2.08-2.13), compared to the general population. DM prevalence, DM control, and obesity rates increased over the years in this population. In 2019, HbA1c testing was marginally lower (OR = 0.88; 95% CI: 0.83-0.94) and uncontrolled DM (HbA1c > 9%) slightly more common among patients with SMI (OR = 1.22; 95% CI: 1.14-1.30), control worsened by decreasing SES. After adjustment, uncontrolled DM (adj. OR = 1.02; 95% CI: 0.96-1.09) was not associated with SMI. Cardio-metabolic morbidity among patients with SMI may be related to high prevalences of obesity and DM rather than poor DM control. Effective screening for metabolic diseases in this population and social reforms are required.

 

 

 Published on: 11/09/2023 |  To the Article

Pediatric overweight and obesity increased in Israel during the COVID-19 period | Adam Rose, Eliana Ein Mor, Michal Krieger, Arie Ben-Yehuda, Shoshana Revel-Vilk, Arnon D. Cohen, Eran Matz, Edna Bar-Ratson, Ronen Bareket, Ora Paltiel, Ronit Calderon-Margalit

 

Reports from many settings suggest that pediatric overweight and obesity increased in 2020 and 2021, presumably due to lifestyle changes associated with the COVID-19 pandemic. Many of these previous reports have relied on convenience samples or subsets of the population. Here, we present results of a longitudinal study of the entire population of Israel, a nation of approximately 9 million people, with the proportion with underweight, normal weight, overweight, and obesity at age 7 and at age 14–15, across the years 2017–2021. Our results show that the prevalence of overweight and obesity, which had been steady or improving through 2019, increased relatively quickly in 2020 and 2021. For example, among 7-year-olds, the percentage of children with obesity in 2019 was 6.8% (99% CI: 6.69–7.05), and by 2021, it had increased to 7.7% (99% CI: 7.53–7.93). There were important disparities in overweight and obesity based on SES; for example, the rate ratio for obesity comparing the poorest with the wealthiest 14–15-year-olds in 2019 was 1.63 (99% CI: 1.55–1.72). However, these disparities did not change meaningfully in 2020 and 2021, implying that while obesity did become more prevalent, this increase in prevalence was not differential across socioeconomic status. Like many other nations, Israel too experienced considerable increases in pediatric overweight and obesity in 2020–2021, erasing the improvements of the previous years among younger children.

 Published on: 05/09/2023 |  To the Article

What is important for people with type 2 diabetes? A focus group study to identify relevant aspects for Patient-Reported Outcome Measures in diabetes care Nura Abdel-Rahman, Orly Manor, Liora Valinsky, Ofri Mosenzon, Ronit Calderon Margalit, Sveta Roberman

 

Background: Patient-Reported Outcome Measures (PROMs) aim to evaluate the quality of care based on the perspectives of patients rather than clinical indicators. Qualitative research is needed to identify these perspectives in people with type 2 diabetes.

Objective: To identify, for the first time in Israel, aspects valuable for people with type 2 diabetes that can be relevant for PROMs in diabetes care.

Methods: A qualitative study included three focus groups totalling 19 people with type 2 diabetes. Inclusion criteria were: (1)type 2 diabetes, (2)diabetes duration of at least six months, and (3)adults aged 45-80 years. Purposive sampling enabled recruitment of heterogeneous participants. Also, two experts' panels with healthcare providers involved in diabetes care (n = 23) were conducted to provide triangulation of information (more testimony about what is valuable for people with type 2 diabetes). Discussions were recorded, transcribed and thematically analysed.

Results: Four domains were deemed valuable for people with type 2 diabetes: (1)challenges of living with diabetes, including reduced physical function, healthy lifestyle struggles, sexual dysfunction, and financial burden, (2)mental health issues, including depression, distress, anxiety, frustration, and loneliness, (3)self-management ability, including management of lifestyle modifications and treatment, knowledge about the disease and treatment, and (4)patient-clinician relationships, including the devotion of clinicians, trust in clinicians and treatment, shared decision-making, and multidisciplinary care under one roof. Experts favour using PROMs in diabetes routine care and even acknowledged their necessity to improve the treatment process. However, only some of the domains raised by people with type 2 diabetes were identified by the experts.

Conclusions: There are content gaps between perspectives of people with type 2 diabetes and their healthcare providers.

PROMs are essential in addressing issues largely not addressed in routine diabetes care. We recommend that researchers and healthcare providers, who intend to utilize PROMs for diabetes care, consider the aforementioned domains.

 Published on: 14/11/2022 |  To the Article

Longitudinal Adherence to Diabetes Quality Indicators and Cardiac Disease: A Nationwide Population-Based Historical Cohort Study of Patients With Pharmacologically Treated Diabetes | Nura Abdel-Rahman, Ronit Calderon-Margalit, Arnon Cohen, Einat Elran, Avivit Golan Cohen, Michal Krieger, Ora Paltiel, Liora Valinsky, Arie Ben-Yehuda, Orly Manor

 

Background: Evidence of the cardiovascular benefits of adherence to quality indicators in diabetes care over a period of years is lacking.

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

Conclusions: Longitudinal adherence to quality indicators in diabetes care is associated with reduced risk of cardiac morbidity. Implementation of programs that measure and enhance quality of care may improve the health outcomes of people with diabetes.

 Published on: 4/10/2022| To the Article

Israeli COVID lockdowns mildly reduced overall use of preventive health services, but exacerbated some disparities | Adam J. Rose, Eliana Ein Mor, Michal Krieger, Arie Ben-Yehuda, Arnon D. Cohen, Eran Matz, Edna Bar-Ratson, Ronen Bareket, Ora Paltiel and Ronit Calderon-Margalit

 

Background: During 2020, Israel experienced two COVID-19-related lockdowns that impacted the provision of primary and secondary preventive care. Methods: We examined the month-by-month performance of selected preventive care services using data from Israel’s national Quality Indicators in Community Healthcare program. Process of care measures included hemoglobin A1c (HbA1c) testing, cholesterol testing, colon cancer screening and mammography. Intermediate outcome measures included low-density lipoprotein control and HbA1c control. Measures were stratifed by sex and by area-level socioeconomic position (SEP). Diabetes and mammography are presented in this abstract due to space limitations. Results: Annual HbA1c testing among persons with diabetes decreased from 90.9% in 2019 to 88.0% in 2020. Performance of HbA1c tests during lockdown months was as low as half the usual amount. There were compensatory increases in testing during post-lockdown months that did not quite make up for the missed tests. In 2019, 9.0% of Israelis with diabetes had poor glycemic control (HbA1c ≥ 9.0); in 2020, it was 8.8%. In total, 4.5% fewer mammograms were performed in 2020 compared with 2019. Women in the lowest SEP level performed 10.4% fewer mammograms in 2020 than in 2019, while women in the highest SEP level performed 3.1% more mammograms. Conclusions: Prolonged COVID lockdowns in 2020 were associated with marked decreases in the performance of preventive health services during those months. Compensatory spikes following the end of lockdowns partly, but did not completely, make up for the missed care. COVID lockdowns may have exacerbated socioeconomic disparities in some preventive health services.

 Published on: 5/9/2022| To the Article

Socioeconomic Disparity Trends in Cancer Screening Among Women After Introduction of National Quality Indicators | Yiska Loewenberg Weisband, Luz Torres, Ora Paltiel, Yael Wolff Sagy, Ronit Calderon-Margalit, Orly Manor

 

Purpose: Primary care physicians have an important role in encouraging adequate cancer screening. Disparities in cancer screening by socioeconomic status (SES) may affect presentation stage and cancer survival. This study aimed to examine whether breast, colorectal, and cervical cancer screening rates in women differed by SES and age, and whether screening rates and SES disparities changed after introduction of a primary care–based national quality indicator program.

Methods: This repeated cross-sectional study spanning 2002-2017 included all female Israeli residents in age ranges appropriate for each cancer screening assessed. SES was measured both as an individual-level variable based on exemption from copayments and as an area-level variable using census data.

Results: In 2017, the most recent year in the study period, screening rates among 1,529,233 women were highest for breast cancer (70.5%), followed by colorectal cancer (64.3%) and cervical cancer (49.6%). Women in the highest area-level SES were more likely to undergo cervical cancer screening compared with those in the lowest (odds ratio=3.56; 99.9% CI, 3.47-3.65). Temporal trends showed that after introduction of quality indicators for breast and colorectal cancer screening in 2004 and 2005, respectively, rates of screening for these cancers increased, with greater reductions in disparities for the former. The quality indicator for cervical cancer screening was introduced in 2015, and no substantial changes have occurred yet for this screening.

Conclusions: We found increased uptake and reduced socioeconomic disparities after introduction of cancer screening indicators. Recent introduction of a cervical cancer screening indicator may increase participation and reduce disparities, as has occurred for breast and colorectal cancer screening. These findings related to Israel’s quality indicators program highlight the importance of primary care clinicians in increasing cancer screening rates to improve outcomes and reduce disparities.

 Published on: 10/2021| To the Article

Adherence to national guidelines for colorectal cancer screening in Israel: Comprehensive multi-year assessment based on electronic medical records | Ora Paltiel, Aravah Keidar Tirosh, Orit Paz Stostky, Ronit Calderon-Margalit, Arnon D Cohen , Einat Elran, Liora Valinsky, Eran Matz, Michal Krieger , Arye Ben Yehuda, Dena H Jaffe and Orly Manor

 

Objectives: To assess time trends in colorectal cancer screening uptake, time-to-colonoscopy completion following a positive fecal occult blood test and associated patient factors, and the extent and predictors of longitudinal screening adherence in Israel.

Setting: Nation-wide population-based study using data collected from four health maintenance organizations for the Quality Indicators in Community Healthcare Program.

Methods: Screening uptake for the eligible population (aged 50–74) was recorded 2003–2018 using aggregate data. For a subcohort (2008–2012, N ¼ 1,342,617), time-to-colonoscopy following a positive fecal occult blood test and longitudinal adherence to screening guidelines were measured using individual-level data, and associated factors assessed in multivariate models.

Results: The annual proportion screened rose for both sexes from 11 to 65%, increasing five-fold for age group 60–74 and >six-fold for 50–59 year olds, respectively. From 2008 to 2012, 67,314 adults had a positive fecal occult blood test, of whom 71% eventually performed a colonoscopy after a median interval of 122 (95% confidence interval 110.2–113.7) days. Factors associated with time-to-colonoscopy included age, socioeconomic status, and comorbidities. Only 25.5% of the population demonstrated full longitudinal screening adherence, mainly attributable to colonoscopy in the past 10 years rather than annual fecal occult blood test performance (83% versus 17%, respectively). Smoking, diabetes, lower socioeconomic status, cardio[1]vascular disease, and hypertension were associated with decreased adherence. Performance of other cancer screening tests and frequent primary care visits were strongly associated with adherence. 

Conclusions: Despite substantial improvement in colorectal cancer screening uptake on a population level, individual-level data uncovered gaps in colonoscopy completion after a positive fecal occult blood test and in longitudinal adherence to screening, which should be addressed using focused interventions.

 Published on: 3/2021 | To the Article

Trends and socioeconomic disparities in diabetes prevalence and quality of care among Israeli children;2011-2018 | Yiska Loewenberg Weisband, Michal Krieger, Ronit Calderon-Margalit and Orly Manor 

Background: Despite Israel’s universal health coverage, disparities in health services provision may still exist. We aimed to assess socioeconomic disparities in diabetes prevalence and quality of care among Israeli children, and to assess whether these changed over time.

Methods: We used repeated cross-sectional analyses in the setting of the National Program for Quality Indicators in Community Healthcare. The data were derived from electronic medical records from Israel’s four health maintenance organizations. The study population included all Israeli children aged 2–17 years in 2011–2018 (2018: N = 2,404,856). Socio-economic position (SEP) was measured using Central Bureau of Statistics data further updated by a private company (Points Business Mapping Ltd), and grouped into 4 categories, ranging from 1 (lowest) to 4 (highest). We used logistic regression to assess the association of SEP with diabetes prevalence, diabetes clinic visits, hemoglobin A1C (HbA1C) testing, and poor glycemic control (HbA1c > 9%), and assessed whether these changed over time.

Results: Diabetes prevalence increased with age and SEP, with a total of 3019 children with diabetes. SEP was positively associated with visiting a specialized diabetes clinic (age and sex adjusted Odds Ratio (aORSEP 4 vs. 1 2.45, 95% Confidence Interval (CI) 1.67–3.69)). Although children in higher SEPs were less likely to undergo HbA1c testing (aORSEP 4 vs. 1 0.54, 95% CI 0.40–0.72), they were also less likely to have poor glycemic control (aORSEP 4 vs. 1 0.25, 95% CI 0.18–0.34). Disparities were especially apparent among children aged 2–9 (6.5% poor glycemic control in SEP 4 vs. 38.2% in SEP 1). Poor glycemic control decreased over time, from 44.0% in 2011 to 34.1% in 2018.

Conclusions: While poor glycemic control rates among children have improved, they remain high compared to rates in adults. Additionally, substantial socioeconomic gaps remain. It is eminent to study the causes of these disparities and develop policies to improve care provided to children in the lower SEP levels, to promote health equity.

 Published on: 20/8/2020| To the Article

Area-level socioeconomic disparity trends in nutritional status among 5–6-year-old children in Israel | Yiska Loewenberg Weisband, Vered Kaufman-Shriqui, Yael Wolff Sagy, Michal Krieger, Wiessam Abu Ahmad, Orly Manor

Objective: This study aimed to assess area-level socioeconomic position (SEP) disparities in nutritional status, to determine whether disparities differed by sex and to assess whether nutritional status and disparities changed over time.

Design: We used repeated cross-sectional data from a national programme that evaluates the quality of healthcare in Israel to assess children’s nutritional status.

Setting: The study included all Israeli residents aged 7 years during 2014–2018 (n=699 255).

Methods: SEP was measured based on the Central Bureau of Statistics’ statistical areas, and grouped into categories, ranging from 1 (lowest) to 10 (highest). We used multivariable multinomial regression to assess the association between SEP and nutritional status and between year and nutritional status. We included interactions between year and SEP to assess whether disparities changed over time.

Results: Children in SEP 1, comprised entirely of children from the Bedouin population from Southern Israel, had drastically higher odds of thinness compared with those in the highest SEP (Girls: OR 5.02, 99%CI 2.23 to 11.30; Boys: OR 2.03, 99%CI 1.19 to 3.48). Odds of obesity were highest in lower-middle SEPs (ORSEP 5 vs 10 1.84, 99%CI 1.34 to 2.54). Prevalence of overweight and obesity decreased between 2014 and 2018, normal weight increased and thinness did not change. SEP disparities in thinness decreased over time in boys but showed a reverse trend for girls. No substantial improvement was seen in SEP disparities for other weight categories.

Conclusions: Our study demonstrates the need to consider initiatives to combat the considerable SEP disparities in both thinness and obesity.

 Published on: 6/5/2020 | To the Article

הטיפול באנטיביוטיקה ברפואת הקהילה בישראל בראי התכנית הלאומית למדדי האיכות. ויסאם אבו אחמד, מיכל קריגר, יעל וולף־שגיא, אריה בן יהודה, יהוד הורביץ, אורה פלטיאל, רונית קלדרון־מרגלית, אורלי מנור

 

 

הקדמה: טיפול בלתי מושכל באנטיביוטיקה הוא שכיח ובעל השלכות חמורות, ובראשן התפתחות עמידות בקרב חיידקים. למרות שבאופן מסורתי הושם דגש על טיפול באנטיביוטיקה בבתי-החולים, 80%-95% מנפח התרופות האנטיביוטיות נרשם בקהילה.

מטרות: לבחון לאורך זמן את היקף הטיפול הכולל באנטיביוטיקה ואת פרופורצית הטיפול באנטיביוטיקות קו-שני ברפואת הקהילה בישראל, לאתר תתי-אוכלוסיות בעלות צריכה גבוהה ולהשוות את הנתונים הישראלים לנתונים בינלאומיים.

שיטות: נתונים לאומיים, אנונימיים ומקובצים נאספו מהרשומות הממוחשבות של קופות-החולים במסגרת התוכנית הלאומית למדדי איכות לרפואת הקהילה בישראל (תמ"ל) לשנים 2016-2014. הופקו שני מדדים: (1) נפח הטיפול הכולל בתרופות אנטיביוטיות מערכתיות בקהילה המבוטא ב-DDD/1,000 איש/יום; (2) פרופורציית הטיפול באנטיביוטיקות קו-שני. הנתונים פולחו על פי מין, גיל ומצב חברתי-כלכלי. לצורך השוואות בינלאומיות, אומצו הגדרות המדדים של ה-OECD.

תוצאות: בשנת 2016, הטיפול הכולל באנטיביוטיקה היה 20.76 DDD/1,000 איש/יום. אנטיביוטיקות קו-שני היוו 22% מנפח הטיפול הכולל. הערכים נשארו יציבים משנת 2014, והם גבוהים מהממוצעים בארצות ה-OECD (20.61 ו-17.02% בשנת 2015, בהתאמה). הטיפול הכולל והטיפול באנטיביוטיקות קו-שני עלו מאוד עם הגיל והיו גבוהים בנשים בהשוואה לגברים, במיוחד בגילים 40-20 שנים (טיפול כולל של 23.98 DDD/1,000 איש/יום ופרופורצית טיפול באנטיביוטיקות קו-שני של 23.98% בנשים, לעומת 17.41 ו-19.17% בגברים, בהתאמה). הטיפול הכולל באנטיביוטיקה עלה ככל שהמצב החברתי-כלכלי היה נמוך. השפעתם של שלושת המשתנים: גיל, מין ומצב חברתי-כלכלי, על הצריכה נותרה מובהקת סטטיסטית בניתוח רב-משתנים.

מסקנות, דיון וסיכום: הטיפול הכולל באנטיביוטיקות מערכתיות ובאנטיביוטיקות קו-שני בקהילה בישראל יציבים וגבוהים יחסית למדינות ה-OECD . גיל מתקדם, מין נקבה ומצב חברתי-כלכלי נמוך קשורים בצריכה גבוהה יותר של אנטיביוטיקה. ממצאי המחקר מצביעים על הצורך בתוכנית התערבות לאומית לטיפול מושכל באנטיביוטיקה ברפואת הקהילה בישראל. התמ"ל עשוייה לשמש כלי לליווי תוכנית התערבות כזו.

 פורסם ב: 5.5.2019 | קישור למאמר

Reflections of the quality of primary care in Canada and Israel Richard H. Glazier

Rachel Podell and her colleagues at the National Program for Quality Indicators in Community Healthcare in Israel have provided a clear and engaging description of thequality of primary care provided to the elderly in Israel. They examine changes overtime, variation across sub-groups, and comparisons with other countries. Over a 13year timeframe, most of the included process measures improved substantially, withfairly minor differences between demographic groups and largely favourablecomparisons with other countries.

In the Podell et al article, there are few direct comparisons of primary care available between Canada and Israel, but we know from other studies that Canadian primary care compares relatively unfavourably with ten other developed countries in a number of measures. These include timely access to care, after-hours care, electronic medical record use and audit and feedback for quality improvement. More concerning is that few of these measures have improved in Canada over a number of years, despite a major policy focus on primary care, investments in payment reforms and the formation of groups and inter-professional teams.

Differences in performance trajectories could relate to the major structural differences in primary care between Canada and Israel. While Canada has universal health insurance coverage for necessary physician and hospital services, most physicians practice privately, are paid mainly through fee-for-service and have few accountabilities to the health care system. Many Canadians lack a regular source of primary care and there is little or no competition between primary care practices or groups, as most of them have full practices, and are not accepting new patients. No Canadian province has completely implemented electronic medical records in primary care. Canada also lacks the organizational, administrative and support structures of Israel's health maintenance organizations.

Canada and other countries can learn from the advances in data, measurement, feedback, and organization of care that are now applied routinely to ongoing quality improvement in Israel, with impressive results. The Israeli experience suggests that future developments designed to improve care and outcomes should include measurement infrastructure, formal reporting, accountability mechanisms, and management systems to address gaps and inequities in care.

 Published on: 4/6/2018| To the Article

The quality of primary care provided to the elderly in Israel  | Rachel Podell , Vered Kaufman-Shriqui , Yael Wolff Sagy, Orly Manor and Arie Ben-Yehuda

Background: In view of increasing global and local trends in population ageing and the high healthcare utilization rates among the elderly, this study assesses the quality of primary care provided to the elderly population in Israel. It examines changes in quality over time, how quality varies across sub-groups of the elderly, and how quality in Israel compares with other countries. Data originate from the National Program for Quality Indicators in Community Healthcare (QICH), which operates in full collaboration with Israel’s four HMOs.

Methods: The study population included all elderly Israeli residents aged 65 years or older during 2002–2015 (N = 879,671 residents in 2015). Seven elderly-specific quality indicators from within the QICH framework were included: influenza and pneumococcal vaccinations, benzodiazepine overuse, long-acting benzodiazepine use, body weight documentation, weight loss and underweight. In addition, two non-age specific quality indicators relating to diabetes mellitus were included: the rate of HbA1C documentation and uncontrolled diabetes. Data were collected from patient electronic medical records (EMR) in accordance with each HMO, and aggregated by three variables: gender, age, and socio-economic position (SEP).

Results: During the measurement period, vaccination rates significantly increased (Influenza: from 42.0% in 2002 to 63.2% in 2015; and pneumococcal vaccination: from 25.8% in 2005 to 77.0% in 2015). Body weight documentation (in 65–74 year old persons) increased from only 16.3% in 2003 to 80.9% in 2015. The rate of underweight (BMI < 23 kg/m2 ) and significant weight-loss (10% or more of their body weight) was only measured in 2015. The overall rate of benzodiazepine overuse remained steady from 2011 to 2015 at around 5%, while the rate of long-acting benzodiazepine use decreased from 3.8% in 2011 to 2.4% in 2015. The rate of HbA1c documentation for elderly diabetics was higher than for non-elderly diabetics in 2015 (92.2% vs 87.9%). The rate of uncontrolled diabetes was lower for the elderly than the non-elderly population in 2015 (6.9% vs. 15.7%). Gender disparities were observed across all measures, after age stratification, with worse indicator rates among females compared to males. SEP-disparities were not consistent across measures. In all indicators except benzodiazepine overuse, Israel showed a higher quality of care for the elderly in comparison with the international healthcare community.

Conclusions: Overall, the quality of care received by elderly Israelis has improved substantially since measurements first began; yet, females receive lower quality care than males. Monitoring results of primary care quality indicators can contribute to population’s successful aging; both chronic conditions at earlier ages (e.g. diabetes), and short-term hazardous conditions such as the use of potentially harmful medications and weight loss should be evaluated.

 Published on: 4/6/2018| To the Article

Defining and measuring population health quality of outpatient diabetes care in Israel: lessons from the quality indicators in community health program | Leonard M. Pogach and David C. Aron

In Israel, as in other Organization for Economic Co-operation and Development countries, performance measurement is a key public health strategy in monitoring and improving population health outcomes. The Israeli Quality Indicators in Community Healthcare (QICH) program has utilized electronic health records to monitor ambulatory care for the entire Israeli population since 2002. In 2006 the measures were updated to include laboratory values. They have been subsequently revised by stratifying by age, duration, adding medications, and changing frequency of testing for certain process measures. However, the QICH glycemic control measures do not address co-morbid conditions either thru exclusion criteria or higher target ranges. They also do not address potential over treatment in patients with complex medication conditions. In the United States there have also been changes in nationally endorsed diabetes specific performance measures since 2007. However, there have also been public disagreements among United States professional societies, government agencies, and performance measurement organizations as to whether the current glycemic dichotomous (“all or none”) threshold measures, without exclusion criteria, are consistent with the most recent evidence. Specifically, most guidelines now recommend individualized target goals based upon co-morbid conditions, risk of harms from medications, and patient preferences. Concerns have been raised that the current glycemic performance measures have resulted in inappropriate care, such as medication over-treatment, and serious harms, such as hypoglycemia, especially in older adults. There currently are no national surveillance systems or measures that monitor these untoward outcomes. We recommend several actions that QICH could consider to advance diabetes specific performance measurement science and population health: Convene an international conference; implement technical modifications of current measures and surveillance systems; and, most importantly, acknowledge patient autonomy by developing measures that document individualization of target values using shared decision making.

 Published on: 3/5/2018| To the Article

Trends in the performance of quality indicators for diabetes care in the community and in diabetes-related health status: an Israeli ecological study | Ronit Calderon-Margalit, Michal Cohen-Dadi, Dana Opas, Dena H. Jaffe, Jacob Levine, Arie Ben-Yehuda, Ora Paltiel and Orly Manor

Background: Israel is one of the few countries that have a national program for quality assessment of community healthcare. We aimed to evaluate whether improved performance in diabetes care was associated with improved health of diabetic patients on a national level.

Methods: We conducted a nationwide ecological study estimating improvements in diabetes-related quality indicators and health outcomes. We estimated both correlations between composite measures of diabetes-related quality indicators and selected outcomes, and assessed through a joinpoint analysis whether trends in selected outcomes changed 4 years after the inception of the national program.

Results: Between 2002 and 2010, the prevalence of diabetes in Israeli adults increased from 4.8% to 7.4%. During these years, an improvement was noticed in most quality indicators (from 53% to 75% for the composite score). Declines were noted in rates of blindness, diabetes-related end-stage kidney disease, lower limbs amputations and diabetes-related mortality. Significant accelerations in decline were noted for amputations in men and diabetes-related mortality in both Arab men and women 4 years after the inception of the national program.

Conclusion: This study suggests that Israel’s national program for quality indicators in diabetes care in the community has probably had a significant impact on the health status of the whole population and may have contributed to narrowing gaps in life expectancy between Israeli Jews and Arabs. Future studies based on individual-level data are needed to confirm these results.

 Published on: 17/1/2018| To the Article

Mandatory national quality improvement systems using indicators: An initial assessment in Europe and Israel | Anke Bramesfelda, Michel Wensing, Paul Bartels, Henning Bobzin, Catherine Grenier, Mona Heugren, Dena Jaffe Hirschfield, Manfred Langenegger, Birgitta Lindelius, Bruno Lucet, Orly Manor, Theres Schneider, Fiona Wardell, Joachim Szecsenyi 

Introduction: Quality improvement systems (QIS) that are based on empirical performance assessment have increasingly been implemented as a mandatory part of health systems across countries. This study aims to describe national mandatory QIS in Europe in 2014.

Materials and methods: Relevant national agencies for national mandatory QIS in Europe were identified through online searches and key informants. A questionnaire was compiled during a workshop with these agencies and filled out by representatives from these particular agencies.

Results: Agencies in charge of national mandatory QIS in seven countries (Denmark, France, Germany, Israel, Scotland, Sweden and Switzerland) were included in the study. An analysis of QIS revealed similarities, such as the use of routine data for performance assessment and the aim to hold healthcare providers accountable. Differences relate to the different forms of feedback systems and improvement mechanisms used. Trends include the development towards greater implementation of QIS within health systems, the inclusion of the patient’s perspective in performance assessment, and experiments with pay for performance-related measures.

Conclusion: On a country level, for health systems striving for newly implementing QIS it is recommended to start where routine data is available, add qualitative methodologies once the QIS is getting more complex, report performance data back to service providers and be patient centred.

On the inter-country level exchange of information between agencies commissioned with implementing national QIS is very much needed for

1. Better understanding the other systems;

2. Gaining inspiration;

3. Working towards obtaining better evidence on the impact that the different tools used and measures taken by national QIS have on the quality of care at health system level.

 Published on: 11/2016| To the Article

Community healthcare in Israel: quality indicators 2007-2009 | Dena H Jaffe, Amir Shmueli, Arie Ben-Yehuda, Ora Paltiel, Ronit Calderon, Arnon D Cohen, Eran Matz, Joseph K Rosenblum, Rachel Wilf-Miron and Orly Manor

Background: The National Program for Quality Indicators in Community Healthcare in Israel (QICH) was developed to provide policy makers and consumers with information on the quality of community healthcare in Israel. In what follows we present the most recent results of the QICH indicator set for 2009 and an examination of changes that have occurred since 2007.

Methods: Data for 28 quality indicators were collected from all four health plans in Israel for the years 2007-2009. The QICH indicator set examined six areas of healthcare: asthma, cancer screening, cardiovascular health, child health, diabetes and immunizations for older adults.

Results: Dramatic increases in the documentation of anthropometric measures were observed over the measurement period. Documentation of BMI for adolescents and adults increased by 30 percentage points, reaching rates of 61% and 70%, respectively, in 2009. Modest increases (3%-7%) over time were observed for other primary prevention quality measures including immunizations for older adults, cancer screening, anemia screening for young children, and documentation of cardiovascular risks. Overall, rates of recommended care for chronic diseases (asthma, cardiovascular disease and diabetes) increased over time. Changes in rates of quality care for diabetes were varied over the measurement period.

Conclusions: The overall quality of community healthcare in Israel has improved over the past three years. Future research should focus on the adherence to quality indicators in population subgroups and compare the QICH data with those in other countries. In addition, one of the next steps in assessing and further improving healthcare quality in Israel is to relate these process and performance indicators to health outcomes.

 Published on: 30/01/2012 | To the Article