Margalit Goldfracht

Antipsychotics and Diabetes: An Age-Related Association

Background Previous studies have reported an association between antipsychotic medications and diabetes. Objective To explore the association between antipsychotic medications and diabetes in patients of different ages. Methods A retrospective analysis of a large health maintenance organizations drug claim database (3.7 million members) was performed. All patients treated with antipsychotic drugs during 1998–2004 were identified. Patients with diabetes were defined by a record of antidiabetic drug uso during 2004. The prevalence of diabetes in different age groups treated with antipsychotics was compared with the prevalence of diabetes among enrollees in the same age groups not treated with antipsychotics. Results: Among 82,754 patients treated with antipsychotics, the association between diabetes and consumption of antipsychotics was strongest in the younger age groups and decreased with increasing age: for patients aged 0–24 years, OR 8.9 (95% CI 7.0 to 11.3); 25–44 years, OR 4.2 (95% CI 3,8 to 4.5); 45–54 years, OR 1.9 (95% CI 1.8 to 2.1); 55–64 years, OR 1.3 (95% CI 1.2 to 1.4); and 65 years or older, OR 0.93 (95% CI 0.9 to 1.0). However, the risk associated with atypical antipsychotics was lower than the risk associated with typical antipsychotics, with ORs ranging from 0.7 in patients 0–24 years old to 0.3 in those 65 years or older. Conclusions: Antipsychotic drug use was associated with diabetes mellitus. This association was stronger in younger patients. In older adults, the difference was much smaller and, in some cases, there was no association. A lowor risk was associated with atypical agents, as compared with typical antipsychotics. Clinicians should bo aware that young adults treated with antipsychotics are at increased risk for diabetes.

Rates and predictors of hypoglycaemia in 27 585 people from 24 countries with insulin-treated type 1 and type 2 diabetes: the global HAT study.

To determine the global extent of hypoglycaemia experienced by patients with diabetes using insulin, as there is a lack of data on the prevalence of hypoglycaemia in developed and developing countries.

Time-Dependent Risk of Cancer After a Diabetes Diagnosis in a Cohort of 2.3 Million Adults

Using a time-dependent approach, we investigated all-site and site-specific cancer incidence in a large population stratified by diabetes status. The study analyzed a closed cohort comprised of Israelis aged 21-89 years, enrolled in a health fund, and followed from 2002 to 2012. Adjusting for age, ethnicity, and socioeconomic status, we calculated hazard ratios for cancer incidence using Cox regression separately for participants with prevalent and incident diabetes; the latter was further divided by time since diabetes diagnosis. Of the 2,186,196 individuals included in the analysis, 159,104 were classified as having prevalent diabetes, 408,243 as having incident diabetes, and 1,618,849 as free of diabetes. In both men and women, diabetes posed an increased risk of cancers of the liver, pancreas, gallbladder, endometrium, stomach, kidney, brain (benign), brain (malignant), colon/rectum, lung (all, adenocarcinoma, and squamous cell carcinoma), ovary, and bladder, as well as leukemia, multiple myeloma, non-Hodgkin lymphoma, and breast cancer in postmenopausal women. No excess risk was observed for breast cancer in premenopausal women or for thyroid cancer. Diabetes was associated with a reduced risk of prostate cancer. Hazard ratios for all-site and site-specific cancers were particularly elevated during the first year following diabetes diagnosis. The findings of this large study with a time-dependent approach are consistent with those of previous studies that have observed associations between diabetes and cancer incidence.

‘Do you think you suffer from depression?’ Reevaluating the use of a single item question for the screening of depression in older primary care patients

The majority of older adults seek depression treatment in primary care. Despite impressive efforts to integrate depression treatment into primary care, depression often remains undetected. The overall goal of the present study was to compare a single item screening for depression to existing depression screening tools.

Reducing health disparities: strategy planning and implementation in Israel's largest health care organization.

OBJECTIVE To describe an organization-wide disparity reduction strategy and to assess its success in quality improvement and reduction of gaps in health and health care. STUDY SETTING Clalit Health Services, Israels largest non-for-profit insurer and provider serving 3.8 million persons. STUDY DESIGN Before and after design: quality assessment before and 12-month postinitiation of the strategic plan. A composite weighted score of seven quality indicators, measuring attainment of diabetes, blood pressure, and lipid control, lack of anemia in infants, and performance of mammography, occult blood tests, and influenza vaccinations. DATA EXTRACTION METHODS Quality indicator scores, derived from Clalits central data warehouse, based on data from electronic medical records. PRINCIPAL FINDINGS Low-performing clinics, of low-socioeconomic and minority populations, were targeted for intervention. Twelve months after the initiation of the project continuous improvement was observed coupled with a reduction of 40 percent of the gap between disadvantaged clinics, serving ~10 percent of enrollees, and all other medium-large clinics. CONCLUSION The comprehensive strategy, following a quality improvement framework, with a top-down top-management incentives and monitoring, and a bottom-up locally tailored interventions, approach, is showing promising results of overall quality improvement coupled with disparity reduction in key health and health care indicators.

Cardiovascular risk management in patients with coronary heart disease in primary care: variation across countries and practices. An observational study based on quality indicators.

BackgroundPrimary care has an important role in cardiovascular risk management (CVRM) and a minimum size of scale of primary care practices may be needed for efficient delivery of CVRM . We examined CVRM in patients with coronary heart disease (CHD) in primary care and explored the impact of practice size.MethodsIn an observational study in 8 countries we sampled CHD patients in primary care practices and collected data from electronic patient records. Practice samples were stratified according to practice size and urbanisation; patients were selected using coded diagnoses when available. CVRM was measured on the basis of internationally validated quality indicators. In the analyses practice size was defined in terms of number of patients registered of visiting the practice. We performed multilevel regression analyses controlling for patient age and sex.ResultsWe included 181 practices (63% of the number targeted). Two countries included a convenience sample of practices. Data from 2960 CHD patients were available. Some countries used methods supplemental to coded diagnoses or other inclusion methods introducing potential inclusion bias. We found substantial variation on all CVRM indicators across practices and countries. We computed aggregated practice scores as percentage of patients with a positive outcome. Rates of risk factor recording varied from 55% for physical activity as the mean practice score across all practices (sd 32%) to 94% (sd 10%) for blood pressure. Rates for reaching treatment targets for systolic blood pressure, diastolic blood pressure and LDL cholesterol were 46% (sd 21%), 86% (sd 12%) and 48% (sd 22%) respectively. Rates for providing recommended cholesterol lowering and antiplatelet drugs were around 80%, and 70% received influenza vaccination. Practice size was not associated to indicator scores with one exception: in Slovenia larger practices performed better. Variation was more related to differences between practices than between countries.ConclusionsCVRM measured by quality indicators showed wide variation within and between countries and possibly leaves room for improvement in all countries involved. Few associations of performance scores with practice size were found.

Twelve-year follow-up of a population-based primary care diabetes program in Israel

OBJECTIVE To describe the effects of a long-term intervention including 72% of Israeli diabetes patients, aimed at improving diabetes care in a primary care setting. DESIGN A retrospective periodic population-based cross-sectional study. SETTING Two health maintenance organizations (HMOs) in Israel-intervention and control. PARTICIPANTS All diagnosed diabetes patients enrolled in both HMOs. INTERVENTION Multifaceted interventions directed toward primary care providers, including educational strategies, registries, clinical pathways, care quality indicators, computerized reminders and feedback. MAIN OUTCOME MEASURES Performance in quality indicators, compared with an HMO that did not implement an intervention program. RESULTS The prevalence of diabetes increased from 20.2/1000 in 1995 to 63.7/1000 in 2007. Annual testing of hemoglobin A1c (HbA1c) rose from 22% in 1995 to 88% in 2007. The corresponding figures for low-density lipoprotein (LDL) were 23 and 89%, and for microalbumin 10 and 69%, respectively (P< 0.0001 for all comparisons). The proportion of HbA1c ≤7% increased from 10 to 53%, while HbA1c >9% decreased from 40 to 13% (P< 0.0001). Good control of LDL ≤100 mg/dl increased from 26 to 59% (P< 0.0001). In the comparison HMO, subtle increases in the performance of HbA1c (55.8-63.4%), LDL (59.7-67.0%) and microalbumin (55.1-67.6%) were noted between 2005 and 2007, respectively. HbA1c ≤7 and >9% remained stable (36 and 13%, respectively), while LDL ≤100 mg/dl rose from 38 to 44% in the control HMO. CONCLUSION A community-oriented program for diabetes care led to improvements in performance of tests, as well as control of HbA1c and LDL among 72% of diabetes patients in Israel.

Psychometric properties of responses by clinicians and older adults to a 6-item Hebrew version of the Hamilton Depression Rating Scale (HAM-D6)

BackgroundThe Hamilton Depression Rating Scale (HAM-D) is commonly used as a screening instrument, as a continuous measure of change in depressive symptoms over time, and as a means to compare the relative efficacy of treatments. Among several abridged versions, the 6-item HAM-D6 is used most widely in large degree because of its good psychometric properties. The current study compares both self-report and clinician-rated versions of the Hebrew version of this scale.MethodsA total of 153 Israelis 75 years of age on average participated in this study. The HAM-D6 was examined using confirmatory factor analytic (CFA) models separately for both patient and clinician responses.ResultsReponses to the HAM-D6 suggest that this instrument measures a unidimensional construct with each of the scales’ six items contributing significantly to the measurement. Comparisons between self-report and clinician versions indicate that responses do not significantly differ for 4 of the 6 items. Moreover, 100% sensitivity (and 91% specificity) was found between patient HAM-D6 responses and clinician diagnoses of depression.ConclusionThese results indicate that the Hebrew HAM-D6 can be used to measure and screen for depressive symptoms among elderly patients.

The European EUCCLID pilot study on care and complications in an unselected sample of people with type 2 diabetes in primary care.

BACKGROUND European studies on quality of diabetes care in an unselected primary care diabetes population are scarce. RESEARCH QUESTION To test the feasibility of the set-up and logistics of a cross-sectional EUropean study on Care and Complications in patients with type 2 diabetes (T2DM) in Primary Care (EUCCLID) in 12 European countries. METHOD One rural and one urban practice from each country participated. The central coordinating centre randomly selected five patients from each practice. Patient characteristics were assessed including medical history, anthropometric measures, quality indicators, UKPDS-risk engine, psychological and general well-being. RESULTS We included 103 participants from 22 GPs in 11 countries. Central data and laboratory samples were successfully collected. Of the participants 54% were female, mean age was 66 years and mean duration of diabetes was 9.6 years. Besides, 18% were using insulin, 31% had a history of cardiovascular disease, mean HbA1c was 7.1% (range 6.6-8.0), mean systolic blood pressure was 133.7 mmHg (range 126.1-144.4) and mean total cholesterol was 4.9 mmol/l (range 4.0-6.2). CONCLUSION A European study on care and complications in a random selection of people with T2DM is feasible. There are large differences in indicators of metabolic control and wellbeing between countries.

Between modern and traditional values: Informal mental health help-seeking attitudes according to Israeli Arab women, primary care patients and their providers

Background: Israeli Arab women under-utilize mental health services. Objectives: The present study evaluated the use of alternative services for dealing with depression and anxiety among Israeli Arab women and primary care providers. Material: Four focus groups with primary care patients and two focus groups with primary care providers were conducted. Constant comparisons were employed in order to identify major themes related to informal help-seeking behaviors. Discussion: Three informal help-seeking behaviors were identified: (a) social support, divided into extended family and neighbors versus nuclear family and close friends; (b) religiosity, divided into inner, direct practices and beliefs versus externally mediated ones; and (c) self-help techniques, such as engagement in activities and distancing oneself from the situation. Both social support and religiosity were viewed with ambivalence by primary care patients and providers. Conclusion: The findings suggest that the Arab population in Israel might be lacking informal sources of support at times of mental health needs.