Nurit Friedman

Fatalism and Mammography in a Multicultural Population

Purpose/Objectives: To assess levels of fatalistic beliefs and their association with mammography use in four population groups in Israel.Design: Telephone survey.Setting: Maccabi Healthcare Services in Israel.Sample: A random sample of 1,550 Arabic and Jewish women.Methods: A random telephone survey was performed during May and June 2007. Womens fatalistic beliefs were measured. Information from claims records regarding mammography use was obtained for each woman.Main Research Variables: Levels of fatalistic beliefs and mammography use.Findings: Fatalistic beliefs included general beliefs that God or fate (external force) was the cause of cancer and related to cancer survivorship. The higher-educated women reported less fatalistic beliefs. Arab women reported more fatalistic beliefs compared to the other women. Mammography use was associated with fatalistic beliefs that external forces were the cause of cancer among Arab and immigrant women but not among veteran Jewish and ultraorthodox women. Fatalistic beliefs about cancer survivorship were not associated with mammography in any of the population groups. Levels of fatalism and education may explain the difference in rates of mammography among Arab and Jewish women.Conclusions: High levels of fatalism may inhibit women from having a mammogram, particularly Arab and immigrant women in Israel. However, this is not a generalizable result for all population groups and all types of fatalism.Implications for Nursing: Interventions to decrease fatalism in Arabs and immigrants may increase compliance with mammography. Nurses may achieve this by developing tailored messages for women who believe that external forces are the cause of cancer.

Brand Versus Generic Alendronate: Gastrointestinal Effects Measured by Resource Utilization:

Background: Adverse reactions related to the upper gastrointestinal tract (UGIT) that are associated with generic alendronate formulations may differ from those associated with the brand drug. Objective: To test the hypothesis that adverse UGIT effects of alendronate formulations may differ between generic and brand products. Methods: We conducted a database health resource utilization analysis of UGIT outcomes in patients who started treatment with generic or brand alendronate formulations during 2001–2005. We included 6962 patients who were treated continuously for 3 months with 1 of 4 alendronate formulations: brand 10 mg/day (Merck, Sharpe & Dohme, n = 1418), generic A 10 mg/day (Teva, Israel, n = 650), generic B 10 mg/day (Unipharm, Israel, n = 628), and brand 70 mg/wk (n = 4266). In these patients, who had neither filled a prescription for alendronate nor had any gastrointestinal problems in the year preceding the study, we compared incidence rates of new use of gastric medications (H2-blockers, proton-pump inhibitors, or antacids), gastroenterology visits, endoscopies, and hospital admissions. Results: Incident rate ratios (IRR) for treatment discontinuation were higher with both daily generic products (IRR 1.3; 95% CI 1.04 to 1.63). Adherence (medication possession ratio [MPR] >80%) was better with brand 10 mg/day (IRR 1.19; 95% CI 1.11 to 1.27). All comparisons were adjusted for use of concurrent corticosteroids, nonsteroidal antiinflammatory drugs, and potassium supplements. Hospitalization rates (2.7-3.2%) were similar in all groups. New use of gastric medications (3.4–4.9%) was lower with brand 10 mg/day (IRR 0.71; 95% CI 0.53 to 0.95). Rates of UGIT endoscopy (n = 49) in patients receiving 10 mg were 0.6% (brand), 1.1% (generic A), and 1.6% (generic B), with generic B higher (IRR 2.88; 95% CI 1.14 to 7.29) in the entire cohort, but not among new users (n = 273) of gastric drugs (IRR 2.46; 95% CI 0.55 to 11.05). Endoscopic findings were normal in 22 patients, hiatal hernia with no mucosal lesion was present in 10 patients, and there was mild-to-moderate esophagitis or gastritis in 17 patients; there were no significant differences among the formulations. Conclusions: We found insufficient evidence to indicate major differences in UGIT adverse effects related to use of daily generic, as compared with brand, alendronates.

Reducing disparities in mammography-use in a multicultural population in Israel

BackgroundIn the past mammography-use has been reported to be low in Israel compared to other western countries. The objectives of this study were (1) to assess the increase in mammography-use during the years 2002 to 2007 in four population groups in Maccabi Healthcare Services (MHS), Israel: non-immigrant non-ultraorthodox, ultraorthodox, and immigrant Jewish women and Arab women; (2) to assess ethnic and socioeconomic disparities in mammography-use.MethodsA random telephone survey of 1,550 women receiving healthcare services from MHS was performed during May-June 2007. Information from MHS claims-records database regarding mammography-use was obtained for each woman for the period 2002 to 2007. Since mammography-use serves as a quality assurance measure for primary care, MHS sent mail and telephone invitations for mammography to all women since the end of 2004.ResultsAt the beginning of the follow-up period (2002) mammography-use among Jewish non-immigrant non-ultraorthodox and ultraorthodox women was higher than among Arab and Jewish immigrant women. During the 5 year follow-up these disparities decreased significantly. In 2007, mammography-use by Arab women was only slightly lower compared to all groups of Jewish women. In 2007, after adjustment for socioeconomic factors there was only a borderline significant difference between Jewish and Arab women. The socioeconomic variables were not associated with mammography-use in 2002 and 2007 in any of the groups except for marital status in immigrant women in 2002.ConclusionThe interventions implemented by MHS may have increased mammography-use in all population groups, decreasing disparities between the groups, however the differences between Jewish and Arab women have not been completely eliminated and indicate a need for further targeted interventions. No significant socioeconomic disparities in mammography-use were observed.

Validity of self-reported mammography in a multicultural population in Israel

OBJECTIVE To validate self-reported mammography against claims records in women aged 52-74 living in Israel and belonging to the Jewish (non-orthodox pre-1989 native or former Soviet Union immigrant or ultra-orthodox) or Arab populations. METHODS In a spring 2007 random telephone survey, 1550 women receiving healthcare at Maccabi Health Services were asked whether they had had a mammography during the previous 2 years. The same information was obtained from claims records and treated as the gold standard. RESULTS Self-reported mammography and claims records disagreed for 17.4%. Compared to the other populations, Arab women tended to report more often that they had obtained a mammogram when it was not registered in the claims data (specificity=47.3%, 95% CI%=38.4, 56.3). Ultra-orthodox women more often failed to report having had the mammogram while the claims records indicated they had had (sensitivity=90.3%, 95% CI%=86.1, 93.6). CONCLUSION Agreement between self-reported mammography and claims records depends on cultural and socioeconomic factors.

Database evaluation of the effects of long-term rosiglitazone treatment on cardiovascular outcomes in patients with type 2 diabetes.

Recent meta‐analyses suggest an increased risk of acute myocardial infarction (AMI) in patients with type 2 diabetes mellitus (T2DM) treated with rosiglitazone. These meta‐analyses have drawn considerable criticisms. Retrospective observational studies do not consistently support this association. The objective of this study was to compare rates of adverse cardiovascular outcomes in T2DM patients treated with rosiglitazone alone or combined with metformin or metformin alone. This retrospective study, using the health maintenance organization database, included patients who were dispensed rosiglitazone (alone or with metformin) for at least 6 months as follows: rosiglitazone alone (n = 745), rosiglitazone and metformin (n = 2753), and metformin alone (n = 11 938). Adverse cardiovascular outcomes were new diagnosis of AMI, acute coronary syndrome (ACS), coronary revascularization (CRV), congestive heart failure (CHF), and all‐cause mortality. Mean on‐treatment follow‐up was 30 months. After adjustment for covariates found to be significant in univariate analyses, rosiglitazone was associated only with CHF (hazard ratio [HR] = 2.23; 95% confidence interval [CI]: 1.41‐1.95) with no increase of risk for AMI (HR = 1.13; 95%CI: 0.60‐2.12), ACS (HR = 0.85; 95% CI: 0.57‐1.26), coronary revascularization (HR = 1.22; 95% CI:0.82‐1.54), or all‐cause mortality (HR = 1.15; 95% CI: 0.85‐1.56). In this community‐based cohort, 30 months of therapy with rosiglitazone treatment was associated with increased risk of CHF but was not associated with increased risk of AMI, ACS, coronary revascularization, or all‐cause mortality.

Use of a Refined Drug Tracer Algorithm to Estimate Prevalence and Incidence of Parkinson's Disease in a Large Israeli Population

Estimating rates of Parkinsons disease (PD) is essential for health services planning and studies of disease determinants. However, few PD registries exist. We aimed to estimate annual prevalence and incidence of PD in a large Israeli population over the past decade using computerized drug purchase data. Based on profiles of anti-parkinsonian drugs, age at first purchase, purchase density, and follow-up time, we developed a refined algorithm for PD assessment (definite, probable or possible) and validated it against clinical diagnoses. We used the prescription database of the second largest Health Maintenance Organization in Israel (covers ~25% of population), for the years 1998-2008. PD rates by age, gender and year were calculated and compared using Poisson models. The algorithm was found to be highly sensitive (96%) for detecting PD cases. We identified 7,134 prevalent cases (67% definite/probable), and 5,288 incident cases (65% definite/probable), with mean age at first purchase 69 ± 13 years. Over the years 2000-2007, PD incidence rate of 33/100,000 was stable, and the prevalence rate increased from 170/100,000 to 256/100,000. For ages 50+, 60+, 70+, median prevalence rates were 1%, 2%, 3%, respectively. Incidence rates also increased with age (RR = 1.76, 95%CI 1.75-1.77, ages 50+, 5-year interval). For ages 50+, rates were higher among men for both prevalence (RR = 1.38, 95%CI 1.37-1.39) and incidence (RR = 1.45, 95%CI 1.42-1.48). In conclusion, our refined algorithm for PD assessment, based on computerized drug purchases data, may be a reliable tool for population-based studies. The findings indicate a burden of PD in Israel higher than previously assumed.

Methodological challenges in international performance measurement using patient-level administrative data☆

AIM AND METHODS We conducted this case study in order to test how health system performance could be compared using the existing national administrative health databases containing individual data. In this comparative analysis we used national data set from three countries, Estonia, Israel and Finland to follow the medical history, treatment outcome and resource use of patients with a chronic disease (diabetes) for 8 years after medical treatment was initiated. RESULTS This study showed that several clinically important aspects of quality of care as well as health policy issues of cost-effectiveness and efficiency of health systems can be assessed by using the national administrative health data systems, in case those collecting person-level health service data. We developed a structured study protocol and detailed data specifications to generate standardized data sets, in each country, for long-term follow up of incident cohort of diabetic persons as well as shared analyzing programs to produce performance measures from the standardized data sets. This stepwise decentralized approach and use of anonymous person-level data allowed us to mitigate any legal, ownership, confidentiality and privacy concerns and to create internationally comparative data with the extent of detail that is seldom seen before. For example, our preliminary performance comparisons indicate that higher mortality among relatively young diabetes patients in Estonia may be related to considerably higher rates of cardiovascular complications and lower use of statins. CONCLUSIONS Modern administrative person-level health service databases contain sufficiently rich data in details to assess the performance of health systems in the management of chronic diseases. This paper presents and discusses the methodological challenges and the way the problems were solved or avoided to enhance the representativeness and comparability of results.

Parkinson's disease patients first treated at age 75 years or older: A comparative study

BACKGROUND Parkinsons disease (PD) first diagnosed at older age reportedly has different clinical characteristics and survival rates than when it is first diagnosed at younger age. We compared these features among PD patients who initiated anti-parkinsonian drugs at age 75-85 years (elderly) with those who started treatment at age 50-74 years (younger). METHODS We used a population-based cohort of 4449 incident cases of PD patients aged 50-85 at treatment initiation, based on a pharmacy registry of Maccabi Health Maintenance Organization, with definite/probable/possible certainty of having PD. Mean follow-up was 3.9 ± 2.6 years. The two age groups were compared for time/risk to levodopa and to death, using Kaplan-Meier curves and Cox regression. Gender-specific standardized mortality rates (SMRs) accounting for Israeli death rates were also compared. RESULTS One-half of the entire cohort (n = 2148) were elderly (>75 years) and more likely to be given levodopa (Hazard Rate (HR) = 1.48, P < 0.05), had a significantly higher frequency of comorbidities (e.g., heart disease, hypertension and cancer), and had a 3-fold increased risk to die (HR = 2.97, P < 0.05) within the same follow-up time as the youngers. Accounting for the general Israeli population death rates, female PD patients had a significantly lower risk to die compared to males especially females who were elderly at treatment initiation (SMR = 1.53 for females vs. 1.73 for males, P < 0.05). CONCLUSIONS PD patients first diagnosed and treated at >74 years of age comprise a unique cluster for inclusion into drugs studies, mortality risk analyses and for projection of disease burden.

Disease management in the treatment of patients with chronic heart failure who have universal access to health care: a randomized controlled trial

BackgroundThe efficacy of disease management programs in improving the outcome of heart failure patients remains uncertain and may vary across health systems. This study explores whether a countrywide disease management program is superior to usual care in reducing adverse health outcomes and improving well-being among community-dwelling adult patients with moderate-to-severe chronic heart failure who have universal access to advanced health-care services and technologies.MethodsIn this multicenter open-label trial, 1,360 patients recruited after hospitalization for heart failure exacerbation (38%) or from the community (62%) were randomly assigned to either disease management or usual care. Disease management, delivered by multi-disciplinary teams, included coordination of care, patient education, monitoring disease symptoms and patient adherence to medication regimen, titration of drug therapy, and home tele-monitoring of body weight, blood pressure and heart rate. Patients assigned to usual care were treated by primary care practitioners and consultant cardiologists.The primary composite endpoint was the time elapsed till first hospital admission for heart failure exacerbation or death from any cause. Secondary endpoints included the number of all hospital admissions, health-related quality of life and depression during follow-up. Intention-to-treat comparisons between treatments were adjusted for baseline patient data and study center.ResultsDuring the follow-up, 388 (56.9%) patients assigned to disease management and 387 (57.1%) assigned to usual care had a primary endpoint event. The median (range) time elapsed until the primary endpoint event or end of study was 2.0 (0–5.0) years among patients assigned to disease management, and 1.8 (0–5.0) years among patients assigned to usual care (adjusted hazard ratio, 0.908; 95% confidence interval, 0.788 to 1.047). Hospital admissions were mostly (70%) unrelated to heart failure.Patients assigned to disease management had a better health-related quality of life and a lower depression score during follow-up.ConclusionsThis comprehensive disease management intervention was not superior to usual care with respect to the primary composite endpoint, but it improved health-related quality of life and depression. A disease-centered approach may not suffice to make a significant impact on hospital admissions and mortality in patients with chronic heart failure who have universal access to health care.Clinical trial registrationClinicaltrials.gov identifier: NCT00533013. Trial registration date: 9 August 2007. Initial protocol release date: 20 September 2007.

Development of an unsupportive social interaction scale for patients with diabetes.

Objectives The positive aspects of social support and its impact on health have been studied extensively. However, there may also be negative effects of social environments on the diabetic patient. This study developed and validated a new diabetic unsupportive social interaction scale (USIS), including two subscales: interference and insensitivity. Methods A list of 22 items depicting unsupportive interactions associated with management of diabetes was developed. A telephone survey was administered to 764 Israelis with diabetes. The questionnaire included the USIS and questions about social networks, social support, health behaviors, and health. The characteristics, validity, and reliability of the scale were tested. Results A principal component analysis was performed for extraction of two factors describing unsupportive social interaction concepts: interference and insensitivity. Cronbach’s alpha for the full 15-item scale was 0.84, indicating internal consistency. The two subscales were calculated to have Cronbach’s alphas of 0.85 and 0.73, respectively. The USIS showed construct validity as it was associated with social support, some measures of social networks, subjective measures of health, and health behaviors. Arabs, older respondents, those defining themselves as more religious, and the less educated reported higher rates of unsupportive interactions. Conclusion This study suggests a new concept of unsupportive interactions including interference and insensitivity. These unsupportive interactions may adversely affect patients’ ability to adhere to treatment and may undermine their health in various ways. Identifying these problems may enable clinicians to help patients cope with their unsupportive environments.