Ronit Peled

Disparities in diabetes care: role of the patient's socio-demographic characteristics

BackgroundThe commitment to promoting equity in health is derived from the notion that all human beings have the right to the best attainable health. However, disparities in health care are well-documented. The objectives were to explore disparities in diabetes prevalence, care and control among diabetic patients. The study was conducted by Maccabi Healthcare Services (MHS), an Israeli HMO (health care plan).MethodsRetrospective study. The dependent variables were diabetes prevalence, uptake of follow-up examinations, and disease control. The independent variables were socio-economic rank (SER), ethnicity (Arab vs non Arab), supplementary voluntary health insurance (SVHI), and immigration from Former Soviet Union (FSU) countries. Chi Square and Logistic Regression Models were estimated.ResultsWe analyzed 74,953 diabetes patients. Diabetes was more prevalent in males, lower SER patients, Arabs, immigrants and owners of SVHI. Optimal follow up was more frequent among females, lower SERs patients, non Arabs, immigrants and SVHI owners. Patients who were female, had higher SERs, non Arabs, immigrants and SVHI owners achieved better control of the disease. The multivariate analysis revealed significant associations between optimal follow up and age, gender (males), SER (Ranks 1-10), Arabs and SVHI (OR 1.02, 0.95, 1.15, 0.85 and 1.31, respectively); poor diabetes control (HbA1C > 9 gr%) was significantly associated with age, gender (males), Arabs, immigrants, SER (Ranks1-10) and SVHI (OR 0.96, 1.26, 1.38, 0.72, 1.37 and 0.57, respectively); significant associations with LDL control (< 100 gr%) were revealed for age, gender (males) and SVHI (OR 1.02, 1.30 and 1.44, respectively).ConclusionDisparities in diabetes prevalence, care and control were revealed according to population sub-group. MHS has recently established a comprehensive strategy and action plan, aimed to reduce disparities among members of low socioeconomic rank and Arab ethnicity, sub-groups identified in our study as being at risk for less favorable health outcomes.

The Influence of Smoking Cessation on Hemodynamics and Arterial Compliance

Cigarette smoking is associated with consistent changes in small arteries and arterioles. Recently, arterial compliance was determined in smokers; however, the effect of smoking cessation on arterial compliance has not yet been investigated. The objective of the study was to assess how smoking cessation, achieved with use of behavioral and pharmacologic therapy, influences vascular compliance and arterial stiffness in smokers. In an open-label study, 60 habitual smokers were treated for 2 months with buproprion 300 mg per day and personal and group conversations in order to facilitate smoking cessation. Hemodynamic variables, including vascular compliance and augmentation index (AI), were measured twice, at the beginning of the study and after 6 months. Of the 60 smokers, 35 stopped smoking and 25 failed at the end of the 2-month treatment period. Of the 35 who were initially successful, 12 went back to smoking, and thus only 23 remained nonsmokers at the end of 6 months. Smoking cessation was accompanied by significantly lower arterial pressure and heart rate but by weight gain. Among the 23 subjects who stopped smoking for 6 months capacitive compliance (C1) did not change but oscillatory compliance (C2) rose significantly (from 5.1 ±2.3 to 6.3 ±3.0 p<0.01), and AI decreased significantly (from 63.1 ±22 to 50.6 ±17 p<0.05), whereas in smokers who still smoked after this period, both C1 and C2 and augmentation index did not change significantly from their basal values. The authors conclude that smoking cessation improves arterial stiffness as assessed by the augmentation index, owing mainly to increasing the small artery compliance, which is known to be an early index of endothelial damage.

Oral contraceptives and liver hemangioma: a case-control study

Objective.  To study whether there is an epidemiological association between liver hemangiomas and oral contraception use, as may be suggested by clinical observations of liver hemangioma growth during pregnancy and under estrogen administration.

Increased incidence of diabetes mellitus in the patients with transitional cell carcinoma of urinary bladder

The progression of bladder cancer to invasive disease is highly dependent on its ability to penetrate basement membrane of urothelium. Studies on diabetic nephropathy have shown a reduction in proteoglycan content of the glomerular basement membrane. Based on the well-known fact that proteoglycans are one of the main components of basement membrane and extracellular matrix we assessed the relationship between diabetes mellitus, bladder cancer incidence and its behavior. These studies include 252 patients with microscopically confirmed transitional cell carcinoma of bladder, and 549 patients with other urological disorders who served as controls. The prevalence of diabetes mellitus in each group was assessed. The group of patients suffering from transitional cell carcinoma was divided according to etiological risk factors such as cigarette smoking, diabetes and patients that were non-smokers and did not suffer from diabetes mellitus. We assessed the features of bladder cancer behavior in each group. Logistic regression model estimation for statistical analysis was used, with transitional cell carcinoma as a dependent binary variable and age, sexes smoking and diabetes as independent variables. Statistical significance was considered at two levels: p <-0.001 and p <-0.05. Odds ratio (OR) adjusted to age, sex, cigarette smoking, diabetes mellitus and 95% Confidence Interval (CI) were calculated for TCC. In the TCC group 22.2% of the patients suffered from diabetes mellitus. In the control group 10.38% suffered from diabetes mellitus. Logistic regression analysis, OR and 95% CI showed a statistically significant relationship between diabetes and TCC. These data are comparable only with smoking (OR -2.3; 95% CI -1.6 –3.5 and OR-1.58; 95% CI -1.08 –2.4 correspondingly). Based on these data we suggest that diabetes mellitus may be considered an etiological risk factor for bladder cancer development.

Effect of short-term dutasteride therapy on prostate vascularity in patients with benign prostatic hyperplasia: a pilot study.

OBJECTIVES In this study we assessed the possible influence of dutasteride (types 1 and 2 isoenzymes of 5-alpha-reductase inhibitors) on prostate tissue vascularity. We also attempted to evaluate whether preoperative treatment with dutasteride could help to avoid excessive bleeding in patients undergoing transurethral resection of prostate (TUR-P). METHODS This pilot study has 3 phases. All patients enrolled in the study had a prostate-specific antigen < 4 ng/mL and normal digital rectal examination. In the first phase we included 10 patients with benign prostatic hyperplasia treated with alpha-blockers. The end point of this phase was to choose the preset that could exclude noise signals and be reproducible. In the second phase, we included 32 patients in whom color Doppler sonography (CDS) was performed before and 6 weeks after treatment with 0.5 mg dutasteride per day. We counted every discrete color Doppler signal (CD-spot). To compare the CDS data, we used the Student t test, and P < .05 was considered significant. Afterward, 46 patients joined the third phase. Patients were assigned to the control and study groups according to sequentially numbered sealed envelopes. Patients in the study group received 0.5 mg dutasteride 6 weeks before TUR-P. RESULTS In the first phase: color Doppler preset with pulse repetition frequency of 0.3 kHz was chosen as the most sensible. In the second phase, a significant decline in CD-spots count was detected in 23 (72%) patients (P < .05) and was more distinctive in the periurethral zone. In the third phase, only 43 of the patients continued with TUR-P (in 3 patients, voiding symptoms improved). Operating time and volume of irrigation fluid were significantly different (50.55 minutes/42.65 minutes, P = .014; 8.03/13.10 L, P = .047). CONCLUSIONS Six weeks of dutasteride treatment may reduce prostate tissue vascularity in the periurethral area proximal to the verumontanum. The third phase of our study confirmed that preoperative treatment with dutasteride could improve operative performance and avoid TUR syndrome.

Using gray-scale and two different techniques of color Doppler sonography to detect prostate cancer

OBJECTIVES To correlate the findings of prostate color Doppler sonography (CDS) with those of site-specific transrectal ultrasound-guided core biopsy; to evaluate the significance of two different color presets in detecting prostate cancer compared with gray-scale transrectal ultrasonography; and to compare the accuracy of conventional gray-scale transrectal ultrasound (CGS)-guided biopsy with CDS-guided biopsy. METHODS Seventy patients were enrolled in this prospective study. CDS was performed before biopsy. Two color presets were used: CDS-1 (high sensitivity) and CDS-2 (high specificity). The color flow was graded on a scale from 0 to 2+. At the completion of the color grading, color maps were constructed. In each case, CDS-guided biopsy was performed followed by CGS-guided biopsy (six sextant biopsies and focal lesional biopsies). RESULTS The cancer detection rate was 33%, 31%, and 27% for CGS-guided biopsy, CDS-1, and CDS-2, respectively. CDS-1 was more sensitive than CDS-2 (81% versus 60%) but both presets had similar specificities (79% versus 82%). CGS-guided biopsy yielded a sensitivity of 90%, a specificity of 38%, and a positive and negative predictive value of 34% and 83%, respectively. A biopsy strategy combining hypoechoicity with increased color flow increased the specificity to 97%, positive predictive value to 68%, and negative predictive value to 84%, but its sensitivity was low (18%). CONCLUSIONS Our experience suggests that low-velocity, high-sensitivity color is superior to all other CDS settings. The presence of focal peripheral zone hypervascularity at CDS is associated with a high likelihood of prostate cancer. However, only a combination of CDS guidance with six sextant biopsies may achieve maximal sensitivity and specificity.

The effect of drug co-payment policy on the purchase of prescription drugs for children with infections in the community

A cross-sectional study was conducted to investigate the influence of the co-payment policy in a community setting on the purchase of prescription medications for children with acute infections. Data for all purchased medications prescribed for children with an acute infectious disease were gathered from a pediatric health care center over a 6-week period. Parents of the sick children and controls were interviewed by telephone, using a short sociodemographic questionnaire, and were asked to state their reasons for not purchasing (either partially or completely) necessary medications, primarily antibiotics. Of the 779 children who received a prescription for antibiotics during the 6-week period, 162 (20.7%) failed to take the complete course of antibiotic treatment. One hundred and one parents of these children (62.3%) were interviewed, of whom 30 (29.7%) claimed that the main reason for not buying the full course of antibiotic medication was the cost. This group is characterized by low income, overcrowded housing conditions and a large quantity of prescription medications. The cost of prescribed medication under the co-payment policy is a serious barrier to the purchase of prescribed medication for children with acute infections in the primary care setting. The policy has a particularly deleterious effect in under-privileged populations and is in contradiction with the proclaimed principles of justice and equality underlying the obligatory Israeli National Israeli Health Insurance Law and similar laws in other western countries.

The association between socio-demographic characteristics and adherence to breast and colorectal cancer screening: Analysis of large sub populations

BackgroundPopulations having lower socioeconomic status, as well as ethnic minorities, have demonstrated lower utilization of preventive screening, including tests for early detection of breast and colorectal cancer.The objectiveTo explore socio-demographic disparities in adherence to screening recommendations for early detection of cancer.MethodsThe study was conducted by Maccabi Healthcare Services, an Israeli HMO (health plan) providing healthcare services to 1.9 million members. Utilization of breast cancer (BC) and colorectal cancer (CC) screening were analyzed by socio-economic ranks (SERs), ethnicity (Arab vs non-Arab), immigration status and ownership of voluntarily supplemental health insurance (VSHI).ResultsData on 157,928 and 303,330 adults, eligible for BC and CC screening, respectively, were analyzed. Those having lower SER, Arabs, immigrants from Former Soviet Union countries and non-owners of VSHI performed fewer cancer screening examinations compared with those having higher SER, non-Arabs, veterans and owners of VSHI (p < 0.001). Logistic regression model for BC Screening revealed a positive association with age and ownership of VSHI and a negative association with being an Arab and having a lower SER. The model for CC screening revealed a positive association with age and ownership of VSHI and a negative association with being an Arab, having a lower SER and being an immigrant. The model estimated for BC and CC screening among females revealed a positive association with age and ownership of VSHI and a negative association with being an Arab, having a lower SER and being an immigrant.ConclusionPatients from low socio-economic backgrounds, Arabs, immigrants and those who do not own supplemental insurance do fewer tests for early detection of cancer. These sub-populations should be considered priority populations for targeted intervention programs and improved resource allocation.

Oral Contraceptive Use and BRCA Penetrance: A Case-Only Study

Background: Women with deleterious mutations in BRCA genes are at increased risk of breast cancer. However, the penetrance of the genetic trait may be regulated through environmental factors. This multinational case-only study tested the interaction between oral contraceptive use and genetic susceptibility in the occurrence of breast cancer. Methods: We recruited 3,123 patients diagnosed with breast cancer before the age of 45 years. Participants were classified according to their probability of carrying a BRCA mutation on the basis of their family history of breast and ovarian cancer. According to a case-only approach, the frequency of relevant exposures among breast cancer cases with high probability of BRCA mutation (“genetic cases”) was compared with the frequency of the same exposures among breast cancer cases with a low probability of BRCA mutation (“sporadic cases”). The interaction odds ratios (OR) and 95% confidence intervals (CI) for oral contraceptive use were estimated by unconditional logistic regression, after controlling for potentially confounding variables. Results: The analysis was carried out comparing 382 “genetic” and 1,333 “sporadic” cases. We found a borderline significant interaction between genetic breast cancer and oral contraceptive use for ever users compared with never users (OR, 1.3; 95% CI, 1.0-1.7). The greatest interaction OR was found for women who started using pill at 18 to 20 years (OR, 1.6; 95% CI, 1.1-2.3). Conclusion: These results suggest that BRCA mutation carriers, as well as women with a significant family history of breast and ovarian cancer are more vulnerable to exogenous hormones in oral contraceptives. (Cancer Epidemiol Biomarkers Prev 2009;18(7):2107–13)

Defining localities of inadequate treatment for childhood asthma: a GIS approach.

BackgroundThe use of Geographic Information Systems (GIS) has great potential for the management of chronic disease and the analysis of clinical and administrative health care data. Asthma is a chronic disease associated with substantial morbidity, mortality, and health care use. Epidemiologic data from all over the world show an increasing prevalence of asthma morbidity and mortality despite the availability of effective treatment. These facts led to the emergence of strategies developed to improve the quality of asthma care.The objectiveTo develop an efficient tool for quality assurance and chronic disease management using a Geographic Information System (GIS).Geographic locationThe southern region of Israel. January 1998 – October 2000.DatabasesAdministrative claims data of the largest HMO in Israel: drug dispensing registry, demographic data, Emergency Room visits, and hospitalization data bases.MethodsWe created a list of six markers for inadequate pharmaceutical treatment of childhood asthma from the Israeli clinical guidelines. We used this list to search the drug dispensing registry to identify asthmatic children who received inadequate treatment and to assess their health care utilization and bad outcomes: emergency room visits and hospitalizations. Using GIS we created thematic maps on which we located the clinics with a high percentage of children for whom the treatment provided was not in adherence with the clinical guidelines.Results81% of the children were found to have at least one marker for inadequate treatment; 17.5% were found to have more than one marker. Children with markers were found to have statistically significant higher rates of Emergency Room visits, hospitalizations and longer length of stay in hospital compared with children without markers. The maps show in a robust way which clinics provided treatment not in accord with the clinical guidelines. Those clinics have high rates of Emergency Room visits, hospitalizations and length of stay.ConclusionIntegration of clinical guidelines, administrative data and GIS can create an efficient interface between administrative and clinical information. This tool can be used for allocating sites for quality assurance interventions.