Cardiac and cardiovascular morbidities in patients with psoriatic arthritis: a population-based case control study.

OBJECTIVE: To assess the prevalence of risk factors associated with cardiovascular disease (CVD) and CVD-related morbidity in a large Middle-Eastern psoriatic arthritis (PsA) cohort. METHOD: A retrospective case control study was conducted using Israel's largest health care provider's patient database from 2000 to 2013. For each patient with PsA, 10 patients with no history of psoriasis or arthritis were matched for age and sex. Analysis of CVD-related risk factors and morbidity included hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus type 2 (DM-2), obesity, smoking, ischemic heart disease (IHD), congestive heart failure (CHF), cerebrovascular accident (CVA), carotid artery disease, peripheral vascular disease (PVD), aortic aneurism, valvular heart disease (VHD), and cardiomyopathy. Statistical analysis was conducted using t test and chi-square tests as appropriate. Univariate and multivariable logistic regression models assessed the association between PsA and CVD-related risk factors and morbidity. RESULTS: Three thousand one hundred sixty-one PsA patients were included, with average age 58 ± 15.0 years, of whom 53.4% were women. Increased prevalence of DM-2, HLD, HTN, and obesity (OR 1.7, 1.5, 1.5, 1.5 respectively) was noted in the PsA group. Increased prevalence of IHD (p < 0.0001), PVD (p < 0.0001), CHF (p = 0.002), VHD (p < 0.0001), and cardiomyopathy (p = 0.006) was found in the PsA group compared to the control group even after adjusting for CVD risk factors. CONCLUSIONS: A high prevalence of CVD-related risk factors and morbidity was found in this Middle Eastern PsA population, in accordance with data from other geographic regions. These results emphasize the importance of clinician awareness of the increased risk for CVD-related complications in PsA patients.

Increased Prevalence of Metabolic Syndrome and Adipocytokine Levels in a Psoriatic Arthritis Cohort.

OBJECTIVE: The aims of this study were to evaluate the prevalence of metabolic syndrome (MetS) in psoriatic arthritis (PsA) patients according to the most recent definition in a Mediterranean population and to determine its association with biomarkers of inflammation and serum adipocytokine levels. METHODS: Demographic, clinical, and laboratory data were collected on 74 patients with PsA and 82 control subjects. The presence of MetS was determined according to the current "harmonization" definition. Serum adipocytokines were analyzed. Continuous variables were compared by t test and discrete variables by χ test. Multivariate regression models compared the association between the presence of MetS and the blood levels of adipocytokines. RESULTS: The prevalence of MetS was higher in PsA patients compared with the control group: 54.8% versus 36.6%, respectively (P = 0.02; odds ratio, 2.33; 95% confidence interval, 1.16-4.69). The main difference between the 2 groups was waist circumference. No association was found between MetS and parameters of articular and skin disease activity or treatment. Leptin levels and leptin/adiponectin ratio were higher in PsA patients compared with control subjects: 83.4 versus 51.7 ng/mL (P = 0.001) and 6.3 × 10 versus 4.1 × 10 (P = 0.015), respectively. There was no significant difference in the adiponectin levels between the groups. CONCLUSIONS: The prevalence of MetS was higher in PsA patients compared with non-PsA control subjects in this Mediterranean population. Clinicians caring for PsA patients ought to be aware of the increased risk of MetS in PsA patients, confirmed in different regions worldwide. The increased MetS seems to be linked to central obesity in these patients, and appropriate treatment recommendations are advised.

Endocrine Comorbidities in Patients with Psoriatic Arthritis: A Population-based Case-controlled Study.

OBJECTIVE: To investigate endocrine comorbidities in patients with psoriatic arthritis (PsA). METHODS: A retrospective, cross-sectional study was performed with the database of Clalit Health Services, the largest healthcare provider in Israel, between 2002 and 2014. Patients with PsA were identified and matched by age and sex to healthy controls. The following morbidities were analyzed: hypo/hyperthyroidism, hypo/hyperparathyroidism, hyperprolactinemia, Cushing disease, Addison disease, diabetes insipidus, diabetes mellitus (DM), pituitary adenoma, acromegaly, and osteoporosis. Descriptive statistics were applied. The associations between PsA and endocrine comorbidities were analyzed by univariable and multivariable analysis. RESULTS: The study included 3161 patients with PsA, 53.4% women, mean age 58.4 ± 15.4 years, and 31,610 controls. Comparative analyses yielded higher proportion of hypothyroidism (12.7% vs 8.6%, p < 0.0001), Cushing disease (0.3% vs 0.1%, p < 0.0001), osteoporosis (13.2% vs 9.1%, p < 0.0001), and DM (27.9% vs 20.7%, p < 0.0001) in the PsA group compared with the control group. In the multivariable regression analysis, the following diseases were more frequent in the PsA group: hypothyroidism (OR 1.61, 95% CI 1.47-1.81), DM (OR 1.35, 95% CI 1.18-1.42), Cushing disease (OR 3.96, 95% CI 1.67-9.43), and osteoporosis (OR 1.56, 95% CI 1.37-1.78). CONCLUSION: PsA is associated with a high frequency of hypothyroidism, osteoporosis, DM, and Cushing disease. Awareness of these comorbidities may help physicians provide the optimal medical care to patients with PsA.

Hemoglobin levels and blood transfusion in patients with sepsis in Internal Medicine Departments.

BACKGROUND: Acute reduction in hemoglobin levels is frequently seen during sepsis. Previous studies have focused on the management of anemia in patients with septic shock admitted to intensive care units (ICU's), including aggressive blood transfusion aiming to enhance tissue oxygenation. AIM: To study the changes in hemoglobin concentrations during the first week of sepsis in the setting of Internal Medicine (IM) units, and their correlation to survival. DESIGN: Observational prospective study. METHODS: We recorded hemoglobin values upon admission and throughout the first week of hospital stay in a consecutive cohort of septic patients admitted to IM units at a community hospital, the patients were enrolled into a prospective registry. Data on blood transfusions was also collected, we examined the correlation between hemoglobin concentrations during the first week of sepsis and survival, the effect of blood transfusion was also assessed. RESULTS: Eight hundred and fifteen patients (815) with sepsis were enrolled between February 2008 to January 2009. More than 20 % of them had hemoglobin levels less than 10g/dL on admission, a rate that was doubled during the first week of sepsis. Overall, 68 (8.3 %) received blood transfusions, 14 of them (20.6 %) due to bleeding. Typically, blood transfusion was given to older patients with a higher rate of malignancy and lower hemoglobin levels. While hemoglobin concentration on admission had strong correlation with in-hospital mortality (O.R-0.83 [95 % C.I. 0.74-0.92], blood transfusion was not found to be an independent predicting factor for mortality. CONCLUSION: Anemia is very common in sepsis. While hemoglobin level on admission exhibit independent correlation with survival, blood transfusion do not.

Gastrointestinal comorbidities in patients with psoriatic arthritis.

Comorbidities associated with psoriatic arthritis (PsA) include cardiovascular diseases, diabetes mellitus, and obesity. This study evaluated the association between PsA and common gastrointestinal (GI) diseases. A retrospective study was performed in Israel's largest health care provider database between 2002 and 2013. 3161 PsA patients were matched for age and sex with 31610 randomly selected patients. We searched these patients' records for the presence of peptic ulcer disease (PUD), reflux esophagitis, Crohn's disease, ulcerative colitis, irritable bowel syndrome (IBS) and celiac disease. T-test was used to compare continuous variables and a Chi-square test was used for categorical variables. Multivariate logistic regression models were used to assess the association between PsA and GI comorbidities. PsA was associated with Crohn's disease (OR 2.4, 95 %CI: 1.75-3.32, p < 0.0001), ulcerative colitis (OR 2.1, 95 %CI: 1.33-3.26, p = 0.001), reflux esophagitis (OR 1.6, 95 %CI: 1.44-1.78, p < 0.0001), PUD (OR 1.5, 95 %CI: 1.31-1.63, p < 0.0001) and IBS (OR 1.4, 95 %CI: 1.01-1.86, p = 0.045). After controlling for known risk factors, the association remained significant between PsA and Crohn's disease (OR 2.2, 95 %CI: 1.59-3.03, p < 0.0001), ulcerative colitis (OR 1.9, 95 %CI: 1.21-3.00, p = 0.005), reflux esophagitis (OR 1.5, 95 %CI: 1.31-1.63, p < 0.0001), and PUD (OR 1.3, 95 %CI: 1.12-1.47, p < 0.0001). No significant association was found between PsA and celiac disease. In the current study PsA was associated with gastrointestinal morbidities including Crohn's disease, ulcerative colitis, PUD and IBS. Physicians treating patients with PsA should be aware of these associations.

[COMMUNITY, HOSPITAL AND IN-BETWEEN: QUALITY MEASURES FOR THE CONTINUITY OF CARE].

INTRODUCTION: The southern district of Clalit Health Services and Soroka University Medical Center are combined in an organizational configuration: the Southern Region. The Region has developed joint programs in order to advance the quality of medical care whilst optimizing the utilization of available resources. An objective continuous method of assessment was needed to evaluate the continuity of care between the community and the hospital. AIMS: To produce objective tools for quantification based on pre-existing data systems, which enable ongoing assessment of the quality of continuity of care between the community and hospital, and the impact of the introduction of novel means of improvement. METHODS: We defined a set of measurements that exemplify continuity of care in different areas of transition between community and hospital, all directly retrievable from existing computerized data sources. RESULTS: About forty different measurements have been defined, in different clinical areas. Of these, a dozen have already been implemented by mapping the process and the main obstacles that the patient goes through, followed by implementation of appropriate solutions. CONCLUSIONS: The application of an objective system of assessment of the results of continuity of care, utilizing pre-existing data sources, is essential for advancing the initiative, and is a breakthrough in the quantification of continuity of care. DISCUSSION: Continuity of care between community and hospital has been applied in the Southern Region to dozens of quality measurements. This is a novel project developing an objective system of measurement, directly assessing the quality of continuity of care for the individual patient.

Bleeding in patients with atrial fibrillation treated with dabigatran, rivaroxaban or warfarin: A retrospective population-based cohort study.

BACKGOUND: Randomized controlled trials (RCTs) have shown that dabigatran, rivaroxaban and warfarin cause similar bleeding rates. METHODS: We performed a retrospective population-based cohort study to determine the incidence of bleeding in patients with atrial fibrillation (AF) beginning dabigatran, rivaroxaban or warfarin. Consecutive patients initiating anticoagulation for AF during a 3year period were identified using a computerized database. Patients who bled and required hospitalization underwent chart review. Bleeding incidences were calculated per 100 patient-years of treatment. RESULTS: 18,249 patients were included: 9564 (52.4%) received warfarin, 5976 (32.7%) dabigatran, and 2709 (14.8%) rivaroxaban. Bleeding incidences were 3.9 (95% CI, 3.6-4.4) in warfarin-treated patients, 4.2 (95% CI, 3.7-4.7) in dabigatran patients, and 4.1 (95% CI, 3.0-5.3) in rivaroxaban patients. Intracranial hemorrhage (ICH) rates were 0.71 (95% CI, 0.56-0.90) for warfarin, 0.4 (95% CI, 0.18-0.87) for dabigatran, and 0.27 (95%CI, 0.10-0.80) for rivaroxaban. GI hemorrhage rates were 1.88 (95%CI, 1.62-2.20) for warfarin, 2.98 (95% CI, 2.4-3.5) for dabigatran and 2.39 (95%CI, 1.6-3.5) for rivaroxaban. CONCLUSIONS: We demonstrate similar bleeding rates with both dabigatran 150mg and 110mg and rivaroxaban compared to warfarin.

Association Between Achieved Low-Density Lipoprotein Levels and Major Adverse Cardiac Events in Patients With Stable Ischemic Heart Disease Taking Statin Treatment.

IMPORTANCE: International guidelines recommend treatment with statins for patients with preexisting ischemic heart disease to prevent additional cardiovascular events but differ regarding target levels of low-density lipoprotein cholesterol (LDL-C). Trial data on this question are inconclusive and observational data are lacking. OBJECTIVE: To assess the relationship between levels of LDL-C achieved with statin treatment and cardiovascular events in adherent patients with preexisting ischemic heart disease. DESIGN, SETTING, AND PARTICIPANTS: Population-based observational cohort study from 2009 to 2013 using data from a health care organization in Israel covering more than 4.3 million members. Included patients had ischemic heart disease, were aged 30 to 84 years, were treated with statins, and were at least 80% adherent to treatment or, in a sensitivity analysis, at least 50% adherent. Patients with active cancer or metabolic abnormalities were excluded. EXPOSURES: Index LDL-C was defined as the first achieved serum LDL-C measure after at least 1 year of statin treatment, grouped as low (≤70.0 mg/dL), moderate (70.1-100.0 mg/dL), or high (100.1-130.0 mg/dL). MAIN OUTCOMES AND MEASURES: Major adverse cardiac events included acute myocardial infarction, unstable angina, stroke, angioplasty, bypass surgery, or all-cause mortality. The hazard ratio of adverse outcomes was estimated using 2 Cox proportional hazards models with low vs moderate and moderate vs high LDL-C, adjusted for confounders and further tested using propensity score matching analysis. RESULTS: The cohort with at least 80% adherence included 31 619 patients, for whom the mean (SD) age was 67.3 (9.8) years. Of this population, 27% were female and 29% had low, 53% moderate, and 18% high LDL-C when taking statin treatment. Overall, there were 9035 patients who had an adverse outcome during a mean 1.6 years of follow-up (6.7 per 1000 persons per year). The adjusted incidence of adverse outcomes was not different between low and moderate LDL-C (hazard ratio [HR], 1.02; 95% CI, 0.97-1.07; P = .54), but it was lower with moderate vs high LDL-C (HR, 0.89; 95% CI, 0.84-0.94; P < .001). Among 54 884 patients with at least 50% statin adherence, the adjusted HR was 1.06 (95% CI, 1.02-1.10; P = .001) in the low vs moderate groups and 0.87 (95% CI, 0.84-0.91; P = .001) in the moderate vs high groups. CONCLUSIONS AND RELEVANCE: Patients with LDL-C levels of 70 to 100 mg/dL taking statins had lower risk of adverse cardiac outcomes compared with those with LDL-C levels between 100 and 130 mg/dL, but no additional benefit was gained by achieving LDL-C of 70 mg/dL or less. These population-based data do not support treatment guidelines recommending very low target LDL-C levels for all patients with preexisting heart disease.

An epitope-specific novel anti-EMMPRIN polyclonal antibody inhibits tumor progression.

Extracellular matrix metalloproteinase inducer (EMMPRIN/CD147) mediates tumor cell-macrophage interactions, and has been shown to induce both matrix metalloproteinases (MMPs) and vascular endothelial growth factor (VEGF). However, the epitope responsible for MMP induction is controversial, and the epitope responsible for VEGF induction is yet unknown. We generated a novel anti-EMMPRIN antibody directed against a specific epitope that successfully inhibited the production of both MMP-9 and VEGF in tumor cell-macrophage in vitro co-culture systems, exhibiting a U-shaped dose response. Furthermore, this antibody efficiently inhibited in vivo tumor progression in both the RENCA renal cell carcinoma and CT26 colon carcinoma subcutaneous tumor models, and reduced tumor size and number of metastatic foci in the 4T1 orthotopic model. This was achieved by inhibiting angiogenesis as assessed by immunohistochemical staining for the endothelial marker CD31, by inhibiting tumor cell proliferation as assessed by the staining for Ki-67, and by enhancing tumor cell apoptosis as assessed in the TUNEL assay. Moreover, administration of the antibody recruited more macrophages into the tumor, and skewed the tumor microenvironment for macrophages from TGFß-dominated anti-inflammatory microenvironment, to a less immunosuppressive one. The antibody improved the ability of stimulated macrophages to perform antibody-dependent cell cytotoxicity (ADCC) and kill tumor cells. Thus, our new antibody maps the epitope capable of inducing both MMPs and VEGF, and places EMMPRIN as a good target for cancer therapy.

OXYGEN MITIGATES THE INFLAMMATORY RESPONSE IN A MODEL OF HEMORRHAGE AND ZYMOSAN-INDUCED INFLAMMATION.

Sequential insults (hits) may change the inflammatory reaction that develops in response to separate single hits (e.g., injury, infection); however, their effects on the long-term clinical outcome are still only partially elucidated. Double-hit models are typically severe and fatal. We characterized in C57BL/6 mice a moderate double-hit model of hemorrhage (35%-40% of total blood volume) and resuscitation, followed by peritoneal injection of zymosan A that induced local and systemic inflammation with 58% mortality. This model allowed exploration of the inflammatory response over time in the surviving mice. We show that after 2 days, mice subjected to the double-hit model had elevated proinflammatory systemic and local peritoneal cytokine response (interleukin [IL]-1ß, tumor necrosis factor-α, IL-6) and moderately elevated anti-inflammatory cytokines (IL-10, transforming growth factor-ß), compared with the single-hit and sham mice. However, this dynamically changed, and by day 7, proinflammatory cytokines were reduced, and anti-inflammatory cytokines were markedly (P < 0.05) elevated in the double-hit group. Mice in the double-hit group that inhaled 100% oxygen intermittently for 6 h every day exhibited markedly reduced serum proinflammatory cytokines as early as day 2 (P < 0.05), inhibited macrophage infiltration into the peritoneum (by 13-fold; P < 0.05), and substantially increased survival rates of 85% (P = 0.00144). Oxygen mitigates the inflammatory response and exerts a beneficial effect on survival in a double-hit model of hemorrhage and zymosan-induced inflammation.

The accuracy of clinical prediction of prognosis for patients admitted with sepsis to internal medicine departments.

INTRODUCTION: Prognosis estimation offered by physicians for patients inflicted by sepsis on their admission to Internal Medicine (IM) departments is considered a challenge. Early prognosis estimation is critical and determines the intensity of treatment offered. The accuracy of prognosis estimation made by physicians has previously been investigated mainly among intensive care physicians and oncologists. OBJECTIVE: To ascertain the accuracy of prognosis prediction made by internists for septic patients on admission to IM departments. METHODS: Physicians were asked to estimate the prognosis of every patient identified to have sepsis on admission. Their intuitive assessment of prognosis was incorporated into the patients' electronic medical record. Survival follow-up was recorded until death or for at least 2 years. Later we compared survival with physicians' prognosis estimations. RESULTS: Prognosis estimation was recorded for 1,073 consecutive septic patients admitted throughout the years 2008-2009 to IM departments. The mean age of patients was 74.7 ± 16.1 years. A total of 42.4% were suspected to have pneumonia, and 65.4% died during a mean follow-up time of 661.1 ± 612.3 days. Almost half of the patients classified to have good prognosis survived compared to 14.9% and 4.9% of those with intermediate and bad prognosis estimation, respectively (P < 0.001). CONCLUSION: Internists can discriminate well between septic patients with good, intermediate, and bad prognosis.

Second-Line Treatment of Her2-Positive Metastatic Breast Cancer: Trastuzumab beyond Progression or Lapatinib? A Population Based Cohort Study.

BACKGROUND: The relative efficacy of lapatinib vs. continuing trastuzumab beyond progression (TBP) in HER2-positive metastatic breast cancer (MBC) patients, who progressed on first-line trastuzumab, is still unclear. The objective of this population based cohort study was to compare outcomes of lapatinib vs. TBP in daily practice. METHODS: All HER2-positive MBC patients who began second-line anti HER2 therapy between 1st January 2010 and 30th August 2013 were selected from Clalit Health Services' (CHS) electronic database. Available data on patient and disease characteristics and treatments were analyzed. The primary endpoint was overall survival (OS). Outcomes were compared using the Kaplan-Meier (log-rank) method and Cox proportional hazards model. RESULTS: 64 patients received second-line lapatinib and 93 TBP. The two treatment groups were similar in age and co-morbidity rates, but differed in proportion of prior adjuvant trastuzumab (lapatinib: 29.7%, TBP: 16.1%, P = 0.043) and rates of prior brain metastases (lapatinib: 32.8%, TBP: 10.8%, P = 0.01). Lapatinib median OS was 13.0 months (95% CI: 9.5-16.5) vs. 31.0 for TBP (95% CI: 20.6-41.4), P<0.001. On multivariate analysis, longer OS was preserved for TBP, after controlling for differences in age, adjuvant trastuzumab, duration of first-line trastuzumab therapy, brain metastases, visceral metastases and hormonal treatment [Hazard Ratio (HR) = 0.63, 95% CI: 0.40-0.99, P = 0.045]. CONCLUSION: In this comparative cohort study, OS of HER2-positive MBC patients treated with TBP was significantly longer than with lapatinib. These results might be especially relevant in settings where ado-trastuzumab-emtansine (TDM-1), the current preferred agent in this setting, is not available yet for patients.

Physicians' behavior following changes in LDL cholesterol target goals.

BACKGROUND: In 01/2011 Clalit Health Services (CHS), changed the LDL-Cholesterol target definitions in its quality indicators program, from a universal target to values stratified by risk assessment based on ATP III criteria. The objective of this study is to evaluate the effect of this change on achievement of LDL-C targets and on physicians' prescriptions of statins. STUDY DESIGN: A descriptive study based on administrative dataset 06/2010-06/2012. SETTING: CHS, The largest health maintenance organization in Israel that insures above 4,000,000 beneficiaries. PATIENTS: PATIENTS who had been in the same risk group throughout the study period. MEASUREMENTS: Attainment of targets for LDL-C and purchases of statins prior to, and following, implementation of the guidelines in the CHS quality indicators program. RESULTS: 433,662 patients remained in the same risk groups throughout the study period; 55.8% were women; the average age was 53.0 ± 10.3 years; 63.9%, 13.4%, and 22.7% were at low, medium, and high risk respectively. After implementation, the proportion of patients reaching LDL-C targets increased in all risk groups: from 58.6% to 61.6%, from 55.1% to 61.1%, and from 44.5% to 49.0%, in low, medium, and high risk groups respectively (p < 0.001). The proportion of patients treated with potent statins increased in all risk groups; from 3.4% to 5.6%, from 6.7% to 10.3%, and from 14.5% to 20.3% respectively (p < 0.001). CONCLUSION: The risk stratification approach as a basis for the quality indicators program was implemented and better achievement of target LDL-C levels ensued. We suggest that implementation of quality indicators that are consistent with the current literature can lead to improvements that exceeds temporal trends.

Systemic Therapy for Psoriasis and the Risk of Herpes Zoster: A 500,000 Person-year Study.

IMPORTANCE: The risk for herpes zoster (HZ) in patients with psoriasis treated with biologic medications or other systemic treatments has been given little attention to date. OBJECTIVE: To describe the risk for HZ in patients with psoriasis and its relation to treatment. DESIGN, SETTING, AND PARTICIPANTS: A cohort study was performed using the administrative database of Clalit Health Services, the largest public health care provider organization in Israel, in the setting of general community clinics, primary care and referral centers, and ambulatory and hospitalized care. We extracted information for all patients who received a psoriasis diagnosis from January 2002 to June 2013. Follow-up was conducted until the end of July 2013. The study included 95,941 patients with psoriasis in the analysis, with 522,616 person-years of follow-up. Incidence of HZ events was calculated for each systemic antipsoriatic medication provided, during a follow-up period of 11 years and 7 months. We used a generalized estimating equation Poisson regression model to examine the effect of each systemic treatment for psoriasis on HZ incidence, adjusting for age, sex, psoriasis severity, Charlson comorbidity index, steroid treatment, and socioeconomic status. MAIN OUTCOMES AND MEASURES: Incidence of HZ associated with systemic therapies. RESULTS: In a multivariate analysis, it was observed that treatment with phototherapy (rate ratio [RR], 1.09 [95% CI, 0.62-1.93]; P = .99), methotrexate (RR, 0.98 [95% CI, 0.78-1.23]; P = .83), cyclosporine (RR, 1.16 [95% CI, 0.48-2.80]; P = .49), and biologic medications as a single agent (RR, 2.67 [95% CI, 0.69-10.3]; P = .14) was not associated with HZ. The use of combination treatment with biologic medications and methotrexate was significantly associated with an increased incidence of HZ (RR, 1.66 [95% CI, 1.08-2.57]; P = .02). The use of acitritin was associated with decreased incidence of HZ (RR, 0.69 [95% CI, 0.49-0.97]; P = .004). CONCLUSIONS AND RELEVANCE: Physicians may need to consider offering an HZ preventive vaccine to patients receiving combination treatment with biologic medications and methotrexate, particularly if they have additional risk factors for HZ.

Sustained Reduction in Health Disparities Achieved through Targeted Quality Improvement: One-Year Follow-up on a Three-Year Intervention.

OBJECTIVE: To assess a quality improvement disparity reduction intervention and its sustainability. DATA SOURCES/STUDY SETTING: Electronic health records and Quality Index database of Clalit Health Services in Israel (2008-2012). STUDY DESIGN: Interrupted time-series with pre-, during, and postintervention disparities measurement between 55 target clinics (serving approximately 400,000 mostly low socioeconomic, minority populations) and all other (126) clinics. DATA COLLECTION/EXTRACTION METHODS: Data on a Quality Indicator Disparity Scale (QUIDS-7) of 7 indicators, and on a 61-indicator scale (QUIDS-61). PRINCIPAL FINDINGS: The gap between intervention and nonintervention clinics for QUIDS-7 decreased by 66.7 percent and by 70.4 percent for QUIDS-61. Disparity reduction continued (18.2 percent) during the follow-up period. CONCLUSIONS: Quality improvement can achieve significant reduction in disparities in a wide range of clinical domains, which can be sustained over time.

Establishing an integrated gastroenterology service between a medical center and the community.

AIM: To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established. METHODS: Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians' knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators. RESULTS: An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient's visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett's esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer. CONCLUSION: Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.

Predicting 30-day readmissions with preadmission electronic health record data.

BACKGROUND: Readmission prevention should begin as early as possible during the index admission. Early identification may help target patients for within-hospital readmission prevention interventions. OBJECTIVES: To develop and validate a 30-day readmission prediction model using data from electronic health records available before the index admission. RESEARCH DESIGN: Retrospective cohort study of admissions between January 1 and March 31, 2010. SUBJECTS: Adult enrollees of Clalit Health Services, an integrated delivery system, admitted to an internal medicine ward in any hospital in Israel. MEASURES: All-cause 30-day emergency readmissions. A prediction score based on before admission electronic health record and administrative data (the Preadmission Readmission Detection Model-PREADM) was developed using a preprocessing variable selection step with decision trees and neural network algorithms. Admissions with a recent prior hospitalization were excluded and automatically flagged as "high-risk." Selected variables were entered into multivariable logistic regression, with a derivation (two-thirds) and a validation cohort (one-third). RESULTS: The derivation dataset comprised 17,334 admissions, of which 2913 (16.8%) resulted in a 30-day readmission. The PREADM includes 11 variables: chronic conditions, prior health services use, body mass index, and geographical location. The c-statistic was 0.70 in the derivation set and of 0.69 in the validation set. Adding length of stay did not change the discriminatory power of the model. CONCLUSIONS: The PREADM is designed for use by health plans for early high-risk case identification, presenting discriminatory power better than or similar to that of previously reported models, most of which include data available only upon discharge.

The 'real-life' impact of adding bevacizumab to first-line therapy in metastatic colorectal cancer patients: a large Israeli retrospective cohort study.

BACKGROUND: After a decade of extensive use, the actual contribution of bevacizumab in first-line treatment of metastatic colorectal cancer (mCRC) is still unclear. OBJECTIVE: To evaluate 'real-life' outcomes of patients with mCRC before and after the introduction of bevacizumab to standard mCRC first-line practice. METHODS: Using the computerized administrative database of Clalit Health Services' (CHS), Israel's largest health care provider, we retrospectively compared two cohorts (n = 1739): (A) all CHS' patients diagnosed with mCRC between January 2000 and December 2004 that received first-line irinotecan or oxaliplatin-based combination chemotherapy (before bevacizumab was introduced) (n = 1052), and (B) all patients that started first-line irinotecan or oxaliplatin combination chemotherapy together with bevacizumab between September 2006 and December 2009 (after bevacizumab was fully reimbursed in Israel for mCRC first-line therapy) (n = 687). The primary endpoint was overall survival (OS) and secondary endpoints were first-line progression-free survival (PFS) and metastatectomy rates. RESULTS: Median OS was longer in Cohort B than in Cohort A [23.0 months vs.15.0, adjusted hazard ratio (HR), 0.75]. Secondary outcomes were also better; PFS of 14.0 months vs. 9.8 in the earlier period (HR, 0.75) and metastatectomy rate of 8.1% versus 3.9%. The longer OS in Cohort B was preserved even after controlling for latter-line epidermal growth factor receptor (EGFR) inhibitor use (HR = 0.77). CONCLUSION: In this analysis, OS, PFS and metastatectomy rates of first-line treatment of mCRC were significantly higher in the later period of the study. These results, derived from 'real-life' practice, suggest that the use of bevacizumab, among other alterations in the clinical management of mCRC between the two periods, might have had a significant contribution to these outcomes, and may therefore support the current practice of adding bevacizumab to first-line treatment of mCRC.

Extending the boundaries of family medicine to perform manual procedures.

A recent survey by Menahem and colleagues revealed that 65% of the surveyed primary care physicians reported that they performed any minor surgical procedures, and 46% reported performance of any musculoskeletal injections. Lack of allocated time and lack of training were the main reported barriers confronting higher performance rates. Healthcare systems are shifting large chunks of traditional hospital-centered activities to competent and comprehensive community-based structures. These changes are very well aligned with key trends in modern consumerism that prefer a close to home availability of medical services. Minor surgical procedures and musculoskeletal injections are good examples of medical activities that had been performed mainly by hospital and community based specialists. The syllabus of specialty training in Family Medicine in Israel includes these skills and trainees should acquire them during the residency program. We estimate that hundreds of family physicians obtain different levels of such training. Yet, only few family physicians have allocated protected time for performance of the procedures. For the skilled physician, performance of such relatively simple procedures extends his professional boundaries and the comprehensiveness of his service. For the healthcare system the "extra effort" and investment needed for performance of minor surgical procedures in primary care clinics is small. The results of the present study reflect on wider issues of care delivery. This study highlights the need for formalized and documented training of family physicians together with allocation of managerial and technical requirements needed to encourage these and similar medically and economically justified endeavors that seem to be perfectly aligned with the wishes of healthcare consumers.