Unravelling the determinants of medical practice variation in referrals among primary care physicians: insights from a retrospective cohort study in Southern Israel.

OBJECTIVES: Reducing medical practice variation (MPV) is a central theme of system improvement because it is associated with poor health outcomes, increased costs and disparities in care. This study aimed to estimate the extent to which each determinant (patient, physician, clinic) explains MPV among primary care physicians and to identify the characteristics of health services with a greater explained variance. METHODS: A retrospective cohort study of primary care physicians practising in non-private clinics of Clalit Health Services in Southern Israel, for longer than a year between 2011 and 2017 and with more than 100 adult patients per practice. We assessed the variation in referral rates among 17 health services and the proportion explained by each domain (patient, physician and clinic). We used generalised linear negative binomial mixed models and the Nakagawa's R2, computing the marginal r2. RESULTS: The study included 243 physicians working in 295 practices and 139 clinics. The mean-explained variance was 28.5%±10.0%, where physician characteristics explained 4.5% of the variation. The intrapractice variation (within a single physician between the years) was explained better than the interphysician (between physicians). Health services with high explained variation were blood tests characterised by both low intrapractice variation (Rs=-0.65, p value=0.005) and high referral rates (Rs=0.46, p value=0.06). CONCLUSION: Over 70% of MPV is not explained by the patient, clinic and physician demographic and professional characteristics. Future research should focus on the fraction of MPV that is explained by the physicians' psychological characteristics, and thus potentially identify psychological targets for behavioural modifications aimed at reducing MPV.

Adapting to change: Clalit's response to the COVID-19 pandemic.

The COVID-19 pandemic is the most significant global health event of the past century. The profound and unexpected changes that it brought about have forced healthcare organizations to make far-reaching adjustments to accommodate the new reality. With the outbreak of the pandemic in Israel and the understanding of its consequences, Clalit Health Services (Clalit), the largest healthcare organization in Israel, rapidly mobilized in order to provide the best response possible from the perspective of both its patients and its employees. In the short term, four designated workgroups were established just days into the pandemic. Their task was to prepare operational work plans to achieve the following goals: providing the best possible treatment for COVID patients; maintaining the level of care for non-COVID patients; protecting healthcare personnel without compromising their competence and level of functioning; and beginning the process of post-crisis planning. In the context of the long term, and with the understanding that the changes in healthcare brought about by the COVID-19 pandemic would be long-lasting and irreversible, and would act as a catalyst in Clalit's preparations for the future, Clalit has carried out the called-for modifications in its organizational strategy. This was based on the need to shift service and treatment foci from the hospitals to the community and the patient's home and his cellular device, by means of strengthening Clalit's strategic abilities to become more proactive, more digital and more home-based. In this article, we present a survey of Clalit's preparations for the new reality in the short and medium terms, as well as the leveraging of insights gained during the first wave of the pandemic, with goal of revising Clalit's long-term strategic plan. We conclude and point out the organizational abilities required for optimal response to future large-scale emergencies: The ability to quickly identify the need for change, respond quickly while harnessing the various parts of the organization in order to provide an agile and adaptive response, and facilitate long-term planning activity in parallel to providing an operational response in the short and medium terms.

Medical Practice Variation Among Primary Care Physicians: 1 Decade, 14 Health Services, and 3,238,498 Patient-Years.

PURPOSE: Variation in medical practice is associated with poorer health outcomes, increased costs, disparities in care, and increased burden on the public health system. In the present study, we sought to describe and assess inter- and intra-primary care physician variation, adjusted for patient and clinic characteristics, over a decade of practice and across a broad range of health services. METHODS: We assessed practice patterns of 251 primary care physicians in southern Israel. For each of 14 health services (imaging tests, cardiac tests, laboratory tests, and specialist visits) we described interphysician and intraphysician variation, adjusted for patient case mix and clinic characteristics, using the coefficient of variation. The adjusted rates were assessed by generalized linear negative-binomial mixed models. RESULTS: The variation between physicians was on average 3-fold greater than the variation of individual physician practice over the years. Services with low utilization were associated with greater inter- and intraphysician variation: rs = (-0.58), P = .03 and rs = (-0.39), P = .17, respectively. In addition, physician utilization ranks averaged over all health services were consistent across the 14 health services (intraclass correlation coefficient, 0.94; 95% CI, 0.93-0.95). CONCLUSIONS: Our results show greater variation in practice patterns between physicians than for individual physicians over the years. It appears that the variation remains high even after adjustment for patient and clinic characteristics and that the individual physician utilization patterns are stable across health services. We propose that personal behavioral characteristics of medical practitioners might explain this variation.

Determinants of Medical Practice Variation Among Primary Care Physicians: Protocol for a Three Phase Study.

BACKGROUND: One of the greatest challenges of modern health systems is the choice and use of resources needed to diagnose and treat patients. Medical practice variation (MPV) is a broad term which entails the differences between health care providers inclusive of both the overuse and underuse. In this paper, we describe a 3-phase research protocol examining MPV in primary care. OBJECTIVE: We aim to identify the potential targets for behavioral modification interventions to reduce the variation in practice patterns and thus improve health care, decrease costs, and prevent disparities in care. METHODS: The first phase will delineate the variation in primary care practice over a wide range of services and long follow-up period (2003-2017), the second will examine the 3 determinants of variation (ie, patient, physician, and clinic characteristics), and attempt to derive the unexplained variance. In the third phase, we will assess a novel component that might contribute to the previously unexplained variance - the physicians' personal behavioral characteristics (such as risk aversion, fear of malpractice, stress from uncertainty, empathy, and burnout). RESULTS: This work was supported by the research grant from Israel National Institute for Health Policy Research (Grant No. 2014/134). Soroka University Medical Center Institutional Ethics Committee has approved the updated version of the study protocol (SOR-14-0063) in February 2019. All relevant data for phases 1 and 2, including patient, physician, and clinic, were collected from the Clalit Health Services data set in 2019 and are currently being analyzed. The evaluation of the individual physician characteristics (eg, risk aversion) by the face-to-face questionnaires was started on 2018 and remains in progress. We intend to publish the results during 2020-2021. CONCLUSIONS: Based on the results of our study, we aim to propose a list of potential targets for focused behavioral intervention. Identifying new targets for such an intervention can potentially lead to a decrease in the unwarranted variation in the medical practice. We suggest that such an intervention will result in optimization of the health system, improvement of health outcomes, reduction of disparities in care and savings in cost. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18673.

Prepregnancy obesity: a risk factor for future development of ovarian and breast cancer.

The aim of this study was to investigate the association between a history of prepregnancy obesity and a woman's future long-term risk for the development of female malignancies. A population-based study compared the incidence of long-term female malignancies in a cohort of consecutive women with and without a diagnosis of prepregnancy obesity. Deliveries occurred between the years 1988 and 2013, with a mean follow-up duration of 11.6 years. Women with known malignancies before the index pregnancy and known genetic predisposition for malignancy were excluded from the study. Female malignancies were divided according to specific type (ovary, uterine, breast, and uterine cervix). A Kaplan-Meier survival curve was used to estimate the cumulative incidence of malignancies. A Cox proportional hazards model was used to estimate the adjusted hazard ratios for female malignancy. During the study period, 106 251 deliveries fulfilled the inclusion criteria; 2.2% (n=2360) occurred in patients with a history of prepregnancy obesity. During the follow-up period, patients with prepregnancy obesity had a significantly increased risk for hospitalization because of female malignancies as a group and specifically ovarian and breast cancer. Using a Kaplan-Meier survival curve, patients with a previous diagnosis of prepregnancy obesity had a significantly higher cumulative incidence of female malignancies. Using a Cox proportional hazards model, adjusted for confounders such as gestational diabetes mellitus and maternal age, prepregnancy obesity remained independently associated with long-term risk for female malignancies (adjusted hazard ratio: 1.4; 95% confidence interval: 1.1-1.9; P=0.045). Prepregnancy obesity is an independent risk factor for long-term female malignancies such as ovarian and breast cancer.

Military Weapon Injury Among Illegal Immigrants at the Southern Border of Israel: A Single Level I Trauma Center Series.

This article describes the characteristics of injuries of illegal immigrants admitted to a Level I trauma center after being shot at the southern border of Israel. This is a retrospective descriptive study. Some of the variables were compared to a group of soldiers who sustained penetrating injury at the same region where the illegal migrant were injured. The study includes 162 patients. The lower body absorbed a higher percentage of the injuries (61 %). The hospitalization time is longer for the migrant patients compared to the soldiers (13 ± 2 vs. 3 ± 0.3 days p = 0.0001). This study on wounded immigrants shows that a conjoint military and civilian system can result in favourable outcomes. The manuscript is an attempt to bring this unique situation, its type of injuries, and the difficulties of the health system in coping with it, to the notice of all authorities that may address a similar challenge.

The association between a history of gestational diabetes mellitus and future risk for female malignancies.

OBJECTIVE: To investigate whether patients with a history of gestational diabetes mellitus (GDM) have an increased future risk for female malignancies. STUDY DESIGN: A population-based study compared the incidence of long-term female malignancies (ovary, uterine, breast, and uterine cervix) in a cohort of women with and without a diagnosis of GDM. Deliveries occurred between the years 1988-2013, with a mean follow-up duration of 12 years. Women with known malignancies prior to the index pregnancy were excluded. Kaplan-Meier survival curve was used to estimate cumulative incidence of malignancies. Cox proportional hazards models were used to estimate the adjusted hazard ratios (HR) for female malignancy. RESULTS: During the study period, 1,04,715 deliveries met the inclusion criteria; 9.4% (n = 9893) occurred in patients with a history of GDM in at least one of their pregnancies. During the follow-up period, patients with GDM had a significantly increased risk of being diagnosed with female malignancies, including ovarian, uterine, and breast cancer. Using a Kaplan-Meier survival curve, patients with a previous diagnosis of GDM had a significantly higher cumulative incidence of female malignancies. Using a Cox proportional hazards model, adjusted for confounders, such as parity, maternal age, and fertility treatments, a history of GDM remained independently associated with female malignancies (adjusted HR, 1.3; 95% CI 1.2-1.6; P = 0.001). CONCLUSION: Patients with a history of GDM have an increased risk for future breast, ovarian, and uterine malignancies.

Preterm delivery and future maternal risk of female malignancies.

PURPOSE: To investigate whether an association exists between preterm delivery and a future risk for female malignancies. METHODS: A population-based study compared the incidence of long-term female malignancies in a cohort of women with and without a history of PTD. Deliveries occurred between the years 1988-2013, with a mean follow-up duration of 12 years. We excluded women with known genetic predisposition or malignancies prior to the index pregnancy. Malignancies investigated included ovarian, uterine, breast and cervix. Cumulative incidence was assessed using a Kaplan-Meier survival curve. A Cox proportional hazards model was used to estimate the adjusted hazard ratios (HR) for female malignancy. RESULTS: During the study period, 105,033 women met the inclusion criteria; 16.8 % (n = 17,596) of the patients delivered preterm. Patients with a history of PTD did not have an increased risk of later being diagnosed with female malignancies. The results remained insignificant in a sub-analysis based on malignancy type, early PTD, induced vs. spontaneous, and number of episodes per patient. Kaplan-Meier cumulative incidence was similar between the groups, and the adjusted HR was not significant (1.04, 95 % CI 0.88-1.22; p = 0.665). CONCLUSION: A history of PTD does not appear to elevate the risk for subsequent long-term female malignancies.

[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.

[SOROKA UNIVERSITY MEDICAL CENTER: THE ROAD TO LEADERSHIP IN QUALITY OF MEDICAL CARE, SERVICE AND RESEARCH].

Soroka University Medical Center is a tertiary hospital, and the sole medical center in the Negev, the southern part of Israel. Soroka has invested in quality, service and research. The region has developed joint programs in order to advance the quality of medical care whilst optimizing the utilization of available resources. In this editorial we describe the path to leadership in quality of medical care, service and research.

Preeclampsia and Future Risk for Maternal Ophthalmic Complications.

Objective To investigate whether patients with a history of preeclampsia have an increased risk of long-term ophthalmic complications. Study Design A population-based study comparing the incidence of long-term maternal ophthalmic complications in a cohort of women with and without a history of preeclampsia. Results During the study period, a total of 103,183 deliveries met the inclusion criteria; 8.1% (n = 8,324) occurred in patients with a diagnosis of preeclampsia during at least one of their pregnancies. Patients with preeclampsia had a significantly higher incidence of long-term ophthalmic morbidity such as diabetic retinopathy and retinal detachment. In addition, a positive linear correlation was found between the severity of preeclampsia and the prevalence of future ophthalmic morbidities (0.3 vs. 0.5 vs. 2.2%, respectively). Kaplan-Meier survival curve indicated that women with preeclampsia had higher rates of total ophthalmic morbidity (0.2 vs. 0.4%, for no preeclampsia and with preeclampsia, respectively; odds ratio = 2.06, 95% confidence interval: 1.42-2.99; p < 0.001). In a Cox proportional hazards model, adjusted for confounders, a history of preeclampsia remained independently associated with ophthalmic complications. Conclusion Preeclampsia is an independent risk factor for long-term maternal ophthalmic morbidity, specifically diabetic retinopathy and retinal detachment. This risk is more substantial depending on the severity of the disease.

Increased Risk for Ophthalmic Complications in Patients with a History of Preterm Delivery.

Objective Spontaneous preterm deliveries (PTDs) have been consistently associated with maternal vascular complications. We aimed to investigate an association between PTD and subsequent maternal ophthalmic morbidity. Study Design In this population-based cohort study, we included all singleton deliveries occurring between 1988 and 2013. We excluded women with known ophthalmic disease. The exposure was at least one pregnancy with PTD. Outcomes included different maternal ophthalmic morbidity. The cumulative incidence and adjusted hazard ratios were assessed using a Kaplan-Meier survival curve and Cox hazards models. Results Of the 105,018 patients included, 17,600 (16.7%) delivered preterm. Patients with a history of PTD (both induced and spontaneous) had higher rates of ophthalmic complications (odds ratio [OR]: 2.12; confidence interval [CI]: 1.6-2.7; p < 0.001), specifically diabetic retinopathy and glaucoma (OR: 4.79 and 2.48, respectively). A linear association was found between the number of previous PTDs and ophthalmic complications (0.2% for no PTD; 0.4% for one PTD; 0.6% for two or more PTDs; p < 0.001) and for early and late PTD (p < 0.001). A Cox model revealed an independent association between PTD and ophthalmic complications (adjusted hazard ratio: 2.2; 95% CI: 1.6-2.9). Conclusion A history of PTD is an independent risk factor for ophthalmic morbidity.

Fertility treatments and the risk for ophthalmic complications: a cohort study with 25-year follow-up.

OBJECTIVE: To investigate whether there is an association between a history of fertility treatments and future risk for long-term maternal ophthalmic complications. STUDY DESIGN: A population-based study compared the incidence of long-term maternal ophthalmic complications in a cohort of women with and without a prior history of fertility treatments, including in vitro fertilization (IVF) and ovulation induction (OI). Deliveries occurred between the years 1988-2013, with a mean follow-up duration of 12 years. Women with known ophthalmic diseases prior to the index pregnancy were excluded from the analysis. Ophthalmic complications were further divided to glaucoma, diabetic retinopathy, macular degeneration and retinal detachment. Kaplan-Meier survival curve was used to estimate cumulative incidence of ophthalmic complications. Cox proportional hazards model was used to estimate the adjusted hazard ratios (HR) for ophthalmic complications. RESULTS: During the study period, 106 004 deliveries met the inclusion criteria; 4.1% (n = 4364) occurred in patients with a history of fertility treatments. Patients with a history of fertility treatments, as a group, did not have a significantly higher incidence of ophthalmic complications. However, the subgroup of patients with a history of IVF (but not OI) had a higher incidence of retinal detachment (0.3% versus 0.1%; p = 0.02). Using a Kaplan-Meier survival curve, patients following IVF had a significantly higher cumulative incidence of retinal detachment. Using Cox proportional hazards models, controlling for maternal age, obesity and parity, IVF was noted as an independent risk factor for retinal detachment (adjusted HR 3.4; 95% 1.2-9.3; p = 0.011). CONCLUSION: Patients following IVF treatments have a significant higher long-term risk for retinal detachment. OI treatments do not pose a risk for long-term maternal ophthalmic complications.

Pre-eclampsia and Future Female Malignancy.

OBJECTIVE: To investigate an association between pre-eclampsia and future genital tract and breast malignancies. METHODS: The incidence of genital tract and breast malignancies was compared in a cohort of women with and without a history of pre-eclampsia. Cumulative incidence was assessed using a Kaplan-Meier survival curve. RESULTS: During the study period, 103 180 deliveries met the inclusion criteria; 8.1% occurred in patients with pre-eclampsia. Patients with pre-eclampsia did not have a significantly different risk of genital tract or breast malignancies. The results remained insignificant in a sub-analysis based on malignancy type, pre-eclampsia severity and number of episodes per patient. No difference in cumulative incidence was demonstrated. CONCLUSION: Pre-eclampsia does not appear to influence the risk of future genital tract or breast malignancies.

[The accreditation program in hospitals: Clalit Health Services experience].

Accreditation is a process for assessing the healthcare organization, to determine if it meets a set of requirements designed to improve quality of care. White research regarding the benefits of accreditation is lacking, accreditation has been shown to be associated with promoting quality. Accreditation differs from licensing and quality assurance audits such as ISO. In various countries, the accreditation processes have been in operation in heaLthcare organization for decades. In the U.S.A., the Leading organization for accreditation of healthcare organizations is the Joint Commission. Accreditation Canada is the leading authority for accreditation in Canada. The Australian Council for Healthcare Standards and the King's Fund in the United Kingdom are other noted authorities for accreditation. Several European countries have initiated accreditation programs and some are in the process of implementing such programs. In Israel, no national accreditation system exists, although the Ministry of Health conducts audits on specific issues, and for relicensing of hospitals, and the Scientific Council of the Israel Medical Association conducts audits for recognizing a department as suitable for residency. Clalit Health Services is the first healthcare organization in Israel to gain Joint Commission International (JCI) accreditation. Three hospitals run by Clalit (Ha'emek, Meir and Soroka) have been accredited by JCI, and another four are in the process of accreditation by JCI. An organized national accreditation scheme in Israel is a challenging process, yet it appears to be a central act for promoting the quality of care in hospitals.

Perioperative patient safety: correct patient, correct surgery, correct side--a multifaceted, cross-organizational, interventional study.

BACKGROUND: It is important to ensure a patient-safe environment in the perioperative setting. With this in mind, a "patient-safety first" philosophy was adopted within our operating room service. METHODS: During the first phase of the interventional study (2001-2002), we defined and executed the organizational and educational aspects of the intervention. Thereafter, the implementation phase (2003-2005) was performed. According to our zero tolerance policy, in the event that a major error in patient readiness for anesthesia and surgery was found in the operating room holding area, the patient would be returned to the parent department ("failure") and the surgical procedure delayed until the major error was corrected. RESULTS: The data of 15,856 patients were recorded. During the 3-yr implementation period, 112 patients (0.71%) were returned to the department. A statistically significant (P < 0.002) reduction in major errors was recorded when comparing the year 2003 to the years 2004 and 2005 (1.04, 0.59, and 0.49% for the years 2003, 2004, and 2005, respectively). Furthermore, stepwise logistic regression demonstrated a time-dependant significant decrease in the incidence of a major error that resulted from inadequate patient preparation (odds ratio = 1.48, 95% CI: 1.16-1.87). In addition, the mean time between failures was 6.6, 11.2, and 14.7 days for the years 2003, 2004, and 2005, respectively (P < 0.03). Finally, a significant (P < 0.0001) improvement in patient preparation over time, as well as the overall probability that the patient preparation score = 100% (P < 0.001), were demonstrated. CONCLUSIONS: Education and increased awareness can decrease perioperative errors. However, even with a carefully designed policy in place, an error-free environment was not achieved. Therefore, monitoring and system analysis should be performed on a continuing basis.