Demographic and health care service utilization by 4417 patients with hidradenitis suppurativa.

BACKGROUND: Data on the health care utilization of patients with hidradenitis suppurativa (HS) in primary care settings are scarce. OBJECTIVE: To investigate the health care service utilization of patients with HS. METHODS: In a cross-sectional study, patients with HS were compared with 2 age- and sex-matched control groups-general population enrollees of Clalit Health Services and a group of patients with psoriasis. Health care services data included inpatient and outpatient community clinic visits and pharmacy claims for topical and systemic treatments. Multivariate analysis of the data for patients with HS and controls was performed. RESULTS: The study included 4417 patients with HS, 22,085 general population enrollees, and 4417 patients with psoriasis. On the basis of multivariate analyses, patients with HS had more annual dermatology clinic visits compared with the general population enrollees (odds ratio [OR], 6.49; 95% confidence interval [CI], 7.06-5.97) and patients with psoriasis (OR, 1.32; 95% CI, 1.44-1.21), more annual surgical clinic visits (OR, 3.78; 95% CI 3.28-4.36 and OR, 1.65; 95% CI, 1.42-1.91, respectively), and more hospitalizations (OR, 2.21; 95% CI, 1.89-2.56 and OR, 1.51; 95% CI, 1.28-1.78, respectively). LIMITATIONS: Underestimation of HS frequency was possible. CONCLUSIONS: The burden on health care systems due to patients with HS is greater than that due to patients with psoriasis and the general population.

Similarities between neuropathic pruritus sites and lichen simplex chronicus sites.

BACKGROUND: Localized itch of non-pruritoceptive origin is often neuropathic and may be referred to as neuropathic itch syndrome. OBJECTIVES: To describe the results of nerve conduction studies in patients with anogenital pruritus, brachioradial pruritus and scalp dysesthesia, and compare these sites to typical sites of lichen simplex chronicus (LSC). METHODS: The study summarizes previously published data combined with unpublished data of patients with scalp dysesthesia. Nerve conduction studies included measurements of distal sensory and motor latency, conduction velocity and F-responses. RESULTS: A neuropathy was demonstrated in 29 of 36 patients with anogenital pruritus (80.5%), 8/14 with brachioradial pruritus (57.1%) and 4/9 with scalp dysesthesia (44.4%). The typical sites overlapped with some but not all LSC sites. CONCLUSIONS: A considerable proportion of patients with brachioradial pruritus, anogenital pruritus and scalp dysesthesia have abnormal nerve conduction findings, suggesting a neuropathic origin. The skin sites overlap with some common LSC sites, suggesting that in some cases of LSC a local neuropathy could be a possible cause.

A natural experiment in mass media modulated pharmacokinetics after a change in tablet formulation.

BACKGROUND: After a new formulation of levothyroxine was distributed in Israel, side effects were reported to the Ministry of Health generating extensive media coverage. The purpose of this study was to determine whether the new formulation was associated with a change in thyroid-stimulating hormone (TSH) levels of treated patients and to evaluate the effect of the extensive media coverage on the incidence of laboratory test performance. STUDY DESIGN: Retrospective-cohort and crosssectional analysis. METHODS: All patients from the Leumit Health Services of Israel treated with levothyroxine between October 2009 and February 2012 were included in the study. A retrospective cohort was constructed of patients treated and maintained within the desired target range (0.35-5 mIU/L) from January to July 2010. A longitudinal analysis was conducted to calculate the monthly distribution of TSH levels from laboratory tests during routine care over 26 months. Data were stratified by cohort and noncohort patients. RESULTS: Data were captured for 18,106 levothyroxine-treated patients; 1140 were included into the retrospective cohort. In both subpopulations a sharp rise in the number of tests performed monthly is observed at the peak of media coverage during October and November 2011. In the retrospective cohort the proportion of TSH results within target range fell to a low of 67.5% during December 2011, with 25.3% between 5.01 and 20 mIU/L. Results>20 mIU/L then peaked at 3.8% indicating an increase in patients who stopped taking levothyroxine. CONCLUSIONS: These results demonstrate the power of mass media to influence patient behavior and to foment a public health scare.

Modifying prescribing behaviour of angiotensin receptor blockers by selectively rescinding managerial prior authorization requirements for losartan.

AIMS: To evaluate whether rescinding the prior authorization (PA) requirement (managerial pre-approval) for losartan in an health maintenance organization (HMO) could reduce prescribing of the more expensive angiotensin receptor blockers (ARBs). METHODS: HMO physicians were notified that losartan would no longer require PA, and appropriate changes were made to the electronic prescribing computer program. The monthly distribution by drug of the number of prescriptions for ARBs dispensed for new patients was calculated before and after the policy change from data captured from electronic records. The proportion of patients (percentage and 95% confidence interval) treated with losartan who met the criteria for treatment with ARBs (hypertension or cardiac insufficiency in patients who have developed adverse effects in response to angiotensin-converting enzyme inhibitors or macroproteinuria) during the first month after the PA requirement was rescinded was calculated. RESULTS: The total number of PA requests for ARBs declined by 48.6% from 961 in December 2008, the month before the policy change, to 494 the following January, rising again to 651 during January 2010. Prescription incidence changed from 121 to 255 patients treated per month (114% increase) for losartan, from 15 to 16 (6.7% increase) for candesartan, and from 89 to 71 (20.2% decrease) for valsartan. The duration of effect for decrease in ARB requests for the more expensive drugs was approximately 1 year. Only 23.3% (95% confidence interval 18.1-28.4) of patients receiving losartan met the criteria for receiving ARBs. CONCLUSIONS: Rescinding the PA requirement for this drug alone was an effective limited-duration strategy for reduction of prescription of relatively expensive drugs.

Drug use evaluation of tamoxifen focusing on off-label use in a managed care population in Israel.

BACKGROUND: Policy development to manage new off-label uses of medications is an issue relevant to health policy stakeholders internationally. Retrospective drug utilization analyses may be useful to identify practice trends in the use of drugs for unapproved (off-label) uses. Since drug use evaluations (DUE) are generally performed for expensive medications or when safety concerns warrant increased scrutiny, patterns of off-label use of inexpensive drugs will probably be undetected. Tamoxifen citrate, an estrogen receptor antagonist, is indicated in Israel exclusively for palliative [sic: meaning adjuvant] treatment of breast cancer. This DUE was motivated by observations that tamoxifen may be used off-label for indications without evidence of safety or efficacy. OBJECTIVES: To assess the extent of off-label prescribing of tamoxifen and ascertain what evidence is available supporting the use of the drug for the off-label indications observed. METHODS: A retrospective DUE of tamoxifen was performed for the 12 months of calendar year 2008 in a 650,000-member HMO in Israel for patients who received at least 1 prescription for tamoxifen. All patients for whom tamoxifen was dispensed in 2008 were identified from pharmacy claims data. The HMO's electronic patient record (EPR) was subsequently queried to identify the diagnoses of patients who received tamoxifen and exclude those patients who had a diagnosis code (ICD-9-CM 174.x or 175.x) for breast cancer. An EPR chart review was also performed to identify and exclude patients who had a diagnosis or treatment of breast cancer that was recorded in free text. For the patients who did not have a diagnosis code or free-text description of breast cancer, the recorded off-label diagnoses and ICD-9-CM codes in the EPR during the visit when tamoxifen was first prescribed were tabulated. A literature search was conducted to collect information supporting the use of tamoxifen for the observed off-label indications. We defined the use as "supported" if studies were found in PubMed, Cochrane database, or Micromedex that supported the clinical decision to use the drug for the off-label indication. RESULTS: 877 patients were treated with tamoxifen in 2008 of whom 826 (94.2%) had a diagnosis of breast cancer, and 51 patients (5.8%) received the drug from 41 physicians in 7 medical specialty categories for 25 different off-label diagnoses. Of these 25 diagnoses, 33 patients (64.7% of 51 patients with off-label use) received tamoxifen for 8 diagnoses that were associated with some evidence to support their off-label use. Malignant neoplasm of ovary (n = 13) and female infertility (n = 13) were the most commonly recorded indications with some evidence to support off-label use. Of the 13 women treated for infertility, 9 (69.2%) had been treated with clomiphene citrate prior to being treated with tamoxifen, suggesting that some physicians may be experimenting with tamoxifen as second-line treatment. CONCLUSIONS: Tamoxifen was found to be used off-label in only 5.8% of the patients who received the drug in 2008 in this HMO, and only 18 patients (2.1%) received tamoxifen for a diagnosis that did not have some supporting evidence of efficacy. Since off-label prescribing of tamoxifen was found to be relatively rare, this HMO did not impose a prior authorization requirement for this drug and instead added an edit in the EPR to block off-label prescribing by requiring the physician to register a diagnosis of breast cancer.

Prior authorization to improve testing of glycosylated hemoglobin in a managed care setting.

OBJECTIVE: To ascertain whether revocation of a prior authorization (PA) requirement by the Leumit Health Fund of Israel resulted in inferior rates of glycosylated hemoglobin (A1C) testing among new users of expensive diabetes medications. STUDY DESIGN: Electronic patient record (EPR) database study. METHODS: Data on new users of the target drugs and on A1C testing in these patients were extracted from EPR databases for the 6-month period after the revocation. The proportion (95% confidence interval [CI]) of patients who obtained at least 1 A1C test during the 4 months before initiation of treatment was calculated. The data were stratified by month to detect possible trends in rates of testing during the period after the policy change. RESULTS: After the PA requirement was rescinded, A1C testing among incident users of the target drugs dropped from 100% during the PA period to rates ranging from 85.6% (95% CI, 79.7%-91.5%) to 94.4% (95% CI, 90.8%-97.9%). Statistically significant variance in monthly rates of testing was not observed. CONCLUSIONS: Prior authorization has been successfully implemented in the managed care setting studied to obtain 100% performance of a laboratory test necessary to monitor drug therapy outcomes in patients with diabetes mellitus. When PA is implemented as a quality assurance strategy, its revocation should be accompanied by continuing education efforts designed to maintain optimal adherence to recommendations for appropriate care.

Nonattendance in pediatric pulmonary clinics: an ambulatory survey.

BACKGROUND: Nonattendance for scheduled appointments disturbs the effective management of pediatric pulmonary clinics. We hypothesized that the reasons for non-attendance and the necessary solutions might be different in pediatric pulmonary medicine than in other pediatric fields. We therefore investigated the factors associated with nonattendance this field in order to devise a corrective strategy. METHODS: The effect of age, gender, ethnic origin, waiting time for an appointment and the timing of appointments during the day on nonattendance proportion were assessed. Chi-square tests were used to analyze statistically significant differences of categorical variables. Logistic regression models were used for multivariate analysis. RESULTS: A total of 1190 pediatric pulmonology clinic visits in a 21 month period were included in the study. The overall proportion of nonattendance was 30.6%. Nonattendance was 23.8% when there was a short waiting time for an appointment (1-7 days) and 36.3% when there was a long waiting time (8 days and above) (p-value < 0.001). Nonattendance was 28.7% between 8 a.m. to 3 p.m. and 37.5% after 3 p.m. (p = 0.007). Jewish rural patients had 15.4% nonattendance, Jewish urban patients had 31.2% nonattendance and Bedouin patients had 32.9% nonattendance (p < 0.004). Age and gender were not significantly associated with nonattendance proportions. A multivariate logistic regression model demonstrated that the waiting time for an appointment, time of the day, and the patients' origin was significantly associated with nonattendance. CONCLUSION: The factors associated with nonattendance in pediatric pulmonary clinics include the length of waiting time for an appointment, the hour of the appointment within the day and the origin of the patient.

Curtailing laboratory test ordering in a managed care setting through redesign of a computerized order form.

OBJECTIVE: To increase appropriate use of blood tests for folic acid and vitamin B12 ordered by primary care physicians in a managed care organization in Israel through redesign of a computerized order form. STUDY DESIGN: Pre-post intervention. METHODS: A new version of the computerized order form was launched. Utilization patterns were calculated for tests of vitamin B12, folic acid, and ferritin, which were previously grouped together. Concomitant utilization patterns for tests of hemoglobin and iron were evaluated as controls. RESULTS: Tests ordered for the 3 targets decreased by 31% to 41% relative to the preintervention month, with a further decrease to 36% to 53% the following month. Negligible changes in utilization patterns were observed for the controls (-2% to 3%) during the postintervention period. CONCLUSIONS: Simple restructuring of a computerized order form significantly reduced the number of laboratory tests suspected of being unnecessary or redundant. When overutilization of laboratory resources is suspected, managers should evaluate the efficiency of the organization's current ordering procedures before implementing resource-intensive interventions.

Factor analysis of the Beer Sheva Psoriasis Severity Score (BPSS).

BACKGROUND: The Beer Sheva Psoriasis Severity Score is a novel instrument for the assessment of psoriasis severity, designed for use in routine clinical conditions. OBJECTIVE: To identify the main factors of the BPSS. METHODS: The sample used to study the BPSS comprised 70 patients with psoriasis vulgaris treated by climatotherapy at the Dead Sea. Psoriasis severity was assessed using BPSS and PASI (Psoriasis Area and Severity Index). Factor analysis was used to identify the main factors of BPSS. Internal consistency analysis was performed. Correlation matrices were generated to compare BPSS factors. RESULTS: Factor analysis demonstrated that BPSS included six factors that explained 74.0% of the variance as follows: patient assessment 26.0%; physician assessment 13.2%; palms and soles involvement 11.9%; genitals, nails, and pruritus 9.0%; face involvement 7.3%; and scalp involvement 6.6%. Total scale Cronbach's alpha was 0.76; alpha for the factors ranged between 0.39 and 0.81. CONCLUSIONS: The major factors of BPSS were identified. BPSS may be used as a comprehensive tool for measuring psoriasis severity.

Physicians' knowledge and attitudes regarding periconceptional folic acid supplementation: a survey in Southern Israel.

BACKGROUND: Pre-conceptional folic acid supplementation is an effective way to reduce the incidence of neural tube defects (NTDs). Primary care providers are an important source of information to promote folic acid intake. This study aimed at evaluating primary care physicians' knowledge and attitudes regarding folic acid supplementation for childbearing women. MATERIAL/METHODS: A questionnaire on physicians' knowledge and attitudes, mostly including multiple-choice questions, was delivered by mail to all physicians (n=370) in a large health provider organization in southern Israel in 2006. Data regarding demographics as well as type of specialty, experience, and place of work were collected. RESULTS: Eighty-seven physicians were included in the study (response rate: 24%). Seventy physicians out of 81 (94%) reported routine recommendation of folic acid for their patients. Most physicians admitted that they needed more information regarding folic acid supplementation. Knowledge about folic acid's role in preventing congenital anomalies was suboptimal, with 2% of the physicians correctly estimating the efficacy of folic acid in decreasing the risk of NTDs and 8% recognizing the association between folic acid supplementation and decreased prevalence of malformations other than NTDs. Knowledge about the correct timing (12%) and dosage (47%) of folic acid preparations for average-risk women was also lacking. CONCLUSIONS: Primary care physicians report that they routinely prescribe folic acid to women in childbearing age in order to prevent congenital anomalies, but their knowledge about folic acid supplementation is insufficient.

A co-payment for consultant services: primary care physicians' referral actualization.

Prospective evaluation of the effect of a new copayment for specialists consultations on actualization of referrals (2,432 patient), was examined. Actualization of the appointment, reasons for not actualizing, and sociodemographic characteristics were recorded. Actualization was 85.1% in community consultation clinics and 91.7% in hospital outpatient clinics. The main reasons for non actualization were: inability to reach the clinic (53.4%), the problem had resolved (15%), and co-payment (2%). In addition, 19.1% stated that they did not actualize a past consultant visit due to co-payment. Referring physicians noted that co-payment had some effect on their decision, especially with the elderly or lower income patients. A relatively small compulsory co-payment was not found to have a long term effect on utilization of specialists' services.

Nonattendance in obstetrics and gynecology patients.

BACKGROUND: Nonattendance for obstetrics and gynecology (OB/GYN) appointments disrupts medical care and leads to misuse of valuable resources. We investigated factors associated with nonattendance in an outpatient OB/GYN clinic. METHODS: Nonattendance was examined for a period of 1 year in first-time visitors of an ambulatory OB/GYN clinic. The effects of age, population sector, the treating physician, waiting time, and timing of the appointment on the proportions of nonattendance were assessed. Chi(2) tests and logistic regression were used for simple and multiple regression models. RESULTS: A total of 8,883 visits were included (median age 36 years). The proportion of nonattendance was 30.1%: 19.9% among rural Jewish, 30.5% in urban Jewish, and 36% in Bedouins (p < 0.001). Nonattendance increased from 26.6% among those waiting up to 1 week to 32.3% among those who waited more than 15 days (p < 0.001) and decreased with age (p < 0.001). A multiple logistic regression model demonstrated that age, population sector and waiting time for an appointment were significantly associated with nonattendance. CONCLUSION: Nonattendance in OB/GYN patients is independently associated with age, population sector and waiting time for an appointment. It is suggested that various solutions should be carefully introduced assessed regarding routine patient scheduling in OB/GYN clinics.

Factors associated with non-attendance at pediatric allergy clinics.

Non-attendance for scheduled appointments is common in many medical specialties. However, there are no published reports on non-attendance in pediatric allergy clinics. We investigated the factors for non-attendance in pediatric allergy patients. We assessed the effects of age, gender, ethnic origin, waiting time for an appointment and the timing of the appointment on non-attendance proportions. Chi-square tests were used to analyze statistically significant differences of categorical variables. Logistic regression models were used for multivariate analyses. A total of 442 visits in a 21-month period were included in the study. The overall proportion of non-attendance at the pediatric allergy clinic was 33.0%. Jewish rural patients had 19.4% non-attendance; Jewish urban patients had 35.6% non-attendance; and Bedouin patients had 57.1% non-attendance (p < 0.001). Non-attendance was higher in spring and winter (43.5% and 36.7%, respectively) than in summer and autumn (26.9% and 26.5%, respectively) (p = 0.016). Non-attendance was not significantly influenced by gender, age, hour of the appointment or waiting time for the appointment. A multivariate logistic regression model demonstrated that the ethnic origin of the patients and the season of the year were significantly associated with non-attendance. We conclude that in children attending allergy clinics, factors that determine non-attendance include the ethnic origin of the patients and the season of the year.

[Factors associated with frequent attendance in a Bedouin primary care setting].

BACKGROUND: Frequent attendance affects delivery and cost of effective health services, quality of care, and burden on primary care physicians. The aim of this study was to investigate factors associated with frequent attendance, as well as types of health care utilization, in a Bedouin primary care setting. METHODS: A case-control study was conducted on adult frequent attenders (FAs) and controls in a primary care clinic serving a Bedouin population in southern Israel. Social, demographic and clinical data were manually extracted by reviewing the clinic's computerized medical records. The associations between these factors and frequent attendance were analyzed. RESULTS: The study included 118 cases and 121 controls (59% female, mean age: 39.6 +/- 14.9 years). FAs were more likely to use consultation referrals, prescriptions, investigative studies, laboratory tests, and emergency department referrals than controls and were prescribed more sick-leave days than controls. Controlling for age and gender, FAs were significantly more likely to have a chronic disease (OR = 4.46, 95% CI: 1.86-10.71), use chronic medications (OR = 3.31, 95% CI: 1.57-6.99), have a musculoskeletal disease (OR = 2.08, 95% CI: 1.02-7.49) and be of African Bedouin ethnicity (OR = 2.77, 95% CI: 1.02-7.49). CONCLUSIONS: FAs in a Bedouin community pose a special challenge for the primary care clinic, as they are more likely to be chronically ill, and utilize referrals to various services and consultations more frequently than controls.

[Physician incentives--an overview].

Physicians are the backbone of every medical system. Physician function and behavior have a major impact on the function and outcomes of medical systems. Physician behavior is influenced by sets of incentives that are an inherent part of the medical system. Incentives may be divided into three groups: 1) moral incentives, i.e. professionalism, empathy, sense of mission; 2) social incentives, i.e. reputation, laws, administrative restrictions and work environment; 3) financial incentives, i.e. payments, salaries and bonuses. Physician behavior is influenced by a combination of all three types of incentives and not by a single incentive. The material incentive has more influence on recruitment while the social incentive has a stronger influence on retainment and attrition reduction. This article discusses the modern physician's environment in view of incentive sets and its impact on the medical system.

Psoriasis and the metabolic syndrome.

Previous reports have shown a possible association between psoriasis and obesity, ischaemic heart disease, hypertension or diabetes mellitus. However, most of these studies were uncontrolled and were based on small sample sizes. We therefore investigated the association between psoriasis and the metabolic syndrome in a case control study. Case patients were defined as patients with a diagnosis of psoriasis vulgaris. Control patients were subjects who underwent hernioplasty or appendectomy. We used data mining techniques utilizing the database of the southern district of Clalit Health Services. The proportions of patients with diseases that belong to the metabolic syndrome were compared between case and control patients by univariate analyses. chi2 tests were used to compare categorical parameters between the groups. Logistic regression models were used to measure the association between psoriasis and the metabolic syndrome. A total of 340 patients with psoriasis and 6643 controls were included in the study. The mean age of case patients was 47.7 years (SD 10.7 years). There were 50.3% men and 49.7% women. Ischaemic heart disease was present in 23.5% of the patients with psoriasis, compared with 17.2% of the controls (p=0.003). Diabetes mellitus was present in 27.9% of the patients with psoriasis, compared with 19.5% of the controls (p <0.001). Hypertension was present in 44.4% of the patients with psoriasis, compared with 37.2% of the controls (p=0.007). Obesity was present in 29.4% of the patients with psoriasis, compared with 23.5% of the controls (p=0.012). Dyslipidaemia was present in 50.9% of the patients with psoriasis, compared with 44.2% of the controls (p=0.015). The association between psoriasis and the metabolic syndrome was pronounced after the age of 50 years and in men. Multivariate models adjusting for age and gender demonstrated that psoriasis was associated with an increased risk for ischaemic heart disease (odds ratio (OR) 1.4 95% confidence interval (CI) 1.0-1.8), diabetes mellitus (OR 1.5 95% CI 1.2-2.0), hypertension (OR 1.3 95% CI 1.0-1.7), obesity (OR 1.3 95% CI 1.0-1.7) and dyslipidaemia (OR 1.2 95% CI 1.0-1.6). Our findings demonstrate a possible association between psoriasis and the metabolic syndrome. Further studies are needed to establish this observation.

Intervention program to reduce waiting time of a dermatological visit: managed overbooking and service centralization as effective management tools.

BACKGROUND: Long waiting times are an impediment of dermatological patient care world-wide, resulting in significant disruption of clinical care and frustration among carers and patients. OBJECTIVE: To reduce waiting times for dermatological appointments. METHODS: A focus group including dermatologists and management personnel reviewed the scheduling process, mapped potential problems and proposed a comprehensive intervention program. The two major approaches taken in the intervention program were revision of the scheduling process by managed overbooking of patient appointments and centralization of the dermatological service into a centralized dermatological clinic. RESULTS: Following the intervention program, the average waiting time for dermatological appointments decreased from 29.3 to 6.8 days. The number of scheduled appointments per 6 months rose from 17,007 to 20,433. Non-attendance proportion (no-show) decreased from 33% to 28%. Dermatologist work-hours were without significant change. CONCLUSIONS: Waiting lists for dermatological consultations were substantially shortened by managed overbooking of patient appointments and centralization of the service.