Search

Objectives The Necesidades Paliativas CCOMS-ICO© (NECPAL) screening tool was developed to identify patients in need of palliative care and has been used in Israel without formal translation, reliability testing, or validation. Because cultural norms significantly affect subscales such as social vulnerability and health-care delivery, research is needed to comprehensively assess the NECPAL’s components, adapt it, and validate it for an Israeli health-care setting. This study linguistically and culturally translated the NECPAL into Hebrew to examine cultural and contextual acceptability for use in the Israeli geriatric health sector. The newly adapted tool was measured for itemized and scale-level content validity, inter-rater reliability (IRR), and construct validity. Methods The NECPAL was back-translated and its content validated by a 5-member expert panel for clarity and relevance, forming the Israeli-NECPAL (I-NECPAL). Six health-care professionals used the I-NECPAL with 25 post-acute geriatric patients to measure IRR. For construct validity, the known-groups method was used, as there is no “gold standard” method for identifying palliative needs for comparison with the NECPAL. The known groups were 2 fictitious cases, predetermined of palliative need. Thirty health-care professionals, blinded to the predetermined palliative status, used the I-NECPAL to determine whether a patient needs a palliative-centered plan of care. Results The findings point to acceptable content and construct validity as well as IRR of the I-NECPAL for potential inclusion as a tool for identifying geriatric patients in need of palliative care. Content-validity assessment brought linguistic changes and the exclusion of the frailty parameter from the annex of chronic diseases. The kappa-adjusted scale-level content-validity index indicated a high level of content validity (0.96). IRR indicated a high level of agreement (all parameters with an “excellent–good” agreement level). The sensitivity (0.93), specificity (0.17), positive predictive value (0.53), and negative predictive value (0.71) revealed how heavily the scale weighed upon the surprise question. These metrics are improved when removing the surprise question from the instrument. Significance of results Similar to other countries, the Israeli health-care system is regulated by policies that portray the local beliefs and culture as well as evidence-based practice. The decision about when to switch a patient to a palliative-centered plan of care is one such example. It is thus of utmost importance that only locally adapted and vigorously tested screening tools be offered to health-care providers to assist in this decision. The I-NECPAL is the first psychometrically tested palliative needs identification tool for use in the geriatric population in Israel, on both a scale and an itemized level. The results indicate that it can immediately replace the current unvalidated version in use. Further research is needed to determine whether all parts of the scale are relevant for this patient population.

Background COVID-19 is disproportionately affecting disadvantaged populations, with greater representation and worse outcomes in low socioeconomic and minority populations, and in persons from marginalized groups. General health care system approaches to inequity reduction (i.e., the minimization of differences in health and health care which are considered unfair or unjust), address the major social determinants of health, such as low income, ethnic affiliation or remote place of residents. Yet, to effectively reduce inequity there is a need for a multifactorial consideration of the aspects that intersect and generate significant barriers to effective care that can address the unique situations that people face due to their gender, ethnicity and socioeconomic situation. Main body To address the health equity challenges of diverse population groups in Israel, we propose to adopt an intersectional approach, allowing to better identify the needs and then better tailor the infection prevention and control modalities to those who need them the most. We focus on the two main ethnic – cultural—religious minority groups, that of Arab Palestinian citizens of Israel and Jewish ultra-orthodox (Haredi) communities. Additionally, we address the unique needs of persons with severe mental illness who often experience an intersection of clinical and sociodemographic risks. Conclusions This perspective highlights the need for responses to COVID-19, and future pandemic or global disasters, that adopt the unique lens of intersectionality and equity. This requires that the government and health system create multiple messages, interventions and policies which ensure a person and community tailored approach to meet the needs of persons from diverse linguistic, ethnic, religious, socioeconomic and cultural backgrounds. Under-investment in intersectional responses will lead to widening of gaps and a disproportionate disease and mortality burden on societies’ most vulnerable groups.

Aim This study explores the potential benefit of combining clinicians' risk assessments and the automated 30-day readmission prediction model. Background Automated readmission prediction models based on electronic health records are increasingly applied as part of prevention efforts, but their accuracy is moderate. Methods This prospective multi-source study was based on self-reported surveys of clinicians and data from electronic health records. The survey was performed at 15 internal medicine wards of three general Clalit hospitals between May 2016 - June 2017. We examined the degree of concordance between the Preadmission Readmission Detection Model, clinicians' readmission risk classification and the likelihood of actual readmission. Decision-trees were developed to classify patients by readmission risk. Results A total of 694 surveys were collected for 371 patients. The disagreement between clinicians' risk assessment and the model was 34.5% for nurses and 33.5% for physicians. The decision-tree algorithms identified 22% and 9% (based on nurses and physicians, respectively) of the model's low-medium risk patients as high-risk (accuracy 0.8 and 0.76 respectively). Conclusions Combining the Readmission Model with clinical insight improves the ability to identify high-risk elderly patients. Implications for nursing management This study provides algorithms for the decision-making process for selecting high-risk readmission patients based on nurses' evaluations.

Many older adults need help with Activities of Daily Living (ADL) and emotional support during hospitalization. Hospital staff is officially responsible for care, but most older adults are accompanied by family members who provide at least some of the support. In this study, we asked physicians, nurses, nursing assistants, and relatives about hospital staff versus family responsibility for providing ADL care and emotional support, and about actual levels of help provision by the hospital staff in Israel. Staff members (except physicians) tended to see staff as more responsible for ADL care than family, while emotional support was a shared responsibility. Nursing assistants were the most likely to report that staff provided high levels of support, and all participants reported that staff provided more ADL care than emotional support. It is important for family members and hospital staff to have open discussions of their expectations and responsibilities when older adults are hospitalized.

Objective: This study examined whether personal characteristics of consumers with serious mental illness (SMI), including being an immigrant, explained the lack of concordance in quality-of-life (QOL) ratings reported by consumers versus those reported by staff caring for consumers. Method: In a sample of consumers with SMI (n = 4,956), including nonimmigrants and immigrants from Ethiopia and countries comprising the former Soviet Union (FSU), we examined consumer-reported and staff-reported QOL ratings. Regression models measured the contributions of covariates to QOL ratings made by both groups. Results: Staff-reported QOL ratings were consistently lower than consumer-reported QOL ratings. Consumer-reported QOL ratings made by FSU immigrants were lower than consumer-reported QOL ratings made by Ethiopian immigrants or by nonimmigrants (p < .01). Conversely, staff-reported QOL ratings on Ethiopian immigrants were lower than staff-reported QOL ratings on FSU immigrants or nonimmigrants (p < .05). While consumer-reported QOL ratings were associated with the covariates of gender (p < .01), disability level (p < .001), and health status (p < .001), staff-reported QOL ratings were associated with the covariates of single marital status (p < .05), education (p < .001), and disability level (p < .001). Conclusions and Implications for Practice: Among consumers with SMI, FSU immigrants reported the lowest QOL ratings, yet staff rated the QOL of Ethiopian immigrants as the lowest. Bias is a potential explanation for this discrepancy. An educational program focusing on cultural awareness, sensitivity, and competency might help staff better understand consumers' needs, thereby contributing to better service and potentially improving staff's ability to make assessments of consumers' functioning and QOL. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

BACKGROUND: Oral anticancer therapy (OACT) poses adherence-related challenges to patients while generating a setting in which both primary care physicians (PCPs) and oncologists are involved in the active treatment of cancer. Continuity of care (COC) was shown to be associated with medication adherence. While maintaining COC is a central role of the PCP, how this affects continuity with oncologists, and jointly affects OACT adherence, is yet unknown. OBJECTIVES: To explore how aspects of COC act together to promote OACT adherence. Specifically, to examine whether better personal continuity with the PCP leads to better personal continuity with the oncologist, which together lead to better cross-boundary continuity between the oncologist and the PCP, jointly leading to good adherence to OACT. DESIGN AND SETTING: A prospective cohort study conducted in five oncology centers in Israel. A bootstrapping method was used to test the serial mediation model. PARTICIPANTS: Adult patients (age > 18 years) receiving a first OACT prescription (n = 119) were followed for 120 days. MAIN MEASURES: The Nijmegen Continuity Questionnaire was used to assess patients’ perceived personal and cross-boundary continuity. The medication possession ratio was used to measure adherence. KEY RESULTS: Better personal continuity with the PCP was associated with better personal continuity with the oncologist (B = 0.35, p < 0.001), which was associated with better cross-boundary continuity (B = 0.33, p < 0.001), which, in turn, was associated with good adherence to OACT (B = 0.46, p = 0.03). Additionally, the indirect effect of personal continuity with the PCP on adherence to OACT through the mediation of personal continuity with the oncologist and cross-boundary continuity was found to be statistically significant (B = 0.053, 95% CI 0.0006–0.17). CONCLUSIONS: In a system where the PCP is the case manager, cancer patients’ perceived personal continuity with the PCP has an essential role for initiating a sequence of care delivery events that positively affect OACT adherence. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06704-w.

Objective Vocational rehabilitation for people with severe mental illness (SMI) has many benefits. Among the existing models, supported employment has consistently shown to have better impact on vocational outcomes while the findings on non-vocational outcomes are inconsistent. One source of variation with regard to non-vocational outcomes could be related to differences between consumers’ self-reports and the providers’ point of view. Design A cross-sectional study of people with SMI consuming three different vocational services and their service providers. Setting Data were collected as part of the Israeli Psychiatric Rehabilitation Patient Reported Outcome Measurement project. Participants The current data is based on 3666 pairs of people with SMI consuming vocational services and their service providers. Interventions Vocational services included supported employment, sheltered workshops and vocational support centers. Main Outcome Measures The consumers-filled self-report questionnaires, which consisted of the following patient-reported outcome measurements (PROMs): quality of life, functioning and illness management. Primary professional providers were given instruments that mirrored the ones designed for self-report. Results According to providers’ ratings, supported employment was associated with higher functioning (F = 78.6, P Conclusions This study provides a deeper insight into non-vocational outcomes of people with SMI participating in vocational services and suggests differences in perspectives between consumers and providers with regard to outcome measures.

Aims To (a) assess patients' interest and perceived capability of participating in haemodialysis; (b) assess nurses' perceptions of patients' interest and perceived capability of participating in haemodialysis; and (c) examine associations between patient characteristics and interest and perceived capability of performing haemodialysis self-care. Design Cross-sectional, questionnaire-based study. Methods Data were collected from dialysis patients and their nurses between October 2018-May 2019. Patients' interest and perceived capability of participation were assessed by a 10-item Likert-type scale developed and tested for this study, with responses ranging from 1 (not interested/no perceived capability) to 5 (already doing task independently). Multivariate linear regression was used to assess the relationship between patient characteristics, including age, sex, education level and severity of illness to ratings of activation level and haemodialysis self-care scale scores. The STROBE checklist was used as a guideline for this study. Results Ninety-one patients and 31 nurses participated. Overall, patients expressed interest (2.43 ± 0.93) and perceived themselves capable (2.34 ± 0.9) of participating in various haemodialysis-related tasks. Nurses assessed lower interest (2.19 ± 0.77) than patients, but similar average capability (2.31 ± 0.8). Both greater interest and perceived capability were correlated with more years of education and higher patient activation; additionally, interest was associated with disease severity and perceived capability was associated with age. Conclusion Haemodialysis patients are interested and perceive themselves capable of participating in the tasks involved in dialysis care. Nurses underestimate patient interest in participation. Relevance to clinical practice Self-care behaviours among haemodialysis patients are important, as they may affect quality of life and survival. Determining interest and perceived capability of participation is a first step towards evaluating the feasibility of self-care in a supervised haemodialysis setting.

BackgroundDisease-specific guidelines are not aligned with multimorbidity care complexity. Meeting all guideline-recommended care for multimorbid patients has been estimated but not demonstrated across multiple guidelines.ObjectiveMeasure guideline-concordant care for patients with multimorbidity; assess in what types of care and by whom (clinician or patient) deviation from guidelines occurs and evaluate whether patient characteristics are associated with concordance.MethodsA retrospective cohort study of care received over 1 year, conducted across 11 primary care clinics within the context of multimorbidity-focused care management program. Patients were aged 45+ years with more than two common chronic conditions and were sampled based on either being new (≤6 months) or veteran to the program (≥1 year).MeasuresThree guideline concordance measures were calculated for each patient out of 44 potential guideline-recommended care processes for nine chronic conditions: overall score; referral score (proportion of guideline-recommended care referred) and patient-only score (proportion of referred care completed by patients). Guideline concordance was stratified by care type.Results4386 care processes evaluated among 204 patients, mean age = 72.3 years (standard deviation = 9.7). Overall, 79.2% of care was guideline concordant, 87.6% was referred according to guidelines and patients followed 91.4% of referred care. Guideline-concordant care varied across care types. Age, morbidity burden and whether patients were new or veteran to the program were associated with guideline concordance.ConclusionsPatients with multimorbidity do not receive ~20% of guideline recommendations, mostly due to clinicians not referring care. Determining the types of care for which the greatest deviation from guidelines exists can inform the tailoring of care for multimorbidity patients.

BACKGROUND: Predictive models based on electronic health records (EHRs) are used to identify patients at high risk for 30-day hospital readmission. However, these models’ ability to accurately detect who could benefit from inclusion in prevention interventions, also termed “perceived impactibility”, has yet to be realized. OBJECTIVE: We aimed to explore healthcare providers’ perspectives of patient characteristics associated with decisions about which patients should be referred to readmission prevention programs (RPPs) beyond the EHR preadmission readmission detection model (PREADM). DESIGN: This cross-sectional study employed a multi-source mixed-method design, combining EHR data with nurses’ and physicians’ self-reported surveys from 15 internal medicine units in three general hospitals in Israel between May 2016 and June 2017, using a mini-Delphi approach. PARTICIPANTS: Nurses and physicians were asked to provide information about patients 65 years or older who were hospitalized at least one night. MAIN MEASURES: We performed a decision-tree analysis to identify characteristics for consideration when deciding whether a patient should be included in an RPP. KEY RESULTS: We collected 817 questionnaires on 435 patients. PREADM score and RPP inclusion were congruent in 65% of patients, whereas 19% had a high PREADM score but were not referred to an RPP, and 16% had a low-medium PREADM score but were referred to an RPP. The decision-tree analysis identified five patient characteristics that were statistically associated with RPP referral: high PREADM score, eligibility for a nursing home, having a condition not under control, need for social-services support, and need for special equipment at home. CONCLUSIONS: Our study provides empirical evidence for the partial congruence between classifications of a high PREADM score and perceived impactibility. Findings emphasize the need for additional research to understand the extent to which combining EHR data with provider insights leads to better selection of patients for RPP inclusion. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05739-9) contains supplementary material, which is available to authorized users.

BackgroundNurse champions are front-line practitioners who implement innovation and reconstruct policy.PurposeTo understand through a network theory lens the factors that facilitate nurse champions’ engagement with radical projects, representing their actions as street-level bureaucrats (SLBs).Materials and methodsA personal-network survey was employed. Ninety-one nurse champions from three tertiary medical centers in Israel participated.FindingsGiven high network density, high levels of advice play a bigger role in achieving high radicalness compared with lower levels advice. High network density is also related to higher radicalness when networks have high role diversity.DiscussionUsing an SLB framework, the findings suggest that nurse champions best promote adoption of innovation and offer radical changes in their organizations through professional advice given by colleagues in their field network. Healthcare organizations should establish the structure and promote the development of dense and heterogeneous professional networks to realize organizations’ goals and nurses’ responsibility to their professional employees, patients, and society.

BackgroundEvidence from various sources suggests that females with schizophrenia tend to report lower quality of life than males with schizophrenia despite having a less severe course of the disorder. However, studies have not examined this directly.AimsTo examine gender differences in the association between quality of life and the risk of subsequent psychiatric hospital admissions in a national sample with schizophrenia.MethodThe sample consisted of 989 (60.90%) males and 635 (39.10%) females with an ICD-10 diagnosis of schizophrenia. Quality of life was assessed and scored using the Manchester Short Assessment of Quality of Life. The course of schizophrenia was assessed from the number of psychiatric hospital admissions. Participants completed the quality of life assessment and were then followed up for 18-months for subsequent psychiatric admissions. Hazard ratios (HR) from Cox proportional hazards regression models were estimated unadjusted and adjusted for covariates (age at schizophrenia onset and birth year). Analyses were computed for males and females separately, as well as for the entire cohort.ResultsA subsample of 93 males and 55 females was admitted to a psychiatric hospital during follow-up. Higher quality of life scores were significantly (P < 0.05) associated with a reduced risk of subsequent admissions among males (unadjusted: HR = 0.96, 95% CI 0.93–0.99; adjusted HR = 0.96, 95% CI 0.93–0.99) but not among females (unadjusted: HR = 0.97, 95% CI 0.93–1.02; adjusted HR = 0.97, 95% CI 0.93–1.02).ConclusionsQuality of life in schizophrenia is a gender-specific construct and should be considered as such in clinical practice and future research.

Subjective age contributes to a range of health and functional outcomes in older adults. Most of the evidence comes from studies in community dwelling older adults. The current study explores whether younger subjective age serves as a protective factor against hospital associated physical, cognitive, and emotional decline. This paper is a secondary analysis of a subsample (N=250) from the HoPE-MOR (Hospitalization Process Effects on Mobility Outcomes and Recovery) study for which subjective age was assessed at the time of hospital admission and outcomes were measured one-month post-discharge. Psychological and physiological subjective age was measured as a person’s report on the degree to which they feel older or younger compared to their chronological age on a 5-point Likert-type scale. Measures of independency in Activities of Daily Living, Life-space mobility, cognitive function and depressive symptoms, were based on participants’ assessment at admission and one-month post-discharge. In a sample of acutely ill participants, age 77.5±6.6, those with younger psychological subjective age had a significantly lower odds for poorer mental (OR=0.66, 95%CI 0.45-0.97), functional (OR=0.62, 95%CI 0.43-0.90) and cognitive state (OR=0.60, 95%CI 0.36-0.98), and better life-space mobility (OR=0.67, 95%CI 0.47-0.95). Findings were significant after controlling for numerous demographic, functional, cognitive, emotional and chronic and acute health predictors. Physiological subjective age was not significantly related to post hospitalization outcomes. Psychological subjective age could serve as a relatively simple parameter to identify older adults who are at risk for poor hospitalization outcomes for consideration of inclusion in preventive in-hospital and post discharge interventions.

Objective We examined whether patients' ratings of their in-hospital discharge briefing and their post-discharge Primary Care Physicians' (PCP) review of the discharge summary are associated with 30-day readmissions. Methods A prospective study of 594 internal-medicine patients at a tertiary medical-center in Israel. The in-hospital baseline questionnaire included sociodemographic characteristics, physical, mental, and functional health status. Patients were surveyed by phone about the discharge and post-discharge processes. Clinical data and health-service use was retrieved from a central data-warehouse. Multivariate regressions modeled the relationship between in-hospital baseline characteristics, discharge briefing, PCP visit indicator, the PCP discharge summary review, and 30-day readmissions. Results The extent of the PCPs' review of the hospital discharge summary at the post-discharge visit was rated higher than the in-hospital discharge briefing (3.46 vs. 3.17, p = 0.001) and was associated with lower odds of readmission (OR=0.35, 95% CI 0.26–0.45). The model that included this assessment performed better than the in-hospital baseline, the in-hospital discharge-briefing, and the PCP visit models (C-statistic = 0.87, compared with: 0.70, 0.81, 0.81, respectively). Conclusions Providing extensive post-discharge explanations by PCPs serves as a significant protective factor against readmissions. Practice implications PCPs should be encouraged to thoroughly review the discharge summary letter with the patient.

Aim Poor food intake is a major concern among hospitalized older adults. This study investigated the frequency and optimal timing of in-hospital food intake assessment in terms of its ability to predict hospitalization functional outcomes. Methods Secondary analysis of a cohort study of 699 older adults (age ≥70 years) admitted to internal medicine wards for non-disabling conditions was carried out. Daily food intake was assessed using self-reported estimation of portions consumed at each meal and calculated according to the caloric composition of the meals. Nutritional status on admission, baseline and discharge activities of daily living, and cognitive status were assessed using validated questionnaires. Repeated measures analysis of variance (n = 263) and multiple logistic regression models (n = 475) for predicting activities of daily living and cognitive decline were used to establish required frequency and optimal timing of food-intake monitoring. Results Mean daily intake significantly increased from the first 48 h from admission (0.51 ± 0.30) to the second and third assessments (0.62 ± 0.30 and 0.63 ± 0.30, respectively). Eating half or less of the served meals both within the first 48 h of admission and after 48 h was associated with higher odds of cognitive decline (OR 1.93, 95% CI 1.27-2.94; OR 1.62, 95% CI 1.04-2.51, respectively). Low intake after 48 h of admission was associated with higher odds of activities of daily living decline (OR 1.66, 95% CI 1.03-2.67). Conclusions Food intake increases from the first 48 h of admission onwards and becomes more consistent 3 days after admission. The associations between low food intake at various time points and worse functional outcomes show the importance of routine food intake monitoring for at least 3 days. Geriatr Gerontol Int 2019; 19: 890-895.

The objective of this study was to evaluate the incremental predictive power of electronic medical record (EMR) data, relative to the information available in more easily accessible and standardized insurance claims data.Using both EMR and Claims data, we predicted outcomes for 118,510 patients with 144,966 hospitalizations in 8 hospitals, using widely used prediction models. We use cross-validation to prevent overfitting and tested predictive performance on separate data that were not used for model training.We predict 4 binary outcomes: length of stay (≥7 d), death during the index admission, 30-day readmission, and 1-year mortality.We achieve nearly the same prediction accuracy using both EMR and claims data relative to using claims data alone in predicting 30-day readmissions [area under the receiver operating characteristic curve (AUC): 0.698 vs. 0.711; positive predictive value (PPV) at top 10% of predicted risk: 37.2% vs. 35.7%], and 1-year mortality (AUC: 0.902 vs. 0.912; PPV: 64.6% vs. 57.6%). EMR data, especially from the first 2 days of the index admission, substantially improved prediction of length of stay (AUC: 0.786 vs. 0.837; PPV: 58.9% vs. 55.5%) and inpatient mortality (AUC: 0.897 vs. 0.950; PPV: 24.3% vs. 14.0%). Results were similar for sensitivity, specificity, and negative predictive value across alternative cutoffs and for using alternative types of predictive models.EMR data are useful in predicting short-term outcomes. However, their incremental value for predicting longer-term outcomes is smaller. Therefore, for interventions that are based on long-term predictions, using more broadly available claims data is equally effective.

ObjectivesThe study examines whether hospital discharge practices and care-transition preparedness mediate the association between patients’ cultural factors and readmissions.MethodsA prospective study of internal medicine patients (n=599) examining a culturally diverse cohort, at a tertiary medical centre in Israel. The in-hospital baseline questionnaire included sociodemographic, cultural factors (Multidimensional Health Locus of Control, family collectivism, health literacy and minority status) and physical, mental and functional health status. A follow-up telephone survey assessed hospital discharge practices: use of the teach-back method, providers’ cultural competence, at-discharge language concordance and caregiver presence and care-transition preparedness using the care transition measure (CTM). Clinical and administrative data, including 30-day readmissions to any hospital, were retrieved from the healthcare organisation’s data warehouse. Multiple mediation was tested using Hayes’s PROCESS procedure, model 80.ResultsA total of 101 patients (17%) were readmitted within 30 days. Multiple logistic regressions indicated that all cultural factors, except for minority status, were associated with 30-day readmission when no mediators were included (pConclusionsThe results show that the association between patients’ cultural factors and 30-day readmission is mediated by the hospital discharge practices and care transition. Providing high-quality discharge planning tailored to patients’ cultural characteristics is associated with better care-transition preparedness, which, in turn, is associated with reduced 30-day readmissions.

Background Parents of children following traumatic medical events (TMEs) are known to be at high risk for developing severe post-traumatic stress symptoms (PTSS). Findings on the negative impact of TMEs on parents’ PTSS have been described in different cultures and societies. Parents from ethnic minority groups may be at particularly increased risk for PTSS following their child’s TME due to a host of sociocultural characteristics. Yet, differences in PTSS manifestation between ethnic groups following a child’s TME has rarely been studied. Objectives We aimed to examine: (1) differences in PTSS between Israeli-Arab and Israeli-Jewish mothers, following a child’s TME, and (2) risk and protective factors affecting mother’s PTSS from a biopsychosocial approach. Methods Data were collected from medical files of children following TMEs, hospitalized in a Department of Pediatric Rehabilitation, between 2008 and 2018. The sample included 47 Israeli-Arab mothers and 47 matched Israeli-Jewish mothers. Mothers completed the psychosocial assessment tool (PAT) and the post-traumatic diagnostic scale (PDS). Results Arab mothers perceived having more social support than their Jewish counterparts yet reported higher levels of PTSS compared to the Jewish mothers. Our prediction model indicated that Arab ethnicity and pre-trauma family problems predicted higher levels of PTSS among mothers of children following TMEs. Conclusions Despite reporting higher social support, Arab mothers reported higher levels of PTSS, as compared to the Jewish mothers. Focusing on ethnic and cultural differences in the effects of a child’s TME may help improve our understanding of the mental-health needs of mothers from different minority groups and aid in developing appropriate health services and targeted interventions for this population.

ObjectivesPatients with haematological malignancies receiving immunosuppressive therapy are at highest risk of invasive pneumococcal disease. Our goal was to investigate whether vaccination of haematological patients with pneumococcal 13-valent conjugated vaccine (PCV13) prior to therapy initiation is associated with decreased hospital admissions due to pneumonia or sepsis within 12 months.Design and settingA longitudinal retrospective cohort study was conducted at the haematology unit of Carmel Medical Center, Israel.ParticipantsInformation on adult patients (>18 years) who were diagnosed between 1 January 2009 and 30 December 2019 with haematological malignancies and received immunosuppressive therapy was retrieved from the electronic health records. Patients with haematological malignancies who received the PCV13 vaccination during or after initiation of the immunosuppressive therapy were excluded from the study.Outcome measuresA multivariate logistic regression model was performed to determine whether PCV13 vaccination is associated with fewer hospital admissions due to pneumonia or sepsis.ResultsThe cohort included 616 patients, of which 418 (67%) patients were not vaccinated and 198 (33%) were vaccinated. Within 12 months, 15.1% (n=63) of non-vaccinated patients compared with only 7.1% (n=14) of the vaccinated patients were hospitalised due to pneumonia or sepsis. The logistic regression analysis demonstrated that receiving PCV13 vaccination is associated with 45% (OR=0.45, 95% CI: 0.246 to 0.839, p=0.012) reduced odds of being hospitalised due to pneumonia or sepsis in patients with haematological malignancies receiving immunosuppressive therapy.ConclusionThis is the first observational study to demonstrate the association between PCV13 vaccination and hospital admissions in patients with haematological malignancies receiving immunosuppressive therapy. Patients receiving PCV13 vaccination before immunosuppressive therapy initiation had significantly reduced odds of hospitalisation due to pneumonia or sepsis compared with non-PCV13-vaccinated patients.

Background: Parents of children following a traumatic medical event (TME) are known to be at high risk for developing severe post-traumatic stress symptoms (PTSS). Findings on the negative impact of TMEs on parents’ PTSS have been described in different cultures and societies worldwide. However, in some cases, a specific ethnic group may also be a minority within a given region or a country, contributing to increased risk for parental PTSS following a child’s TME.Objectives: The current study aimed to examine differences in PTSS between Israeli-Arab and Israeli-Jewish mothers, following a child’s TME. More specifically, we aimed to examine the risk and protective factors affecting mother’s PTSS from a biopsychosocial approach.Methods: Data were collected from medical files of children following TMEs, hospitalized in a pediatric rehabilitation department, during the period 2008–2018. The sample included 47 Israeli-Arab mothers and 47 Israeli-Jewish mothers. Mothers completed the psychosocial assessment tool (PAT), the post-traumatic diagnostic scale (PDS).Results: Arab mothers self-reported significantly higher levels of PTSS than their Jewish counterparts. Further, Arab mothers perceived having more social support than Jewish mothers did. Finally, our prediction model indicated that both Arab ethnicity and pre-trauma family problems predicted higher levels of PTSS among mothers of children following TMEs.Conclusions: Focusing on ethnic and cultural effects following a child’s TME may help improve our understanding of the mental health needs of mothers from different minority ethnic groups and aid in developing appropriate health services and targeted interventions for this population.

Reasons why care does not conform to single-disease guideline recommendations for multimorbid patients have not been systematically measured in practice. Using a mixed methods approach, we identified and quantified types of reasons why care deviates from nine sets of disease guideline recommendations for multimorbid patients. Utilizing a focus group concept mapping technique, we built on a categorization of reasons explaining guideline deviation, and surveyed treating nurses about these reasons for patients’ specific care processes. Directed content analysis was conducted to classify the responses into reasons categories. Of 4,386 guideline-recommended care processes evaluated, 920 were not guideline-concordant (944 reasons). Three broad categories of reasons and 18 specific reasons were identified: Biomedical-related occurred 35.2% of the time, patient personal-related (30.4%), context-related (18.4%), and unknown (16.0%). Patient- and context-related factors are prevalent drivers for guideline deviation in multimorbidity, demonstrating that patient-centered aspects are as much a part of care decisions as biomedical aspects.

Introduction Informal caregiving during hospitalization of older adults is significantly related to hospital processes and patient outcomes. Studies in home settings demonstrate that ethno-cultural background is related to various aspects of informal caregiving; however, this association in the hospital setting is insufficiently researched. Objectives Our study explore potential differences between ethno-cultural groups in the amount and kind of informal support they provide for older adults during hospitalization. Methods This research is a secondary data analysis of two cohort studies conducted in Israeli hospitals. Hospitalized older adults are divided into three groups: Israeli-born and veteran immigrant Jews, Arabs, and Jewish immigrants from the Former Soviet Union (FSU). Duration of caregiver visit, presence in hospital during night hours, type of support (using the Informal Caregiving for Hospitalized Older Adults scale) are assessed during hospitalization. Results are controlled by background parameters including functional Modified Barthel Index (MBI) and cognitive Short Portable Mental Status Questionnaire (SPMSQ) status, chronic morbidity (Charlson), and demographic characteristics. Results Informal caregivers of “FSU immigrants” stay fewer hours during the day in both cohorts, and provide less supervision of medical care in Study 2, than caregivers in the two other groups. Findings from Study 1 also suggest that informal caregivers of “Arab” older adults are more likely to stay during the night than caregivers in the two other groups. Conclusions Ethno-cultural groups differ in their patterns of caregiving of older adults during hospitalization. Health care professionals should be aware of these patterns and the cultural norms that are related to caregiving practices for better cooperation between informal and formal caregivers of older adults.

Self-management, or self-care, by individuals and/or families is a critical element in chronic illness management as more care shifts to the home setting. Mobile device-enhanced health care, or mHealth, is being touted as a means to support self-care. Previous mHealth reviews examined the effect of mHealth on patient outcomes, however, none used a theoretical lens to examine the interventions themselves. The aims of this integrative review were to examine recent (e.g., last 10 years) chronic illness mHealth empiric studies and (1) categorize self-care behaviors engaged in the intervention according to the Middle-Range Theory of Self-care of Chronic Illness, and (2) conduct an analysis of gaps in self-care theory domains and behaviors utilized. Methods included: (1) Best practice study identification, collection, and data extraction procedures and (2) realist synthesis techniques for within and across case analysis. From a pool of 652 records, 33 primarily North American clinical trials, published between 2010 and 2019 were examined. Most mHealth interventions used apps, clinician contact, and behavioral prompts with some wireless devices. Examination found self-care maintenance behaviors were supported in most (n = 30) trials whereas self-care monitoring (n = 12) and self-care management behaviors (n = 8) were less so. Few trials (n = 2) targeted all three domains. Investigation of specific behaviors uncovered an overexamination of physical activity and diet behaviors and an underexamination of equally important behaviors. By examining chronic illness mHealth interventions using a theoretical lens we have categorized current interventions, conducted a gap analysis uncovering areas for future study, and made recommendations to move the science forward.

To develop and test the relationship between nurse champions' personal social networks and innovation success in terms of spread.A cross sectional.Data were collected on 94 nurse champions at three medium-large tertiary medical centres from 2015-2016. Data from champions on their personal network were assessed via a standardized and acceptable three-step network survey. Success in terms of innovation spread was assessed via perceived extent of spread. Network structural and relational characteristics were depicted by level of spread. Multivariate linear regression was used to assess the relationship between network characteristics and innovation spread.Above and beyond various project and network control variables, network density was significantly and positively related to project spread, tie-strength diversity was significantly and negatively related to project spread and difference in ethnic origin between champions and alters was significantly and positively related to project spread. Maximum age of network members was marginally significantly related to project spread.Our findings show that high-density personal social networks; networks where tie strength among network members is similar, thus, creating liking and trust among members; having at least one older network member who might have close access to professional and organizational resources acquired throughout their career; and having ties with network members from different ethnic groups to prevent knowledge stickiness, all promote innovation spread. Champions should be carefully nominated based on their ability to engage network members and to build ties with various network members inside and outside the nursing unit; once selected, champions should be aware of their social networks.The current study explored champions' personal-network structure, composition and variance measures and their implications for innovation project spread. The findings demonstrated that nursing champions' personal social networks matter for innovation spread. This finding has implications for the nominating and the coaching of champions.目的: 发展和测试护士拥护者的个人社交网络与成功创新传播之间的关系。 设计: 横向研究。 方法: 2015年至2016年间,我们共收集三家大中型三级医疗中心的94名护士拥护者的数据。将通过标准化、可接受的三步网络调查对拥护者的个人网络数据进行评估。创新传播的成功将可通过感知的传播程度来评估。网络的结构特征和关系特征均可通过传播水平来描述。此外,可运用多元线性回归分析网络特征与创新传播之间的关系。 发现: 除各类项目和网络控制变量外,网络密度与项目传播呈明显正相关,联系强度多样性与项目传播呈明显负相关,而拥护者和替补人员之间的种族差异与项目传播呈明显正相关。网络成员的最高龄与项目传播显著相关。 结论: 研究结果表明,高密度的个人社交网络,或网络成员之间联系强度相似且可用于创建联系和信任的网络,内部都至少有一名年纪教长的网络成员,且该成员有可能有近距离接触相关专业和组织资源;可与不同民族的网络成员建立联系,降低知识粘性,最终促进创新传播。拥护者的提名应以其吸引网络成员的能力以及与护理单位内外各种网络成员建立联系的能力为基础;如选中,拥护者应了解其社交网络。 影响: 本研究探讨了拥护者的个人网络结构、构成和差异测度及其对创新项目传播的影响。研究结果表明,护理拥护者的个人社交网络对创新传播至关重要。此研究结果对拥护者的提名和执教都有影响。.

We study a large intervention intended to reduce hospital readmission rates in Israel. Since 2012, readmission risk was calculated for patients aged 65 and older, and high-risk patients were flagged to providers upon admission and after discharge. Analyzing 171,541 admissions during 2009–2016, we find that the intervention reduced 30-day readmission rates by 5.9% among patients aged 65–70 relative to patients aged 60–64, who were not targeted by the intervention and for whom no risk-scores were calculated. The largest reduction, 12.3%, was among high-risk patients, though some of it may reflect substitution of attention away from patients with unknown high-risk at the point of care. Post-discharge follow-up encounters were significantly expedited. Estimated effects declined after incentives to reduce readmission rates were discontinued. The evidence demonstrates that informing providers about patient risk in real-time coupled with incentives to reduce readmissions can improve care continuity and reduce hospital readmissions.

Documentation of primary care teams' involvement in disparity reduction efforts exists, yet little is known about how teams interact or perceive their effectiveness. We investigated how the social network and structural ties among primary-care-clinic team members relate to their perceived team effectiveness (TE), in a large-scale disparity reduction intervention in Israel's largest insurer and provider of services. A mixed-method design of Social Network Analysis and qualitative data collection was employed. 108 interviews with medical, nursing, and administrative teams of 26 clinics and their respective managerial units were performed and information on the organizational ties, analyzing density and centrality, collected. Pearson correlations examined association between network measures and perceived TE. Clinics with strong intra-clinic density and high clinic-subregional-management density were positively correlated with perceived TE. Clinic in-degree centrality was also positively associated with perceived TE. Qualitative analyses support these findings with teamwork emerging as a factor which can impede or facilitate teams' ability to design and implement disparity reduction interventions. The study demonstrates that in an organization-wide disparity reduction initiative, cohesive intra-network structure and close relations with mid-level management increase the likelihood that teams perceive themselves as possessing the skills and resources needed to lead and implement disparity reduction efforts.

Aims To identify the sociodemographic attributes, project characteristics and champion strategies that differentiate formal from informal nursing champions, and to test their success in terms of project spread and novelty. Background Champions spread innovation in healthcare organizations. Empirical research has not explored the differences between formal and informal champions in terms of their antecedents and success. Design A quantitative cross-sectional design. Method Data were collected on 93 nursing champions in three hospitals from 2015 - 2016. Champions were identified according to a validated approach; data on their sociodemographic attributes, project characteristics and strategies were assembled through interviews and validated questionnaires. Their success in terms of novelty and spread was assessed via expert ratings and validated questionnaire. Findings Informal champions had longer tenure and were involved mainly in bottom-up projects aimed mostly at improving human resources and services; formal champions were mostly involved in top-down projects aimed at quality control. Informal champions expressed more enthusiasm and confidence about the innovation; formal champions tended to use more online resources and peer-monitoring strategies. Projects of informal champions were more novel than those of formal champions. Project spread did not differ between the two groups. Conclusion Formal and informal champions differ in their characteristics and implementation strategies. To encourage project's innovation, the organizational climate should encourage the emergence of informal champions; formal and informal champions should be chosen wisely, assuring that they possess enough organizational resources; and coaching programmes for junior champions should be planned to equip them with championing behaviours.

Background Performance of function-preserving hospitalization processes related to patient mobility, use of continence aids and food intake is significantly associated with outcomes in older adults. Nurses are the front-line personnel responsible for promoting performance of such processes. The degree to which nurse staffing is related to this performance is unclear. Objective To identify nurse-staffing characteristics and nursing-related care needs associated with older patients’ mobility, continence care and food intake during acute hospitalization. Design Cross-sectional study using survey data from the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR) cohort study combined with day-level administrative nurse staffing data and clinical day-level aggregated data for all patients hospitalized during the HoPE-FOR study period. Setting Internal medicine units in two medical centers in Israel. Participants Eight hundred seventy-three older adults. Methods Mobility, continence care and food intake were assessed within 2 days of admission using validated questionnaires. Nurse-to-patient ratios and nursing-skill mix (i.e. registered nurses (RNs), nurse aides, nurses with advanced clinical training and RNs with an academic degree) were assessed using administrative data. Decision trees were developed for mobility, continence care and food intake, applying classification and regression-tree analysis. Results The mobility decision tree identified three characteristics subdividing patients into six nodes: pre-admission functioning, pre-admission activity level and percentage of nurses with advanced training. The percentage of nurses with advanced training classified low-functioning patients into those walking in corridors versus walking or sitting only inside the room. The continence-care classification decision tree identified two characteristics that subdivided the patients into four nodes: pre-admission functioning and bladder control. Nurse-to-patient-ratio variables and patients’ nursing-related care needs did not contribute to this classification. The food-intake decision tree identified four characteristics—pre-admission functioning, gender, percentage of nurses with advanced training and percentage of nurse aides—subdividing patients into eight nodes. Low-functioning patients exposed to a higher percentage of nurses with advanced training had food-intake scores 14% higher than patients exposed to a lower percentage of nurses with advanced training. Independent men exposed to a higher percentage of nurse aides had a 14% higher habitual daily in-hospital food-intake score than independent men exposed to a lower percentage of nurse aides. Conclusions A higher percentage of nurses with post-graduate education is associated with better performance of mobility and food intake of hospitalized older adults. To maintain the potential benefits of highly trained staff, education levels should be considered in scheduling and assignment decision-making processes in internal medicine units. Tweetable abstract: A higher percentage of nurses with post-graduate education is associated with better mobility and food intake of hospitalized older adults.

Mobile health (mHealth)—hand-held technologies to address health priorities—has significant potential to answer the growing need for patient chronic illness self-care interventions. Previous reviews examined mHealth effect on patient outcomes. None have a detailed examination and mapping of specific technology features to targeted health outcomes. Examine recent chronic illness mHealth self-care interventions; map the study descriptors, mHealth technology features, and study outcomes. (1) Information extracted from PubMed, CINAHL, and Web of Science databases for clinical outcomes studies published 2010–January 2020; and (2) realist synthesis techniques for within and across case analysis. From 652 records, 32 studies were examined. Median study duration was 19.5 weeks. Median sample size was 62 participants. About 47% of interventions used solely patient input versus digital input; 50% sent tailored messages versus generic messages; 22% augmented the intervention with human interaction. Studies with positive clinical outcomes had higher use of digital input. Software descriptions were lacking. Most studies built interventions: only two incorporated target audience participation in development. We recommend researchers provide sufficient system description detail. Future research includes: data input characteristics; impact of augmentation with human interaction on outcomes; and development decisions.

Benzodiazepines and benzodiazepine-receptor agonists (BDZRAs, often known as "Z-drugs") are commonly used in older adults despite well-documented harms.To evaluate patterns of benzodiazepine and BDZRA use in Israel, focusing on potential leverage points where quality improvement initiatives might effectively curtail new use or the transition from intermittent to chronic use.We used national electronic medical data to assess a 10% random sample of adults receiving care in Clalit Health Services, which serves half of Israel's population. The sample included 267,221 adults, of whom 56,808 (21%) were age 65 and older.Medication use from 2013 to 2015 was ascertained using pharmacy dispensing data.In 2014, 7% of adults age 21-64 and 32% of adults age 65 and older received at least one benzodiazepine/BDZRA, including 49% of adults age 85 and older (P 0.001). The majority of older users (59%) were long-term users of the drugs, and 21% of older adults who were short-term users in 2014 transitioned to medium- or long-term use in 2015. Older Arab Israelis were much less likely to receive benzodiazepine/BDZRAs than older Jewish Israelis (adjusted OR 0.28, 95% 0.25-0.31), but within each community there was no major variation in prescribing rates across clinics. Depression diagnosis was associated with particularly high rates of benzodiazepine/BDZRA use: 17% of older adults with depression received a benzodiazepine/BDZRA but no antidepressant, and 42% received both. Recent hospitalization increased the risk of new benzodiazepine/BDZRA use (adjusted OR 1.41, 95% CI 1.01-1.96), but the absolute risk increase was only 3%.Benzodiazepines/BDZRAs are used at exceptionally high rates by older Israeli adults, especially the oldest old. Important leverage points for quality improvement efforts include curtailing the transition from short-term to long-term use, reducing use in older adults with depression, and identifying reasons that explain large differences in benzodiazepine/BDZRA prescribing between different ethnic groups.

Aim To assess the relationship between continuity in nursing assignment in older adults' acute hospitalization and patient experience and functional decline. Background In-hospital functional decline affects up to 40% of hospitalized older adults. Nurses are responsible for performing functioning-preserving interventions. Whether continuity of nursing care contributes to patients' functional outcomes is unclear. Method A retrospective observational study of 609 patients aged ≥70 admitted to internal medicine units. Patients were surveyed on their functional (cognitive and physical) status and satisfaction with the hospital care experience. Dispersion and sequence of nursing assignment were measured by the Continuity of Care Index and Sequential Continuity Index. Multivariate logistic regressions were modelled for each continuity score and outcome. Results Achieving 25% of the maximum Continuity of Care Index was associated with lower odds of cognitive decline (OR = 0.64, 95% CI = 0.43-0.94) and higher odds of satisfaction (OR = 1.52, 95% CI = 1.06-2.17). Achieving 25% of the maximum Sequential Continuity Index was associated only with higher odds of satisfaction (OR = 1.43, 95% CI = 1.01-2.02). Continuity scores were not associated with physical functioning decline. Conclusion Continuity in nursing assignment is related to a positive patient experience and cognitive functioning of hospitalized older adults. Implications for nursing management Continuity should be prioritized in scheduling and assignment algorithms.

The two components of hope (i.e., hope-agency defined as the ability to envision and believe in one's ability to achieve goals; hope-pathway defined as belief in one's ability to devise strategies to achieve one's goals) propel adolescents toward well-being, academic achievement and personal fulfillment. This study compares levels of hope and its components, for different groups of immigrant and ethnic non-immigrant youths, while adjusting for and measuring the impact of racism, school and family characteristics, and the youth's unique individual attributes. Using a community-based participatory research approach and a cross-sectional study design, data were collected from immigrant and non-immigrant youth (n = 567) between May 2015 and December 2015 at three Israeli public high schools. The study included five groups of youth based on their self-descriptions: Ethiopian immigrant (n = 48), Russian immigrant (n = 145), Israeli-born Mizrachi/Sephardi (n = 59), Israeli-born Ashkenazi (n = 49), or Israeli-born Unspecified (n = 266). Linear regression models showed that Ethiopian immigrant youth, compared to Russian immigrant youth and all Israeli-born groups of youth, had significantly lower hope-agency, hope-pathway and overall hope. However, an interaction effect between racism and ethnicity indicated that adolescents who perceived racism and self-identified as Ethiopian had higher hope-agency, hope-pathway and overall hope. This effect was not found with Russian immigrant or Israeli-born youth. Immigrants of color compared to other immigrants and ethnicities have less overall hope; but those who acknowledge racism feel more control over their future (hope-agency), able to devise strategies to surmount barriers blocking goals (hope-pathway), and have greater overall hope.

Background:The aim of this study was to test the association between anxiety at the time of hospitalization and falls occurring within one month of discharge, and to offer potential mechanisms for this association.Methods:One-month, prospective cohort study of 556 older adults in two medical centers in Israel. Anxiety and functional decline were assessed during hospitalization and falls were assessed one month post-discharge.Results:A total of 72 (12.9%) participants reported at least one fall during the 30-day post-discharge period. Controlling for demographics, functional decline and pre-morbid functional status, the odds of falls between discharge, and 1-month follow-up were almost twice as high among patients with anxiety symptoms (OR = 1.89, 95% CI: 1.04-3.48) compared with those who screened negative for anxiety. After accounting for in-hospital functional decline, the relationship between anxiety symptoms and falls decreased by 11% (from OR = 2.13 to 1.89), indicating that the relationship between anxiety and falls was partially mediated by functional decline during hospitalization.Conclusions:Anxiety at time of hospitalization is associated with falls 30-days post-discharge, controlling for several well-known confounders. This relationship is partially mediated by functional decline. Identifying patients with anxiety for inclusion in targeted rehabilitation interventions may be an important component of fall prevention strategies.

Background Frontline nurse champions are key innovation-implementation agents. Despite the growing interest in nurse champions’ innovation, whether project novelty is a product of championship behavior (e.g., expressing confidence in the innovation's success and network building), the project's contextual characteristics (project type and initiation level), or their joint effects, remains unsolved. Purpose To develop and test an interactionist model of project novelty in nursing. Methods A cross-sectional design with a multisource approach to data collection. Findings Results demonstrated a direct effect of project type, a two-way interaction effect of level of initiation and project type, a two-way interaction effect of championship and project type, and a three-way interaction effect of project type, initiation level, and championship on project's novelty. Discussion Bottom-up service and administrative projects require champions’ championship behaviors to foster novelty, whereas for bottom-up quality-improvement projects, such behaviors can harm project novelty. For human-resource projects and for top-down projects, championship behaviors do not matter.

To explore factors associated with necessity beliefs and concerns among patients receiving oral anticancer therapy (OACT) and, specifically, to examine the relationship between continuity of care (COC) and patients’ beliefs about OACT. A cross-sectional study was conducted among patients from four oncology centers receiving OACT (either targeted, hormonal, or chemotherapy). Two months after OACT initiation, patients were asked to participate in a face-to-face or telephone survey. The Beliefs about Medicines Questionnaire was used to examine patients’ perceptions of their personal necessity for OACT and concerns about potential adverse effects. The Nijmegen Continuity Questionnaire was used to assess patients’ perceived COC. Data on clinical characteristics were collected from medical records. Participants’ beliefs about OACT necessity (n = 91) were found to be associated with COC within the oncology team, and with COC between the oncology specialist and the primary care physicians (β = 0.27, p = 0.003; β = 0.22, p = 0.02, respectively), beyond age, depression, and cancer type (ΔR2 = 0.14, p

Introduction: Most of readmission prediction models are implemented at the time of patient discharge. [1] However, interventions which include an early in-hospital component are critical for reducing readmissions and improving patient outcomes. [2] Thus, at-discharge high-risk identification may be too late for effective intervention. Nonetheless, the tradeoff between early versus at-discharge prediction and the optimal timing of the risk prediction model application remains to be determined. We examined a high-risk patient selection with readmission prediction models using data available at two time points: at admission and at the time of hospital discharge. Methods: A retrospective cohort study of adults (≥65 years) discharged alive from internal medicine units in Clalit’s (the largest integrated payer-provider health fund in Israel) general hospitals in 2015.The outcome was all-cause 30-day emergency readmissions to any internal medicine ward at any hospital. We used the previously validated Preadmission Readmission Detection Model (PREADM) [3] and developed a new model incorporating PREADM with hospital data (PREADM‑H). We compared the percentage of overlap between the models and calculated the positive predictive value (PPV) for the subgroups identified by each model separately and by both models. Results: The final cohort included 35,156 index hospital admissions. The PREADM-H model included 17 variables with a C‑statistic of 0.68 (95% CI: 0.67–0.70) and PPV of 43.0% in the highest-risk categories. Of patients categorized by the PREADM‑H in the highest-risk decile, 78% were classified similarly by the PREADM. The 22% classified by the PREADM‑H at the highest decile, but not by the PREADM, had a PPV of 37%. Applying both the PREADM and PREADM-H allowed accurate detection of additional subsequently readmitted patients at the 10% highest-risk group. Discussions: Our results show that the timing of readmission risk prediction both at admission and discharge should be considered when making the decision regarding which population should be identified for inclusion in readmission prevention programs. Use of the PREADM model allowed early identification of high-risk patients, yet missed a portion whose readmission risk was almost as high. Alternatively, the PREADM‑H enabled accounting for risk factors that accrued during the hospital stay, though missed some patients who had an a priori high-risk according to the PREADM and whose actual readmission rate was much higher than the general population. Conclusions: Readmission prediction models should be implemented twice, to allow for early intervention at-admission and to capture new at-risk patients at-discharge. Lessons learned: The timing of readmission risk prediction makes a difference in terms of the population identified at each prediction time point. Limitations: Our results may not be generalizable to other settings where clinic and hospital data are not linked. However, with the growing use of EHRs,[4] the data included in the final PREADM‑H may be increasingly available to many healthcare organizations. Suggestions for future research: Our results provide an example of the potential complementary implementation of the predictive models to maximize their power in identifying various groups of high-risk patients for inclusion in within as well as post-discharge interventions. Further studies are needed to strengthen our findings.

Processes related to daily care of older adults during hospitalization, such as mobility and nutrition, have long-term consequences for their health and functioning. Although instrumental support provided by family members during hospitalization is highly prevalent, its relationship to older adults' actual walking and eating is unknown. Data on walking level (walking outside vs. inside the room) and nutritional intake were collected from 493 independent older adults admitted to internal medicine wards through up to three daily interviews using validated questionnaires. Informal support with walking and eating was assessed with the modified Informal Caregiving for Hospitalized Older Adults scale. Multivariate regression showed that informal support with walking and eating was associated with greater likelihood of walking inside the room and with lower nutritional intake. This association between informal support and less walking and eating call for routine functional assessments and tailored counseling of informal caregivers to meet older patients' support needs.

Background Medication-related problems are common in older adults with multiple chronic conditions. We evaluated the impact of a nurse-based primary care intervention, based on the Guided Care model of care, on patient-centered aspects of medication use. Methods Controlled clinical trial of the Comprehensive Care for Multimorbid Adults Project (CC-MAP), conducted among 1218 participants in 7 intervention clinics and 6 control (usual care) clinics. Inclusion criteria included age 45–94, presence of ≥3 chronic conditions, and Adjusted Clinical Groups (ACG) score > 0.19. The co-primary outcomes were number of changes to the medication regimen between baseline and 9 month followup, and number of changes to symptom-focused medications, markers of attentiveness to medication-related issues. Results Mean age in the intervention group was 72 years, 59% were women, and participants used a mean of 6.6 medications at baseline. The control group was slightly older (73 years) and used more medications (mean 7.1). Between baseline and 9 months, intervention subjects had more changes to their medication regimen than control subjects (mean 4.04 vs. 3.62 medication changes; adjusted difference 0.55, p = 0.001). Similarly, intervention subjects had more changes to their symptomatic medications (mean 1.38 vs. 1.26 changes, adjusted difference 0.20, p = 0.003). The total number of medications in use remained stable between baseline and follow-up in both groups (p > 0.18). Conclusion This nurse-based, primary care intervention resulted in substantially more changes to patients’ medication regimens than usual care, without increasing the total number of medications used. This enhanced rate of change likely reflects greater attentiveness to the medication-related needs of patients. Trial registration This trial is registered at https://clinicaltrials.gov, trial number NCT01811173. Electronic supplementary material The online version of this article (10.1186/s12877-018-0905-1) contains supplementary material, which is available to authorized users.

Background: Diabetes Conversation Map™ (Map™) is a global education program that engages patients with type 2 diabetes Mellitus (T2DM) in group-based discussions on diabetes-related topics. This study compares outcomes annually between participants and matched controls over a 4-year period. Methods: This was a retrospective cohort study of 11,053 Clalit Health Services members with T2DM who enrolled in the Map™ program between 1.1.2010 and 4.1.2016. The associations between program participation and annual laboratory test results (HbA1c, glucose and LDL levels), health behaviors (frequency of glucose and HbA1c testing), and healthcare utilization (hospital, physician and specialist visits) were assessed between cases and controls using regression analysis. Results: The Map™ group had significantly improved HbA1c, glucose, and LDL levels and more frequent blood glucose testing each year up to 36 months post-enrollment compared to matched-controls. They also had significantly fewer annual primary care visits but more annual ophthalmologist and nutritionist visits up to 24, 36, and 48 months post-enrollment, respectively, compared to matched-controls. The annual frequency of hospital admissions and length of hospital stay was lower up to 36 and 48 months post enrollment, respectively, in the Map™ group compared to matched-controls. Conclusions: Participation in the Map™ program was associated with improved clinical outcomes, behaviors, and healthcare utilization for at least 24 months, suggesting that an intervention booster may be needed beyond this time period. These findings support the significant impact of the Map™ program on the lives of patients with T2DM. Disclosure E. Srulovici: None. M. Leventer-Roberts: None. B. Curtis: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. X. He: None. M.B. Hoshen: None. M. Rotem: None. I. Gofer: None. E. Shadmi: None. C. Key: None. N. Levin-Iaina: Employee; Self; Eli Lilly and Company. A. Strizek: None. B.S. Feldman: None.

Background: The Diabetes Conversation Mapࡊ Program serves Clalit Health Services members with type 2 diabetes Mellitus (T2DM) for over 7 years, administered by over400 trained certified nurses. A formal evaluation of the programmatic factors of Mapࡊ has not yet been performed. Methods: This was a retrospective cohort study of 5,597 participants with T2DM who enrolled in the Map™ program between 1.1.2010 and 4.1.2015. Using Gamma and Poisson regression models and testing for hierarchical regression with random effects, we assessed the association between program factors (nurse instructor, enrollment year, and number of Map™ sessions attended), and outcomes (laboratory test results, adherence, and healthcare utilization) during a 12 month follow-up period. Results: Introducing the random effect of nurses who conducted the sessions yielded a low explained variance. Similarly, there were no significant differences in the outcomes across year of enrollment. However, Map™ participants who attended at least one session had on average a 2.1% reduction in HbA1c levels compared to those who enrolled but did not attend any sessions. Among participants who attended 1 session, the frequency of hospital admissions decreased by 55%, a decreased that did not change up to 4 sessions, compared to those who attended 0 sessions. There was no increased benefit in attending more than 4 sessions on frequency of hospital admissions within the follow-up period. The number of sessions was not associated with any other outcomes. Conclusions: Our results suggest that attending up to four sessions in the Map™ program is associated with improved HbA1c and decreased hospitalizations, and this does not vary by enrollment year or instructor. We suggest that nurses who instruct the Map™ program should try to improve participants' attendance to at least four sessions in order to maximize reductions in these two outcomes. Disclosure E. Srulovici: None. M. Leventer-Roberts: None. B. Curtis: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. X. He: None. A. Akriv: None. M.B. Hoshen: None. M. Rotem: None. I. Gofer: None. E. Shadmi: None. C. Key: None. N. Levin-Iaina: Employee; Self; Eli Lilly and Company. A. Strizek: None. B.S. Feldman: None.

Aim To investigate the characteristics of participants in the Diabetes Conversation Map™ (Map™) program who had higher vs. lower compliance to the program, to determine if program tailoring and monitoring is needed among these groups. Methods This was a retrospective cohort study of 8990 patients enrolled in the Map™ program (low compliance [attending 0–1 sessions, n = 2759] and high compliance [attending ≥2 sessions, n = 6231]). Socio-demographic, clinical, health behaviors, and healthcare utilization characteristics were extracted. Multivariable stepwise logistic regression was used as the analysis strategy. Results Those who were of higher socio-economic status (OR = 1.567, 95%CI:1.317–1.865), who lived in urban area (OR = 1.501, 95%CI:1.254–1.798), with greater frequency of primary care visits (OR = 1.012, 95%CI:1.002–1.021), with medium (OR = 1.176, 95%CI:1.013–1.365) or high oral medication adherence (OR = 1.198, 95%CI:1.059–1.356), and with a greater frequency of blood glucose tests (OR = 1.102, 95%CI:1.033–1.175) had greater odds of being in the high compliance group. Conversely, those aged 35–44 (OR = 0.538, 95%CI:0.402–0.721) and 45–54 years (OR = 0.763, 95%CI:0.622–0.937), with longer Type 2 diabetes duration (OR = 0.980, 95%CI:0.967–0.993), with higher blood glucose levels (OR = 0.999, 95%CI:0.998–1.000), and current (OR = 0.659, 95%CI:0.569–0.762) or former smokers (OR = 0.831, 95%CI:0.737–0.938) had reduced odds for being in the higher compliance group. Conclusions Instructors in advance can target sub-groups to increase their attendance rates, and consequently improve their outcomes.

Hospital-associated functional decline (HAFD) is recognized as a leading cause of adverse hospitalization outcomes, such as prolonged hospitalization, falls, readmission, and mortality. Since most patients hospitalized in internal medicine wards are older-adults, HAFD presents a major challenge to internal medicine.Describe functional trajectories of older-adults (aged ≥70 years) before, during and after acute hospitalization in internal-medicine units.A prospective cohort study was conducted of 741 older-adults, hospitalized in two tertiary hospitals in Israel during the period 2009-2011. Basic functional status two weeks before admission, on-admission, at-discharge and one-month post-discharge was assessed using the modified Barthel Index (BI). Eight trajectories were identified.Two-thirds of the participants were completely or almost independent at the pre-morbid period. About a half of the older-adults were hospitalized with pre-admission functional decline, a quarter deteriorated or died during hospitalization, and one-third improved during hospitalization. Most of the older-adults who were stable in functioning at the pre-admission period (57.1%) remained stable during and post-hospitalization; however, about a third of them did not return to their pre-morbid functioning levels. Approximately half of those with pre-morbid functional decline experienced additional deterioration of at least 5 points on the BI scale. Pre-morbid instrumental functional status, comorbidity and depressive symptoms have been found to distinguish older adults with similar pre-admission and in-hospital functional trends.Eight functional trajectories describe the hospitalization period of older-adults in internal-medicine units. On-admission personal characteristics may be used to identify older-adults who are at risk of unwarranted hospitalization outcomes and thus allow intervention in the hospital-community interface.

BACKGROUND Readmission to a different hospital than the original discharge hospital may result in breakdowns in continuity of care. In different-hospital readmissions (DHRs), continuity can be maintained when hospitals are connected through health information exchange (HIE) systems. OBJECTIVE To examine whether length of readmission stay (LORS) differs between same-hospital readmissions and DHRs, and whether in DHRs the LORS differs by the availability of HIE. DESIGN A retrospective cohort study of all internal medicine 30-day readmissions in 27 Israeli hospitals between January 1, 2010 and December 31, 2010. SETTING Clalit Health Services—Israel's largest integrated healthcare provider and payer. POPULATION Adult Clalit members (aged 18 and older) with at least 1 readmission during the study period. METHODS A multivariate marginal Cox model tested the likelihood for discharge during each readmission day in same-hospital readmissions (SHRs), DHRs with HIE, and DHRs without HIE. RESULTS Of the 27,057 readmissions, 3130 (11.6%) were DHRs and 792 where DHRs with HIE in both the index and readmitting hospital. Partial continuity (DHRs with HIE) was associated with decreased likelihood of discharge on any given day compared with full continuity (SHRs) (hazard ratio [HR] = 0.85, 95% confidence interval [CI]: 0.79–0.91). Similar results were obtained for no continuity (DHRs without HIE) versus full continuity (HR = 0.90, 95% CI: 0.86–0.94). The difference between DHRs with and without HIE was not significant. CONCLUSIONS The prolonged LORS in DHRs versus SHRs was not mitigated by the existence of HIE systems. Future research is needed to further elucidate the effects of actual use of HIE on length of DHRs. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine

In this article we present the design, development and implementation of the Psychiatric Rehabilitation Routine Outcome Measurement (PR-ROM) project, the first systematic effort to implement mental health routine outcome measures in Israel. The goal of the PR-ROM is to provide updated information about the process and impact of psychiatric rehabilitation services in Israel and to establish a sustainable infrastructure and foundation for routine outcome monitoring of rehabilitation services to improve care, inform policy, generate incentives for service improvement, increase informed decision-making and provide data for research purposes. The rehabilitation services evaluated and the characteristics of the population being served are described and the methods and nature of the collected data as well as some preliminary findings are presented. We discuss the major barriers encountered, our efforts to deal with them and lessons learned during the process. We conclude with a description of the current state of the initiative and plans for the future.

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.

Readmission prevention should begin as early as possible during the index admission. Early identification may help target patients for within-hospital readmission prevention interventions.To develop and validate a 30-day readmission prediction model using data from electronic health records available before the index admission.Retrospective cohort study of admissions between January 1 and March 31, 2010.Adult enrollees of Clalit Health Services, an integrated delivery system, admitted to an internal medicine ward in any hospital in Israel.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).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.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.

Objectives To investigate the combined contribution of processes of hospitalization and preadmission individual risk factors in explaining functional decline at discharge and at 1-month follow-up in older adults with nondisabling conditions. Design Prospective cohort study. Setting Internal medicine wards in two Israeli medical centers. Participants Six hundred eighty-four individuals aged 70 and older admitted for a nondisabling problem. Measurements Functional decline was measured according to change in modified Barthel Index from premorbid to discharge and from premorbid to 1 month after discharge. In-hospital mobility, continence care, sleep medication consumption, satisfaction with hospital environment, and nutrition intake were assessed using previously tested self-report instruments. Results Two hundred eighty-two participants (41.2%) reported functional decline at discharge and 317 (46.3%) at 1 month after discharge. Path analysis indicated that in-hospital mobility (standardized maximum likelihood estimate (SMLE) = −0.48, P

This study tested concordance between consumers' and providers' reports of personal goal setting and its relationship to self-reported goal attainment.Data are from the Israeli Psychiatric Rehabilitation Patient Reported Outcome Measurement project. Consumers (N=2,885) and the providers who were most knowledgeable about their care indicated two domains from a list of ten in which consumers had set goals during the previous year. Consumers reported on goal attainment in each domain.A total of 2,345 consumers (82%) reported a personal goal. Overall, consumer-provider concordance reached 54%. Concordance was greatest in the employment (76%), housing (71%), and intimate relationship (52%) domains and lowest in family relationships (23%) and finances (15%). For most domains, concordance was less than 50%. On average, 75% of consumers reported having achieved their goals. Consumer-provider concordance was associated with goal attainment (p.001).These findings emphasize the importance of agreed-upon goals and call for conceptualizing goal setting as an interpersonal process central to recovery.

Disparities between mental health patients and their professional caregivers in quality of life appraisals have been identified, however, the structure that such disparities assume is unknown.To examine the network structure of quality of life appraisals and disparities using network analysis.Participants were 1639 persons with schizophrenia using psychiatric rehabilitation services and their primary professional caregivers (N=582). Quality of life for persons with schizophrenia was measured based on an abbreviated version of the Manchester Short Assessment of Quality of Life. Appraisals were made self-reported and by professional caregivers. Disparities scores between the aforementioned were computed. Network analysis was performed on all quality of life appraisals. Sensitivity analyses were conducted.The self-appraised network significantly (p0.05) differed by network strength compared to the caregiver-appraised network. Self-appraised network communities (clusters of quality of life items) were health conditions and socioeconomic system, whereas caregiver-appraised network communities were social activities, and combined socioeconomic and health conditions. Strength centrality was highest for self-appraised social status and for caregiver-appraised residential status (Z=1.63, Z=1.12, respectively). The disparity scores network clustered into two communities: social relations and combined financial and health conditions. The most central appraisal disparities were in social status.Quality of life differed when self-appraised by persons with schizophrenia compared to when appraised by their professional caregivers, yet the salient role of social relations was shared. The latter may be an initial focus of discussion by persons with schizophrenia and their caregivers.