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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: 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.Methods: 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.Results: 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 < 0.001). Additionally, the difference between participants' beliefs about OACT necessity and their OACT-related concerns was associated with COC within the oncology team (β = 0.30, p = 0.001), beyond age, income, family status, and cancer type (ΔR2 = 0.09, p = 0.001).Conclusions: This study shows that cancer patients' perceptions about the COC between care providers are related to their beliefs about OACT necessity, thus providing evidence for the importance of health care delivery approaches that support COC within the oncology team and between the oncology specialist and the primary care physician. [ABSTRACT FROM AUTHOR]

Few studies have assessed healthcare experiences in apparently healthy adolescents, or whether healthcare attitudes are linked to the two leading adolescent health indicators, smoking and obesity. Even fewer have examined these relationships in adolescent immigrant groups or made comparisons to adolescent non-immigrants. Using a cross-sectional study, healthcare experiences were compared among three groups of adolescents (n = 589) including Russian immigrants (n = 154), Ethiopian immigrants (n = 54), and non-immigrants (n = 381). Bootstrap estimates indicated positive healthcare experiences were less common among Russian adolescent immigrants (OR = 0.38, CI = 0.17, 0.86) compared to non-immigrants, unless the Russian adolescent immigrants reported above average socioeconomic status, in which case they were more likely than non-immigrant adolescents to report positive healthcare experiences (OR = 3.22, CI = 1.05, 9.85). Positive healthcare experiences were less likely among adolescents who were smokers (OR = 0.50, CI = 0.27, 0.91), and more likely for adolescents with a normal or low BMI (OR = 3.16, CI = 1.56, 6.40) and for those relying on parents for health information (OR = 1.97, CI = 1.05, 3.70).Conclusion: Findings suggest a social gradient in which positive healthcare experiences were more common among adolescence with higher socioeconomic status for some immigrants (Russian adolescents) but not for others. The two leading health indicators were related to healthcare experiences, but as adolescent smokers were less likely to have positive healthcare experiences, proactive efforts are needed to engage this group. What is Known: • Health indicators (such as obesity) and healthcare attitudes are linked to healthcare service use among adolescents sampled from outpatient and inpatient populations. What is New: • A social gradient involving socioeconomic status and being an adolescent immigrant was found regarding risky health indicators (i.e., smoking, use of internet as the primary source of health information). • Problematic health indicators, such as smoking, is linked to less positive healthcare attitudes in apparently healthy adolescents (both immigrants and non-immigrants). [ABSTRACT FROM AUTHOR]

Background: Benzodiazepines and benzodiazepine-receptor agonists (BDZRAs, often known as "Z-drugs") are commonly used in older adults despite well-documented harms.Objective: 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.Design and Participants: 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.Main Measures: Medication use from 2013 to 2015 was ascertained using pharmacy dispensing data.Results: 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%.Conclusions: 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. [ABSTRACT FROM AUTHOR]

Background: Use of sleep medications as a result of hospitalization among older adults is common and has been shown to result in chronic use and increased risks for adverse effects such as falls and cognitive decline. However, few studies have explored in-hospital sleep medication use or disuse as a possible factor related to subsequent home use. Objective: The aim of this study was to examine changes in sleep medication use pre-to post-hospitalization as a function of in-hospital use. Methods: The study was designed as a prospective cohort study, and included 485 acute medical patients aged 70 years and older, hospitalized in a large, Israeli, teaching medical centre. Sleep medication use was assessed by patient interviews regarding patterns of use prior to, during and at 1 and 3 months after discharge. Post-discharge using patterns were assessed as a function of inhospital discontinuation or initiation of sleep medications; background demographic and clinical characteristics were assessed as well. Logistic regressions were modelled separately for discontinuation and initiation of sleep medication use at each follow-up. Results: Of those patients who used sleep medications prior to admission, 37 (18% of 206 prior users) discontinued use during the hospital stay. Non-use of sleep medications during hospitalization was the main significant characteristic associated with post-hospitalization discontinuation among prior users, when comparing patients who continued with those who discontinued using sleep medications in bivariate analyses. Discontinuation was associated with an adjusted odds ratio (AOR, adjusted for cognitive status) of 3.91 (95% confidence interval [CI] 1.64, 9.30) for non-use at the 1-month follow-up. Of those who did not use sleep medications prior to admission, 39(14% of 279 non-prior users) initiated use during hospitalization. Again, sleep medication initiation at time of hospitalization was the main correlate of change in post- hospitalization medication use status, when comparing post-discharge users and non-users, among the non-prior users. Hospital initiation of sleep med- ications was associated with an AOR (adjusted for levels of education and morbidity, readmission, and functional status) of 4.65 (95% CI 1.95, 11.09) for post-discharge use. Similar results were obtained for the 3-month follow- up, reaching significance levels only for the discontinuation group. Conclusions: Though overall prevalence rates of sleep medication use pre- and post-hospitalization are fairly similar, rigorous scrutiny of the findings demonstrates that in-hospital sleep medication use and disuse may be a significant turning point both for initiation and discontinuation of sleep medications, especially in the short post-discharge time frame. Thus, in-hospital sleep medication prescribing policies should acknowledge the potential for changes in the post-discharge sleep medication regimen. [ABSTRACT FROM AUTHOR]

Objective: Improving health care of multimorbid older adults is a critical public health challenge. The objective of this study is to evaluate the effect of a pilot intervention to enhance the quality of primary care experiences for chronically ill older persons (Guided Care).Design: Nonrandomized prospective clinical trial.Patients/participants: Older, chronically ill, community-dwelling patients (N = 150) of 4 General Internists in 1 urban community practice setting who were members of a capitated health plan and identified as being at high risk of heavy use of health services in the coming year by claims-based predictive modeling.Interventions: Guided Care, an enhancement to primary care that incorporates the operative principles of chronic care innovations, was delivered by a specially trained, practice-based registered nurse working closely with 2 primary care physicians. Each patient received a geriatric assessment, a comprehensive care plan, evidence-based primary care with proactive follow-up of chronic conditions, coordination of the efforts of health professionals across all health care settings, and facilitated access to community resources.Measurements and Main Results: Quality of primary care experiences (physician-patient communication, interpersonal treatment, knowledge of patient, integration of care, and trust in physician) was assessed using the Primary Care Assessment Survey (PCAS) at baseline and 6 months later. At baseline, the patients assigned to receive Guided Care were similar to those assigned to receive usual care in their demographics and disability levels, but they had higher risk scores and were less likely to be married. Thirty-one of the 75 subjects assigned to the Guided Care group received the intervention. At 6 months, intention-to-treat analyses adjusting for age, gender, and risk score suggest that Guided Care may improve the quality of physician-patient communication. In per-protocol analyses, receipt of Guided Care was associated with more favorable change than usual care from baseline to follow-up in all 5 PCAS domains, but only physician-patient communication showed a statistically significant improvement.Conclusions: In this pilot study, Guided Care appeared to improve the quality of primary care experiences for high-risk, chronically ill older adults. A larger cluster-randomized controlled trial of Guided Care is underway. [ABSTRACT FROM AUTHOR]