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Abstract: Background: Patients with cancer must deal with complex and fragmented healthcare systems in addition to coping with the burden of their illness. To improve oncology treatment along the care continuum, the barriers and facilitators for streamlined oncologic care need to be better understood. Purpose: This study sought to gain insight into the hospital–community interface from the point of view of patients with cancer, their families, and health care providers on both sides of the interface i.e., the community and hospital settings. Methods and sample: The sample comprised 37 cancer patients, their family members, and 40 multidisciplinary health care providers. Twelve participants were interviewed individually and 65 took part in 10 focus groups. Based on the grounded theory approach, theoretical sampling and constant comparative analyses were used. Results: Two major concepts emerged: “ambivalence and confusion” and “overcoming healthcare system barriers.” Ambiguity was expressed regarding the roles of health care providers in the community and in the hospital. We identified three main strategies by which these patients and their families overcame barriers within the system: patients and families became their own case managers; patients and health care providers used informal routes of communication; and nurse specialists played a significant role in managing care. Conclusions: The heavy reliance on informal routes of communication and integration by patients and providers emphasizes the urgent need for change in order to improve coordinating mechanisms for hospital–community oncologic care. [ABSTRACT FROM AUTHOR]

Objectives Care transitions are an especially vulnerable juncture in the course of patient care. Patients from ethnic minority populations face additional unique challenges during hospital to community care transitions due to language and cultural barriers, yet, this phenomenon is understudied. This study examines the quality of care transitions of minority patients (immigrants) versus the general population, and specifically assesses the association between in-hospital provider–patient communication and the quality of minority care transitions. Design Prospective study of older hospitalized adults. Setting A large teaching hospital. Participants Participants (n = 385) were patients hospitalized for non-disabling medical conditions, from one of the two groups: the general Israeli population (Hebrew speakers) or immigrants from the former Soviet Union (Russian speakers). Main outcome measures One-month phone follow-up assessed the quality of patients’ transitional care using the care transitions measure. Results Russian speakers rated their transitional care on average 10% lower than Hebrew speakers (54.4 versus 64.2, respectively, P = 0.002). On average, Russian speakers’ ratings on the physician interpersonal-communication scale were significantly lower than Hebrew speakers’ ratings. For Russian speakers, but not Hebrew speakers, the interpersonal physician communication scale was significantly positively associated with the quality of care transitions in multivariate analyses (P = 0.01), controlling for gender, education, economic status and length of stay. Conclusions Minority patients experience lower quality of care transitions than the general population. Interpersonal physician–patient communication during the hospital stay is associated with better care transitions of ethnic minority patients and should be considered in efforts to improve the quality of minority patients’ care transition processes. [ABSTRACT FROM PUBLISHER]

Targeting patients for multimorbid care management interventions requires accurate and comprehensive assessment of patients' need in order to direct resources to those who need and can benefit from them the most. Multimorbid patient selection is complicated due to the lack of clear criteria--unlike disease management programs for which patients with a specific condition are identified. This ambiguity can potentially result in inequitable selection, as biases in selection may differentially affect patients from disadvantaged population groups. Patient selection could in principal be performed in three ways: physician referral, patient screening surveys, or by statistical prediction algorithms. This paper discusses equity issues related to each method. We conclude that each method may result in inequitable selection and bias, such as physicians' attentiveness or familiarity, or prediction models' reliance on prior resource use, potentially affected by socio-cultural and economic barriers. These biases should be acknowledged and dealt with. We recommend combining patient selection approaches to achieve high care sensitivity, efficiency and equity. [ABSTRACT FROM AUTHOR]

Objective: Ample research has examined physicians' evidence-based medicine (EBM) knowledge and skills; however, previous research has not linked EBM knowledge to objective measures of process of care. [ABSTRACT FROM PUBLISHER]

The objective of this study was to describe the clinical features of older persons identified as high risk by a predictive modeling algorithm and to determine their suitability for clinical interventions like case management or disease management. A cross-sectional survey was undertaken at a community-based general internal medicine practice with 826 older patients enrolled in a Medicare-like health plan for military retirees and their dependents. Administrative claims data provided information about all 826 enrollees' chronic conditions, their use of health services, and the cost of those services during the past year. A survey mailed to 150 identified high-risk enrollees provided information about sociodemographic characteristics, general health, bed disability days, restricted activity days, activities of daily living (ADL) limitations, and instrumental activities of daily living (IADL) limitations. Compared to the 676 low-risk enrollees, the 150 high-risk enrollees had higher prevalence of eight individual chronic conditions, higher total chronic conditions (2.93 vs. 1.48, p < 0.001), higher annual rates of hospital admission (1.1 vs. 0.1, p < 0.001), more annual hospital days (7.3 vs. 0.5, p <0.001), and higher total health insurance expenditures ($22,815 vs. $3,726, p < 0.001). The highrisk respondents to the survey (response rate = 80.0%) had suboptimal health (42.8% "fair or poor"), impaired functional ability (36.3% with 1+ ADL limitations, 58.1% with 1+ IADL limitations), and frequent health-related disruptions in their activities during the previous six months (38.7% with 1+ bed disability day, 52.3% with 1+ restricted activity day). A claimsbased predictive modeling algorithm identifies older persons whose health, functional ability, and use of health services suggest they are good candidates for clinical interventions such as case management and disease management. (Disease Management 2006;9:56–62) [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Patients receiving oral anticancer medications (OAMs) are at increased risk for fragmentation and lack of continuity which can potentially significantly hinder their ability for self-management. Factors such as the complexity of the regimen, the need for special safety precautions, occurrence of side effects, and drug-drug interactions require close collaboration between the oncology and primary care providers and the alignment of treatment and follow-up plans (1-3). The multiplicity of providers and institutions challenges care coordination, and can impair continuity of care (COC) and outcomes. This study aimed to asses: (1) Patient- reported COC for each type of health care provider involved in oral anticancer treatment (the oncology specialist (OS), the oncology nurse specialist (ONS), and the primary care physician (PCP)); (2) Care coordination as perceived by the patients, within the oncology team (between the OS and the ONS) or across specialty boundaries (between the PCP and the OS or the ONS.) Methods: A prospective multicenter cohort study was conducted among cancer patients >18yrs, receiving a first prescription (in the prior 2 weeks) for one of the following OAMs: chemotherapy (Capecitabine, Vinorelbine), targeted therapy (Erlotinib, Sunitinib, Everolimus), or hormonal therapy (Abiraterone). Two-three months after OAMs initiation, a survey containing the Nijmegen Continuity Questionnaire (NCQ) was administered. The NCQ consists of "personal continuity" (8 items) and "collaboration between providers" (4 items) Likert-type subscales (1=strongly disagree to 5= strongly agree) (4). Results: 99 participants completed the NCQ-Hebrew version. Mean subscale score (MSS) for personal continuity was significantly higher for the PCP, followed by the OS, and the ONS (MSS (SD)= 3.53(0.97); 3.27(1.00); 2.9(1.23), respectively; p<0.05). MSS for collaboration within the oncology team was 2.95±1.90, and MSS for collaboration across boundaries were significantly lower (PCP-OS collaboration: MSS= 1.88(1.29); and PCP-ONS collaboration: MSS=1.56(1.30); p<0.05). Discussion: This study is the first to measure COC in a multi provider-multi setting context of OAM treatment.OAMs patients rated the COC with the PCP significantly higher than the COC with the OS or the ONS. Additionally, patients perceived care coordination between the oncology team and the PCP to be relatively low. Conclusions: The lack of COC between patients taking OAMs and their oncology providers as well as the low (patient) perceived coordination among OS and PCPs found in this study signifies major areas for much needed improvement in the quality of the cancer care trajectory. [ABSTRACT FROM AUTHOR]

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. To identify nurse-staffing characteristics and nursing-related care needs associated with older patients' mobility, continence care and food intake during acute hospitalization. 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. Internal medicine units in two medical centers in Israel. Eight hundred seventy-three older adults. 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. 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. 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. [ABSTRACT FROM AUTHOR]

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. Impact and Implications: This study found that staff-reported quality of life (QOL) ratings on consumers with severe mental illness (SMI) were consistently lower than the consumer-reported QOL ratings, for both immigrant and non-immigrant consumers. Additionally, this study found that the lack of concordance between staff-reported and consumer-reported QOL ratings tended to differ by immigrant status as well as by immigrants' country of origin. [ABSTRACT FROM AUTHOR]

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: 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. [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]

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. [ABSTRACT FROM AUTHOR]

Background: 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.Aims: To examine the network structure of quality of life appraisals and disparities using network analysis.Methods: 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.Results: The self-appraised network significantly (p<0.05) 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.Conclusions: 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. [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]

Objectives To identify, describe, and assess the evidence regarding the effects that the Diabetes Conversation Map™ program, an educational tool that engages patients with diabetes in group discussions about diabetes-related topics, has over a range of patient outcomes. Study design A systematic review. Data sources Five databases, including PubMed, CINAHL, Scopus, EMBASE, and Cochrane Collaboration, were utilized to identify studies that evaluated the Conversation Map™ program. Additionally, the reference lists of the identified studies were manually reviewed. Review methods Studies that evaluated the Conversation Map™ program since 2005 were included. Non-English languages, non-journal papers, and studies that only included a description of the program were excluded. A quality assessment of relevant studies was performed. Outcomes were grouped into: objective (e.g., HbA1c levels), subjective (e.g., self-efficacy), and health behaviors (e.g., medication adherence). Results Of the 85 studies originally identified, 24 studies were included in the final sample. The overall methodological quality of the studies was intermediate (score: 17 of 28). Almost all studies examined objective health measures, with most indicating non-significant differences between the Conversation Map™ intervention and the control groups. Conflicting results were found regarding the influence the program had on HbA1c. The majority of studies reported no significant change in blood pressure and mixed results were found regarding other health indicators. Twelve studies examined subjective measures and 11 assessed the effects on health behaviors, mostly reporting non-significant or positive findings. Conclusions Our review shows that although the Diabetes Conversation Map™ program holds the potential to improve patient behaviors and outcomes, current research on the program provides limited support as to their relationship with positive patient outcomes. Larger, more sophisticated studies are needed in order to determine the potential influence Conversation Map™ can have on long-term health outcomes. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the association between currently recommended guidelines and commonly used clinical criteria for body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR) and all-cause mortality in frail older women. Design Longitudinal prospective cohort study. Setting Women's Health Initiative (WHI)-Observational Study. Participants A sample of women aged 65-84 with complete data to characterize frailty in the third year of WHI follow-up (N = 11,070). Measurements Frailty phenotype was determined using the modified Fried criteria. Information on anthropometric measures (BMI, WC, WHR) was collected in clinical examinations. Cox proportional hazards models were used to estimate the effect of BMI, WC, and WHR on mortality adjusted for demographic characteristics and health behaviors. Results Over a mean follow-up of 11.5 years, there were 2,911 (26%) deaths in the sample. Women with a BMI from 25.0 to 29.9 kg/m2 (hazard rate ratio ( HR) = 0.80, 95% confidence interval ( CI) = 0.73-0.88) and those with a BMI from 30.0 to 34.9 kg/m2 ( HR = 0.79, 95% CI = 0.71-0.88) had lower mortality than those with a BMI from 18.5 to 24.9 kg/m2. Women with a WHR greater than 0.8 had higher mortality (HR = 1.16, 95% CI = 1.07-1.26) than those with a WHR of 0.8 or less. No difference in mortality was observed according to WC. Stratifying according to chronic morbidity or smoking status or excluding women with early death and unintentional weight loss did not substantially change these findings. Conclusion In frail, older women, having a BMI between 25.0 and 34.9 kg/m2 or a WHR of 0.8 or less was associated with lower mortality. Currently recommended healthy BMI guidelines should be reevaluated for frail older women. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Psychiatric rehabilitation for people with severe mental illness (SMI) has many documented benefits, but less is known about cultural related aspects. To date, no comparison of psychiatric rehabilitation outcomes between Israeli Jews and Israeli Arabs has been carried out. Thus, the purpose of the present study was to compare the outcome measures of Israeli Arabs and Israeli Jews consuming psychiatric rehabilitation services. As part of the Israeli Psychiatric Rehabilitation Reported Outcome Measurement project (PR-ROM), a cross-sectional study comparing different ethnic-religious groups was performed. Data is based on 6,751 pairs of psychiatric rehabilitation consumers and their service providers. The consumers filled questionnaires on quality of life (QoL) and functioning, and their providers completed mirroring instruments. The findings revealed that QoL and functioning ratings were lower among Muslim Arabs compared to Jews on both consumers' and providers' ratings. Among Muslim Arabs, differences in outcomes according to the service's location were indicated. The observed differences between Israeli Arabs and Israeli Jews with SMI in the PR-ROM point to the need for culturally adapted rehabilitation services that take into account how cultural differences may affect the benefits of such services., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The high rates of psychiatric re-hospitalizations (also termed "revolving door") presents a "wicked problem" which requires a systematic and holistic approach to its resolution. Israel's mental-health rehabilitation law provides a comprehensive set of services intended to support the ability of persons with severe mental illness to rely on community rather than in-patient facilities for their ongoing care needs. Guided by the Health Behavior Model, we examined the relationship between psychiatric re-hospitalizations and the three Health Behavior Model factors (predisposing factor: socio-demographic characteristics and health beliefs; enabling factor: personal and social/vocational relationships facilitated by rehabilitation interventions and services; and need factor: outcomes including symptoms, and mental health and functional status) among persons with severe mental illness receiving rehabilitation services., Methods: Logistic regression models were used to measure the association between re-hospitalization within a year and variables comprising the three Health Behavior Model factors on the sample of consumers utilizing psychiatric services (n = 7,165). The area under the curve for the model was calculated for each factor separately and for all three factors combined., Results: A total of 846 (11.8%) consumers were hospitalized within a year after the study began. Although multivariable analyses showed significant associations between re-hospitalization and all three Health Behavior Model factors, the magnitude of the model's area under the curve differed: 0.61 (CI = 0.59-0.64), 0.56 (CI = 0.54-0.58), 0.78 (CI = 0.77-0.80) and 0.78 (CI = 0.76-0.80) for predisposing, enabling, need and the full three-factor Health Behavior Model, respectively., Conclusion: Findings revealed that among the three Health Behavior Model factors, the need factor best predicted re-hospitalization. The enabling factor, comprised of personal relationships and social/vocational activities facilitated by interventions and services representing many of psychiatric rehabilitation's key goals, had the weakest association with reduced rates of re-hospitalization. Possible explanations may be inaccurate assessments of consumers' personal relationships and social/vocational activities by the mental healthcare professionals, problematic provider-consumer communication on the consumers' involvement in social/vocational activities, or ineffective methods of facilitating consumer participation in these activities. Clearly to reduce the wicked "revolving-door" phenomenon, there is a need for targeted interventions and a review of current psychiatric rehabilitation policies to promote the comprehensive integration of community rehabilitation services by decreasing the fragmentation of care, facilitating continuity of care with other healthcare services, and utilizing effective personal reported outcomes and experiences of consumers with severe mental illness., (© 2024. The Author(s).)

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.

Introduction: Studies of community-dwelling older adults find subjective age affects health and functional outcomes. This study explored whether younger subjective age serves as a protective factor against hospital-associated physical, cognitive, and emotional decline, well-known consequences of hospitalization among the elderly., Methods: This study is a secondary data analysis of a subsample (N = 262; age: 77.5 ± 6.6 years) from the Hospitalization Process Effects on Mobility Outcomes and Recovery (HoPE-MOR) study. Psychological and physical subjective age, measured as participants' reports on the degree to which they felt older or younger than their chronological age, was assessed at the time of hospital admission. Independence in activities of daily living, life-space mobility, cognitive function, and depressive symptoms were assessed at hospital admission and 1 month post-discharge., Results: The odds of decline in cognitive status, functional status, and community mobility and the exacerbation of depressive symptoms were significantly lower in those reporting younger vs. older psychological subjective age (odds ratio [OR] = 0.68, 95% CI = 0.46-0.98; OR = 0.59, 95% CI = 0.36-0.98; OR = 0.64, 95% CI = 0.44-0.93; OR = 0.64, 95% CI = 0.43-0.96, respectively). Findings were significant after controlling for demographic, functional, cognitive, emotional, chronic, and acute health predictors. Physical subjective age was not significantly related to post-hospitalization outcomes., Conclusion: Psychological subjective age can identify older adults at risk for poor hospitalization outcomes and should be considered for preventive interventions., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Background: low mobility of hospitalised older adults is associated with adverse outcomes and imposes a significant burden on healthcare and welfare systems. Various interventions have been developed to reduce this problem; at present, however, their methodologies and outcomes vary and information is lacking about their long-term sustainability. This study aimed to evaluate the 2-year sustainability of the WALK-FOR (walking for better outcomes and recovery) intervention implemented by teams in acute care medical units., Methods: a quasi-experimental three-group comparative design (N = 366): pre-implementation, i.e. control group (n = 150), immediate post-implementation (n = 144) and 2-year post-implementation (n = 72)., Results: mean participant age was 77.6 years (± 6 standard deviation [SD]) and 45.3% were females. We conducted an analysis of variance test to evaluate the differences in primary outcomes: number of daily steps and self-reported mobility. Levels of mobility improved significantly from the pre-implementation (control) group to the immediate and 2-year post-implementation groups. Daily step count: pre-implementation (median: 1,081, mean: 1,530 SD = 1,506), immediate post-implementation (median: 2,225, mean: 2,724. SD = 1,827) and 2-year post-implementation (median: 1,439, mean: 2,582, SD = 2,390) F = 15.778 P < 0.01. Self-reported mobility: pre-implementation (mean:10.9, SD = 3.5), immediate post-implementation (mean: 12.4, SD = 2.2), 2-year post-implementation (mean: 12.7, SD = 2.2), F = 16.250, P < 0.01., Conclusions: the WALK-FOR intervention demonstrates 2-year sustainability. The theory-driven adaptation and reliance on local personnel produce an effective infrastructure for long-lasting intervention. Future studies should evaluate sustainability from a wider perspective to inform further in-hospital intervention development and implementation., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

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., (© 2023. The Author(s).)

Background: Low in-hospital mobility is widely acknowledged as a major risk factor in acquiring hospital-associated disabilities. Various predictors of in-hospital low mobility have been suggested, among them older age, disabling admission diagnosis, poor cognitive and physical functioning, and pre-hospitalization mobility. However, the universalism of the phenomena is not well studied, as similar risk factors to low in-hospital mobility have not been tested., Methods: The study was a secondary analysis of data on in-hospital mobility that investigated the relationship between in-hospital mobility and a set of similar risk factors in independently mobile prior to hospitalization older adults, hospitalized in acute care settings in Israel (N = 206) and Denmark (N = 113). In Israel, mobility was measured via ActiGraph GT9X and in Denmark by ActivPal3 for up to seven hospital days., Results: Parallel multivariate analyses revealed that a higher level of community mobility prior to hospitalization and higher mobility ability status on admission were common predictors of a higher number of in-hospital steps, whereas the longer length of hospital stay was significantly correlated with a lower number of steps in both samples. The risk of malnutrition on admission was associated with a lower number of steps, but only in the Israeli sample., Conclusions: Despite different assessment methods, older adults' low in-hospital mobility has similar risk factors in Israel and Denmark. Pre-hospitalization and admission mobility ability are robust and constant risk factors across the two studies. This information can encourage the development of both international standard risk evaluations and tailored country-based approaches., (© 2023. The Author(s).)

Background: Nurse champions are front-line practitioners who implement innovation and reconstruct policy., Purpose: To 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 Methods: A personal-network survey was employed. Ninety-one nurse champions from three tertiary medical centers in Israel participated., Findings: Given 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., Discussion: Using 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., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Sperling, Shadmi, Drach-Zahavy and Luz.)

Objectives: Patients 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 Setting: A longitudinal retrospective cohort study was conducted at the haematology unit of Carmel Medical Center, Israel., Participants: Information 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 Measures: A multivariate logistic regression model was performed to determine whether PCV13 vaccination is associated with fewer hospital admissions due to pneumonia or sepsis., Results: The 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., Conclusion: This 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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Evidence 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., Aims: To examine gender differences in the association between quality of life and the risk of subsequent psychiatric hospital admissions in a national sample with schizophrenia., Method: The 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., Results: A 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)., Conclusions: Quality of life in schizophrenia is a gender-specific construct and should be considered as such in clinical practice and future research.

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 (ΔR 2  = 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 (ΔR 2  = 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.

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., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: 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., Data and Methods: 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., Main Outcomes: We predict 4 binary outcomes: length of stay (≥7 d), death during the index admission, 30-day readmission, and 1-year mortality., Results: 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., Conclusion: 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.

Background: Most of readmission prediction models are implemented at the time of patient discharge. However, interventions which include an early in-hospital component are critical in reducing readmissions and improving patient outcomes. 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 process with readmission prediction models using data available at two time points: at admission and at the time of hospital discharge., Methods: An historical prospective study of hospitalized 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) 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% (n = 229) classified by the PREADM-H at the highest decile, but not by the PREADM, had a PPV of 37%. Conversely, those classified by the PREADM into the highest decile but not by the PREADM-H (n = 218) had a PPV of 31%., Conclusions: The timing of readmission risk prediction makes a difference in terms of the population identified at each prediction time point - at-admission or at-discharge. Our findings suggest that readmission risk identification should incorporate a two time-point approach in which preadmission data is used to identify high-risk patients as early as possible during the index admission and an "all-hospital" model is applied at discharge to identify those that incur risk during the hospital stay.

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., (Copyright © 2018 Elsevier Inc. All rights reserved.)

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 .

Objective: Patient reported outcome measures (PROMs) are increasingly used to measure psychiatric service consumers' progress and to provide feedback to consumers and providers. We tested whether PROMs can predict and be used to identify groups at high risk for future hospitalization., Methods: A total of 2842 Israeli users of psychiatric rehabilitation services reported on their quality of life (QoL) and the effect of symptoms on their daily functioning. Survey data were linked with information on psychiatric hospitalization 6 and 12months after survey completion. Variables associated with each of the outcomes were tested for significance and entered into a multivariate logistic regression model. Prediction scores were developed to identify the highest-risk groups according to each model., Results: QoL was found to be a significant predictor of future hospitalization within 6months (odds ratio [OR]=0.71, 95% CI: 0.59-0.86), and self-report of the impact of symptoms on functioning significantly predicted 12-month hospitalization (OR=0.83, 95% CI: 0.74-0.93), controlling for known risk factors. Positive predictive values for the 6- and 12-month risk scores were 31.1 and 40.4, respectively, for the 10% highest risk categories., Conclusions: Reports of psychiatric service consumers on their QoL and on the effect of symptoms on their functioning significantly predict of future hospitalization risk, beyond other well-known risk factors. PROMs can identify consumers at high risk for future hospitalization and thus direct interventions for those at highest risk., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Introduction: 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., Objectives: Describe functional trajectories of older-adults (aged ≥70 years) before, during and after acute hospitalization in internal-medicine units., Methods: 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., Results: 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., Discussion: 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 2016;11:401-406. © 2015 Society of Hospital Medicine., (© 2015 Society of Hospital Medicine.)

Objective: to assess the extent of information gaps between three information sources available at admission to a pediatric Emergency Department (ED): Health Information Exchange (HIE) system, physicians' referral letters and information collected from patients/parents at admission to the ED (patient's medical history)., Materials and Methods: A retrospective cohort study of 170 medical records of children aged 6 months to 18 years referred to a pediatric ED for a common childhood disease. Each record was reviewed for information on lab and imaging tests, vaccinations, allergies, previous diagnoses, recent and chronic medical treatment in the HIE system and referral letter, or from the patient's medical history taken on admission to the ED. The percent overlap between information sources and information gaps was assessed., Results: The most informative source, in terms of addressing all key areas, was the patient's medical history, with an average of 73.5% indication of each information key area. Next was the HIE system, with 54.1% indication of each key area; the least informative was the referral letter (43.9%). The overall overlap in data availability among all information sources occurred on average in 23% of the cases. HIE's ability to provide data missing from other routinely available sources was mainly in the area of chronic medication dosages (37% of cases)., Conclusions: Each of the three major information sources available at admission to a pediatric ED lack important data and each makes its own unique contribution. Improving documentation in electronic health records, on which HIE systems feed from can narrow significant information gaps at the most critical time-point-admission to a pediatric ED., (Copyright © 2016. Published by Elsevier Ireland Ltd.)

Objectives: To determine whether addition of written-prescription data to existing adherence measures improves identification of nonadherent patients and prediction of changes in low-density lipoprotein (LDL) cholesterol., Study Design: Retrospective database analysis of all health plan members prescribed a statin in 2008 and followed through 2010., Methods: We examined statin use in a 4-millionmember health plan with 100% electronic medical record coverage. A novel type of medication possession ratio (MPR), integrating prescribed with dispensed medication data, was developed. This measure, MPRp, was compared with a standard dispensed-only adherence measure, MPRd. Adherence below 20% was considered nonadherence. The 2 adherence measures were compared regarding (1) the number of patients identified as nonadherent, (2) percent changes in LDL from study enrollment to study termination, and (3) receiver-operator curves assessing the association between adherence and a 24% decrease in LDL., Results: A total of 67,517 patients received 1,386,270 written prescriptions over the 3-year period. MPRp identified 93% more patients as nonadherent than did MPRd (P <.001). These newly identified patients exhibited minimal LDL decreases over the course of the study. Adherence by MPRp was more strongly associated with decreases in LDL than was adherence by MPRd (area under the curve 0.815 vs 0.770; P <.001). During the study period, 18.2% of patients did not fill any prescriptions and were thus unidentifiable by dispensed-only measures., Conclusions: Addition of written-prescription data to adherence measures identified nearly twice the number of nonadherent patients and markedly improved prediction of changes in LDL.

Technological advances combined with the aging of the population bring about an increasingly growing number of patients with chronic conditions and multi-morbidity. Multi-morbidity, the co-occurrence of chronic and/or non-chronic conditions in an individual, is the norm among elderly patients, and is becoming increasingly common among younger adults. The Israeli health system, like other systems worldwide, is faced with the challenges posed by the increase in complex multi-morbidity, in an era of growing fiscal constraints, a situation that can induce financial and organizational crises. To effectively cope with such circumstances, a paradigm shift is needed. Health systems need to focus on overall morbidity burden and multi-morbidity (rather than the prevailing one disease at a time approach) and on better care integration. The Israeli health system entails many of the essential elements for addressing the challenges of integrated care, including universal health coverage and advanced health information technology systems. Yet, like other health systems, there is a need for care management support mechanisms that are more effectively tailored to meet the needs of the highly multimorbid patients. This review outlines the organizational approach required to better align care for the main customers of health care in the 21st century: patients with multi-morbidity. We focus on four domains: assessment of morbidity burden according to measures that account for the interaction and synergism amongst conditions; integration across the care continuum; enhancement of primary care and self-management support approaches; and provision of uniquely tailored care management solutions for the highest risk multi-morbid patients.

In March 2010 the United States enacted the most significant health care reform in several decades. The Patient Protection and Affordable Care Act, amongst other provisions, addresses two of the main current shortcomings of the U.S. health system: the large portion of the population that are uninsured and the high percentage of hsealth expenditures (mostly private] which amounts to about 16% of the GDP. Changes to the current structure and financing of the U.S. health system will have implications for other health systems, for science (e.g., through enhanced federal funding for comparative effectiveness research), and for technological advance (e.g., through accelerated development and use of electronic health records). There are several lessons from the reform, and the factors leading to its implementation, for the Israeli health system. Firstly, the basic principles of the Israeli health system are a source of pride, and undermining its main values can have deleterious effects. Overreliance on private, out-of-pocket, spending and lack of support for public practice of medicine (in community and hospital settings) will weaken the public sector, strengthen the private sector, and could result in a tiered lower quality and less accessible public system with greater widening of gaps in health and health care utilization. This paper reviews the main provisions of the U.S. health care reform and the potential implications for the IsraeLi health system.

Background: Equitable distribution of healthcare resources and fair assessments of providers' performance necessitates adjusting for case-mix. The feasibility and validity of applying case-mix measures, based on inpatient and outpatient diagnoses, has yet to be tested in Israel., Aims: Assessment of the feasibility and validity of applying the Johns-Hopkins University Adjusted Clinical Groups (JHU-ACG) case-mix system, using diagnoses from hospitalizations or physician visits, at Clalit Health Services (CHS)., Methods: A representative sample of 117,355 enrollees during 2006. The distribution of ACG morbidity groups and relative resource weights in CHS and the degree to which it corresponds to ACGs' distribution in other countries was examined. The degree to which ACGs can explain utilization of primary and specialty care in CHS was determined., Results: ACGs explained a large percent of the variance in primary care and specialist visits (R2 = 38-54%), better than age and gender alone (R2 =12-13%). A high degree of correlation was found between the distribution of the population into ACG groups in CHS and samples from Canada or the United States (r = 0.91), and between the relative resource use for each ACG at CHS compared to the Canadian and US samples (r = 0.78-0.98)., Conclusions: The JHU-ACG case-mix system can be applied in the Largest healthcare organization in Israel based on diagnoses generated at hospitalizations and physician visits. The system can now be applied for a variety of purposes, including resource allocation according to medical need, and for conducting fair assessments of providers' performance, which are currently being tested by CHS.

Objective: To assess the validity and reliability of the Hebrew and Arabic translations of the complete and shortened versions of the Care Transition Measure (CTM)-a measure of patients' experience of the transition between hospital and community care., Design: Translation of questionnaire's items, evaluation of reliability, construct validity, factor structure and convergent validity., Setting: An oncology center at a tertiary care facility that serves the entire population of the north part of Israel., Participants: Patients receiving care at the clinics of an oncology treatment center. Main outcome measure Psychometric properties of both the 15-item (complete) and 3-item (shortened) versions of the CTM in Hebrew and Arabic. Reliability established using internal consistency with Cronbach's-alpha. Exploratory factor analysis conducted using Varimax rotation. Convergent validity determined with Pearson correlation and ANOVA tests., Results: Three hundred and eighteen Hebrew- and Arabic-speaking oncology patients completed the questionnaire. Cronbach's-alpha for the questionnaire was 0.94 and 0.90 for the Hebrew and the Arabic versions, respectively. Factor analysis resulted in three factors in each of the translated versions with a cumulative variance of 73.41% and 69.2% in the Hebrew and Arabic versions, respectively. Tests of the convergent validity showed that the measure is correlated with health status and that the shortened and complete versions' ratings are consistent across different patient groups., Conclusion: The translated Hebrew and Arabic versions of the questionnaire are reliable and valid instruments to assess patients' transitions across settings in diverse populations.

Purpose: The purpose of this article is to identify and test the effectiveness of work strategies employed by regional implementation teams to attain high quality care for diabetes patients., Design/methodology/approach: The study was conducted in a major health maintenance organization (HMO) that provides care for 70 per cent of Israel's diabetes patients. A sequential mixed model design, combining qualitative and quantitative methods was employed. In-depth interviews were conducted with members of six regional implementation teams, each responsible for the care of 25,000-34,000 diabetic patients. Content analysis of the interviews revealed that teams employed four key strategies: task-interdependence, goal-interdependence, reliance on top-down standardised processes and team-learning. These strategies were used to predict the mean percentage performance of eight evidence-based indicators of diabetes care: percentage of patients with HbA1c < 7 per cent, blood pressure < or = 130/80 and cholesterol < or = 100; and performance of: HbA1c tests, LDL cholesterol tests, blood pressure measurements, urine protein tests, and ophthalmic examinations., Findings: Teams were found to vary in their use of the four strategies. Mixed linear models analysis indicated that type of indicator (simple process, compound process, and outcome) and goal interdependence were significantly linked to team effectiveness. For simple-process indicators, reliance on top-down standardised processes led to team effectiveness, but for outcome measures this strategy was ineffective, and even counter-effective. For outcome measures, team-learning was more beneficial., Practical Implications: The findings have implications for the management of chronic diseases., Originality/value: The advantage of allowing team members flexibility in the choice of the best work strategy to attain high quality diabetes care is attested.