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Summary Background Diabetes prevalence is increasing in most places in the world, but prevalence is affected by both risk of developing diabetes and survival of those with diabetes. Diabetes incidence is a better metric to understand the trends in population risk of diabetes. Using a multicountry analysis, we aimed to ascertain whether the incidence of clinically diagnosed diabetes has changed over time. Methods In this multicountry data analysis, we assembled aggregated data describing trends in diagnosed total or type 2 diabetes incidence from 24 population-based data sources in 21 countries or jurisdictions. Data were from administrative sources, health insurance records, registries, and a health survey. We modelled incidence rates with Poisson regression, using age and calendar time (1995–2018) as variables, describing the effects with restricted cubic splines with six knots for age and calendar time. Findings Our data included about 22 million diabetes diagnoses from 5 billion person-years of follow-up. Data were from 19 high-income and two middle-income countries or jurisdictions. 23 data sources had data from 2010 onwards, among which 19 had a downward or stable trend, with an annual estimated change in incidence ranging from −1·1% to −10·8%. Among the four data sources with an increasing trend from 2010 onwards, the annual estimated change ranged from 0·9% to 5·6%. The findings were robust to sensitivity analyses excluding data sources in which the data quality was lower and were consistent in analyses stratified by different diabetes definitions. Interpretation The incidence of diagnosed diabetes is stabilising or declining in many high-income countries. The reasons for the declines in the incidence of diagnosed diabetes warrant further investigation with appropriate data sources. Funding US Centers for Disease Control and Prevention, Diabetes Australia Research Program, and Victoria State Government Operational Infrastructure Support Program.

BACKGROUND: Diabetes is a major public health issue. Because lifetime risk, life expectancy, and years of life lost are meaningful metrics for clinical decision making, we aimed to estimate these measures for type 2 diabetes in the high-income setting.; METHODS: For this multinational, population-based study, we sourced data from 24 databases for 23 jurisdictions (either whole countries or regions of a country): Australia; Austria; Canada; Denmark; Finland; France; Germany; Hong Kong; Hungary; Israel; Italy; Japan; Latvia; Lithuania; the Netherlands; Norway; Scotland; Singapore; South Korea; Spain; Taiwan; the UK; and the USA. Our main outcomes were lifetime risk of type 2 diabetes, life expectancy in people with and without type 2 diabetes, and years of life lost to type 2 diabetes. We modelled the incidence and mortality of type 2 diabetes in people with and without type 2 diabetes in sex-stratified, age-adjusted, and calendar year-adjusted Poisson models for each jurisdiction. Using incidence and mortality, we constructed life tables for people of both sexes aged 20-100 years for each jurisdiction and at two timepoints 5 years apart in the period 2005-19 where possible. Life expectancy from a given age was computed as the area under the survival curves and lifetime lost was calculated as the difference between the expected lifetime of people with versus without type 2 diabetes at a given age. Lifetime risk was calculated as the proportion of each cohort who developed type 2 diabetes between the ages of 20 years and 100 years. We estimated 95% CIs using parametric bootstrapping.; FINDINGS: Across all study cohorts from the 23 jurisdictions (total person-years 1577234194), there were 5119585 incident cases of type 2 diabetes, 4007064 deaths in those with type 2 diabetes, and 11854043 deaths in those without type 2 diabetes. The lifetime risk of type 2 diabetes ranged from 16·3% (95% CI 15·6-17·0) for Scottish women to 59·6% (58·5-60·8) for Singaporean men. Lifetime risk declined with time in 11 of the 15 jurisdictions for which two timepoints were studied. Among people with type 2 diabetes, the highest life expectancies were found for both sexes in Japan in 2017-18, where life expectancy at age 20 years was 59·2 years (95% CI 59·2-59·3) for men and 64·1 years (64·0-64·2) for women. The lowest life expectancy at age 20 years with type 2 diabetes was observed in 2013-14 in Lithuania (43·7 years [42·7-44·6]) for men and in 2010-11 in Latvia (54·2 years [53·4-54·9]) for women. Life expectancy in people with type 2 diabetes increased with time for both sexes in all jurisdictions, except for Spain and Scotland. The life expectancy gap between those with and without type 2 diabetes declined substantially in Latvia from 2010-11 to 2015-16 and in the USA from 2009-10 to 2014-15. Years of life lost to type 2 diabetes ranged from 2·5 years (Latvia; 2015-16) to 12·9 years (Israel Clalit Health Services; 2015-16) for 20-year-old men and from 3·1 years (Finland; 2011-12) to 11·2 years (Israel Clalit Health Services; 2010-11 and 2015-16) for 20-year-old women. With time, the expected number of years of life lost to type 2 diabetes decreased in some jurisdictions and increased in others. The greatest decrease in years of life lost to type 2 diabetes occurred in the USA between 2009-10 and 2014-15 for 20-year-old men (a decrease of 2·7 years).; INTERPRETATION: Despite declining lifetime risk and improvements in life expectancy for those with type 2 diabetes in many high-income jurisdictions, the burden of type 2 diabetes remains substantial. Public health strategies might benefit from tailored approaches to continue to improve health outcomes for people with diabetes.; FUNDING: US Centers for Disease Control and Prevention and Diabetes Australia. Copyright © 2022 Elsevier Ltd. All rights reserved.

Population-level trends in mortality among people with diabetes are inadequately described. We aimed to examine the magnitude and trends in excess all-cause mortality in people with diabetes.In this retrospective, multicountry analysis, we collected aggregate data from 19 data sources in 16 high-income countries or jurisdictions (in six data sources in Asia, eight in Europe, one from Australia, and four from North America) for the period from Jan 1, 1995, to Dec 31, 2016, (or a subset of this period) on all-cause mortality in people with diagnosed total or type 2 diabetes. We collected data from administrative sources, health insurance records, registries, and a health survey. We estimated excess mortality using the standardised mortality ratio (SMR).In our dataset, there were approximately 21 million deaths during 0·5 billion person-years of follow-up among people with diagnosed diabetes. 17 of 19 data sources showed decreases in the age-standardised and sex-standardised mortality in people with diabetes, among which the annual percentage change in mortality ranged from -0·5% (95% CI -0·7 to -0·3) in Hungary to -4·2% (-4·3 to -4·1) in Hong Kong. The largest decreases in mortality were observed in east and southeast Asia, with a change of -4·2% (95% CI -4·3 to -4·1) in Hong Kong, -4·0% (-4·8 to -3·2) in South Korea, -3·5% (-4·0 to -3·0) in Taiwan, and -3·6% (-4·2 to -2·9) in Singapore. The annual estimated change in SMR between people with and without diabetes ranged from -3·0% (95% CI -3·0 to -2·9; US Medicare) to 1·6% (1·4 to 1·7; Lombardy, Italy). Among the 17 data sources with decreasing mortality among people with diabetes, we found a significant SMR increase in five data sources, no significant SMR change in four data sources, and a significant SMR decrease in eight data sources.All-cause mortality in diabetes has decreased in most of the high-income countries we assessed. In eight of 19 data sources analysed, mortality decreased more rapidly in people with diabetes than in those without diabetes. Further longevity gains will require continued improvement in prevention and management of diabetes.US Centers for Disease Control and Prevention, Diabetes Australia Research Program, and Victoria State Government Operational Infrastructure Support Program.

Background: Agreements between payers and pharmaceutical/medical device companies are widely implemented to address financial and clinical uncertainties. We analyzed the main characteristic...

PReCIS:: A 15-year analysis of 198,843 visual field (VF) tests revealed a growing trend for their performance for nonglaucoma indications. Adherence to glaucoma management guidelines was suboptimal. Guidelines for referral to VF assessments should be established. Purpose The purpose of this study was to identify trends in VF assessments over 15 years among patients with and without suspected or confirmed glaucoma, in a large healthcare maintenance organization. Methods This was a population-based retrospective cohort study, conducted by means of electronic medical database analyses. Study population Maccabi Healthcare Services is an healthcare maintenance organization that insures 2 million members constituting 25% of the population. All members who underwent at least 1 VF test between January 2000 and December 2014 were included. In addition, all members with glaucoma or suspected glaucoma diagnosis or who were prescribed with antiglaucoma medications were evaluated. Main outcome measures VF performance rates. Results A total of 93,617 Maccabi Healthcare Services members underwent 198,843 VF tests; of whom 47.9% involved patients without any glaucoma-related conditions. There was a growing trend over time toward more of those members to undergo VF tests and, by 2014, non-glaucoma-related members comprised 74.0% of new VF assessments. In contrast, 32.3% of glaucoma-related patients did not perform even 1 VF test throughout the entire study period. Although over 2 years (25.95±6.33 mo) passed between the first glaucoma-related diagnosis and first VF test, once a patient underwent the first VF test, an average once-a-year VF follow-up (0.95±0.37 annual tests) began. Conclusion There is a growing trend for VF tests being apparently overused for indications other than glaucoma. Concurrently, adherence to glaucoma management guidelines on VF tests is suboptimal, leading to discernible underuse. Guidelines for VF assessments in nonglaucoma patients should be established. Adherence to existing glaucoma management guidelines should be improved.

Introduction The aim of this study was to evaluate the direct costs of patients with diabetes ensured in a large health maintenance organization, Maccabi Health Services (MHS), in order to compare the medical costs of these patients to the medical costs of other patients insured by MHS and to assess the impact of poorly controlled diabetes on medical costs. Methods A retrospective analysis of patients insured in MHS during 2012 was performed. Data were extracted automatically from the electronic database. A glycated hemoglobin (HbA1c) level of >9% (75 mmol/mol) was considered to define poorly controlled diabetes, and that of

The salutary effects of statin therapy in patients with cardiovascular disease (CVD) are well established. Although generally considered safe, statin therapy has been reported to contribute to induction of diabetes mellitus (DM).To assess the risk-benefit of statin therapy, prescribed for the prevention of CVD, in the development of DM.In a population-based real-life study, the incidence of DM and CVD were assessed retrospectively among 265,414 subjects aged 40-70 years, 17.9% of whom were treated with statins. Outcomes were evaluated according to retrospectively determined baseline 10 year cardiovascular (CV) mortality risks as defined by the European Systematic COronary Risk Evaluation, statin dose-intensity regimen, and level of drug adherence.From 2010 to 2014, 5157 (1.9%) new cases of CVD and 11,637 (4.4%) of DM were observed. Low-intensity statin therapy with over 50% adherence was associated with increased DM incidence in patients at low or intermediate baseline CV risk, but not in patients at high CV risk. In patients at low CV risk, no CV protective benefit was obtained. The number needed to harm (NNH; incident DM) for low-intensity dose regimens with above 50% adherence was 40. In patients at intermediate and high CV risk, the number needed to treat was 125 and 29; NNH was 50 and 200, respectively.Prescribing low-dose statins for primary prevention of CVD is beneficial in patients at high risk and may be detrimental in patients at low CV risk. In patients with intermediate CV risk, our data support current recommendations of individualizing treatment decisions.

To evaluate the association between levonorgestrel-releasing intrauterine system (LNG-IUS) use and breast cancer (BC) risk. A cohort of all Maccabi Healthcare Services (MHS) female members aged 40–50 years between 1/2003 and 12/2013 was used to identify LNG-IUS users as “cases,” and 2 age-matched non-users as “controls.” Exclusion criteria included: prior BC diagnosis, prior (5 years pre-study) and subsequent treatment with other female hormones or prophylactic tamoxifen. Invasive tumors were characterized by treatments received (chemotherapy, hormonal therapy, trastuzumab, or combination thereof). The analysis included 13,354 LNG-IUS users and 27,324 controls (mean age: 44.1 ± 2.6 vs. 44.9 ± 2.8 years; p

Childhood and adolescent obesity constitute a significant public health concern. Family health care settings with multidisciplinary teams provide an opportunity for weight loss treatment. The objective of this study was to examine the effect of intensive treatment designed to reduce weight using a parent-child lifestyle modification intervention in a family health care clinic for obese and overweight children who had failed previous treatment attempts.This was a practice-based 6-month intervention at Maccabi Health Care Services, an Israeli health maintenance organization, consisting of parental education, individual child consultation, and physical activity classes. We included in the intervention 100 obese or overweight children aged 5 to 14 years and their parents and 943 comparison children and their parents. Changes in body mass index z-scores, adjusted for socioeconomic status, were analyzed, with a follow-up at 14 months and a delayed follow-up at an average of 46.7 months.The mean z-score after the intervention was lower in the intervention group compared to the comparison group (1.74 and 1.95, respectively; P = .019). The intervention group sustained the reduction in z-score after an average of 46.7 months (P.001). Of the overweight or obese children, 13% became normal weight after the intervention, compared with 4% of the comparison children.This multidisciplinary team treatment of children and their parents in family health care clinics positively affected measures of childhood obesity. Additional randomized trials are required to verify these findings.

This case-control study uses nationwide health plan data from Israel to compare the extent of chronic comorbidities and mortality hazard between Holocaust survivors and an age-matched control group of individuals born in Israel., Key Points Question What are the rates of comorbidities and mortality among Holocaust survivors compared with control individuals? Findings In this case-control study of 38 597 Holocaust survivors and 34 931 control individuals, significantly higher rates of comorbidities were reported in the Holocaust survivor group than in the control group. In contrast, the overall mortality rate was lower among Holocaust survivors (25.3%) compared with the control group (41.1%) after adjustment for confounders. Meaning The findings suggest that although Holocaust survivors may experience more comorbidities, the mortality in the group may be lower, which may be associated with the improved health literacy and unique resilience characteristics among Holocaust survivors., Importance Previous studies have suggested that Holocaust survivors may experience different chronic comorbidities more often than the general population. However, the mortality hazard among these individuals has not been addressed. Objective To assess the overall mortality rate and comorbidities of a cohort of Holocaust survivors compared with an age-matched control group. Design, Setting, and Participants This cross-sectional study included all Holocaust survivors insured by Maccabi Healthcare Services in Israel who were born between 1911 and 1945 in Europe and control individuals born in Israel during the same years and insured by the same service. Data were collected from January 1, 1998, through December 31, 2017. Outcomes and Measures Rates of morbidities and mortality rates adjusted for sex, socioeconomic status, and body mass index using logistic regression, Cox regression, and Kaplan-Meier analysis. Results The 38 597 Holocaust survivors included 22 627 women (58.6%) and had a mean (SD) age of 81.7 (5.4) years, and the 34 931 individuals in the control group included 18 615 women (53.3%) and had a mean (SD) age of 77.7 (5.3) years. The Holocaust survivors had higher rates than control individuals of reported hypertension (32 038 [83.0%] vs 23 285 [66.7]), obesity (12 838 [33.3%] vs 9254 [26.5]), chronic kidney disease (11 929 [30.9%] vs 6927 [19.8]), cancer (11 369 [29.5%] vs 9721 [27.8]), dementia (6389 [16.6%] vs 3355 [9.6]), ischemic heart disease, nonmyocardial infarction (5729 [14.8%] vs 4135 [11.8]), myocardial infarction (3641 [9.4%] vs 2723 [7.8]), and osteoporotic fractures among women (6429 [28.4%] vs 4120 [22.1]). In contrast, the overall mortality rate was lower among Holocaust survivors (25.3%) compared with the control group (41.1%). After adjustment for confounders, mean age at death was significantly higher in the survivor group compared with the control group. Conclusions and Relevance The findings showed higher rates of comorbidities and lower mortality among Holocaust survivors, which may be associated with a combination of improved health literacy and unique resilience characteristics among Holocaust survivors. More research is needed to explore the biologic and psychosocial basis for these results.

There are major differences in the prevalence and management of patients with atherothrombotic disease including coronary artery disease (CAD), cerebrovascular disease (CVD) and peripheral artery disease (PAD) across different geographical regions. There is, however, little data allowing comparisons of management and outcomes across broad geographic regions. We aimed to describe geographical differences in baseline characteristics, management and outcomes in stable outpatients with established atherothrombotic disease.From the REACH Registry of atherothrombosis, patients with documented CAD, PAD or CVD and with 4-year follow-up were included. Baseline characteristics, treatments and 4-year outcomes were recorded. Event rates were compared between geographical regions and were adjusted for risk scores predicting ischemic and bleeding events. The analyses of baseline characteristics and medications according to geographical region showed marked differences. For the composite primary outcome (cardiovascular death, non-fatal myocardial infarction (MI) and non-fatal stroke), rates ranged from 12.1% in Japan to 18.2% in Eastern Europe. After adjustment, substantial variations remained: taking North America as a reference, patients from Western Europe and Japan had a lower risk of primary outcome event (hazard ratio (HR) 0.93; p = 0.045, and HR = 0.67; p 0.001 respectively) whereas patients from Eastern Europe had a higher risk (HR = 1.24; p 0.001). There were no obvious differences between patients from North America and those from Latin America, the Middle East and Asia.There are important variations in the outcomes of patients with atherothrombotic across geographic regions. These observations have important implications for public health and clinical research.

The incidence of metabolic syndrome (MetS), diabetes mellitus (DM), and their coexistence is increasing but whether MetS increases cardiovascular risk beyond component risk factors is controversial.We compared the risk of cardiovascular death, myocardial infarction, or stroke among patients with MetS, newly detected DM, established DM, or coexistent MetS and DM in the global REduction of Atherothrombosis for Continued Health (REACH) registry.Outpatients with or at risk for atherothrombosis were recruited between 1 December 2003 and 31 December 2004 and followed up to 4 years for cardiovascular events. Risk was compared in patients with or without MetS or DM after adjustment for age, sex, risk factors, vascular disease, fasting blood glucose, therapy, and region.Among 44,548 REACH participants, 17,887 (40%) were without MetS or DM; 6459 had MetS (15%); 12,059 had established DM (27%); 7503 had both (17%); and 640 had newly detected DM (1%). Presence of MetS was not associated with higher cardiovascular events (12.6%, adjusted HR 0.98, 95% CI 0.89-1.08). In addition, once DM was evident, patients with coexistent MetS had similar increased risk (16.1%, adjusted HR 1.33, 95% CI 1.21-1.47) as DM alone (16.7%, adjusted HR 1.36, 95% CI 1.24-1.48). Newly detected DM was associated with increased cardiovascular risk (18.5%, adjusted HR 1.26, 95% CI 1.02-1.57), similar to longstanding DM. MetS was associated with incident DM (adjusted OR 1.94).In the REACH registry, presence of newly detected DM but not metabolic syndrome was associated with an increased risk of cardiovascular events.

Objective Assess the cardiovascular safety of Thiazolidinediones (TZD) in routine clinical practice. Background TZD are insulin-sensitizing antidiabetic drugs commonly used in type 2 diabetes, but their cardiovascular safety has been questioned. We examined the association between TZD use and major cardiovascular outcomes. Methods We examined 2-year mortality, non-fatal myocardial infarction (MI), and congestive heart failure (CHF) rates among outpatients with high cardiovascular risk and diabetes according to TZD use in the REACH Registry. Multivariable adjustment and propensity scores were used in the analyses. Results A total of 4997 out of 28,332 patients took TZDs at baseline. During follow-up, 1532 patients died. The mortality rates (95% confidence interval [CI]) were 6.5% (5.5–7.6) with TZD and 7.2% (6.33–8.06) without; adjusted hazard ratio (HR) was 1.06 (0.89–1.26, P =0.54). The lack of association with mortality was consistent across subgroups regardless of history of atherothrombosis or CHF. Rates of non-fatal MI (HR 1.10, 95% CI 0.83–1.45, P =0.50) and non-fatal CHF (HR 0.90, CI 0.75–1.09, P =0.27) were similar in users and non-users. TZD use was associated with an increased risk of CHF in patients aged >80years (HR 1.59, CI 1.06–2.40, P= 0.03). Conclusions Use of TZD was not associated with increased incidence of major cardiovascular events in patients with diabetes from this large registry. Older patients experienced an increased risk of CHF over the study interval. Limitations of this study include its observational design, and thus unmeasured confounders cannot be excluded.

Although the beneficial effect of statins in secondary prevention of cardiac events is well established, their effectiveness in primary prevention is questionable when most evidence derives from randomized controlled trials and not "real-life" data. To evaluate the association between persistent use of statins and risk of acute nonfatal cardiovascular events in primary prevention patients in community settings, we retrospectively analyzed a cohort of 171,535 adults 45 to 75 years old with no indication of cardiovascular disease who began statin therapy from 1998 to 2009 in a large health maintenance organization in Israel. Persistence with statins was measured by the proportion of days covered with dispensed prescriptions of statins during the follow-up period. Main outcome measurements were occurrence of myocardial infarction or performance of a cardiac revascularization procedure. Incidence of acute cardiovascular events during the follow-up period (993,519 person-years) was 10.22 per 1,000 person-years. Persistence with statins was associated with a lower risk of incident cardiac events (p for trend0.01). The most persistent users (covered with statins for ≥80% of their follow-up time) had a hazard ratio of 0.58 (95% confidence interval 0.55 to 0.62) compared to nonpersistent users (proportion of days covered20%). Similar results were found when analyses were limited to patients with5 years of follow-up. Treatment with high efficacy statins was associated with a lower risk of cardiac events. In conclusion, our large and unselected community-based study supports the results of randomized controlled trials regarding the beneficial effect of statins in the primary prevention of acute cardiac events.

Background There is a global trend of large increases in the prevalence and incidence of Attention Deficit Hyperactivity Disorder (ADHD). This study aimed to address potential causes of these major changes. Methods The authors used a large cohort to analyze data employing patients’ electronic medical records, with physicians’ diagnosis of ADHD, including records of medication purchases. Results The prevalence of ADHD diagnoses rose twofold from 6.8% to 14.4% between 2005 and 2014 (p

Background Israel reports the world’s highest IVF cycles per capita. However, clinical outcome data of these treatments are scarce. In a previous publication, we summarized IVF results among Maccabi Healthcare Services members for the years 2007-2010. The main findings included an increase in mean patients’ age over the period studied, a 50 % increase in cycle numbers during this time, and a decrease in success rate (live birth) from 18.8 % in 2007 to 14.8 % in 2010. The purpose of the current publication is to summarize IVF outcome for the years 2011-2014, and to explore possible changes in the trends we reported previously. Methods IVF and live births data were collected from Maccabi Healthcare Services’ fertility treatments registry. Analyses were conducted by treatment year and patients’ age at the initiation of treatment cycles. Autologous cycles, were included (ovum donation cycles and frozen-thaw cycles were excluded). A successful cycle was defined if a live birth was recorded within 10 months of its initiation. Results In accordance with previous data for the years 2007-2010, mean patients’ age continued to rise (from 36.2 in 2011 to 37.1 in 2014). In contrast to previous years, during which a continued increase in treatment cycles was recorded, we found that treatment number decreased from a peak of 9,751 in 2011 to 8,623 in 2014. Contrary to that trend, the number of patients over 40 years of age increased from 3,204 in 2011 to 3,648 in 2014. Success rate fluctuated between 14.4 % in 2014 to 16.4 % in 2013. The majority (78 %) of treatment cycles were conducted in four private medical centers. Conclusions The decrease in treatment cycles in recent years notwithstanding, Israel is still leading the world with IVF treatments relative to population. Success rate is relatively low compared to international data. Given the steady increase in patients’ mean age, and particularly, the increase in patients over 40 years of age, we maintain that the low success rate reflects a growing number of treatments that a priori have a low chance of success.

Background The importance of heart failure with preserved ejection fraction is being increasingly recognized. However, there is a paucity of data about effective treatment for this condition. The present study investigated the impact of beta blocker therapy for 3 months before admission on the two-year survival of patients with heart failure and preserved systolic function hospitalized due to decompensated heart failure. Methods We performed a retrospective cohort analysis of 345 consecutive patients with heart failure with preserved systolic function older than 18 years hospitalized due to decompensated heart failure. Two groups of patients were compared: those who received beta blockers within 3 months before admission (BB) and those who did not (NBB). The primary outcome was two year all cause mortality (maximal follow-up available in all subjects). To adjust for a potential misbalance between BB and NBB groups in baseline characteristics, a propensity score for beta blocker therapy was incorporated into the survival model. Results 154 patients (44.6%) received beta blockers prior to admission. Overall two year mortality rate in the BB group was 50% vs. 62.8% in the NBB group, log-rank test p = 0.016. Beta blockers showed protective effect on two-year survival after adjustment for comorbidities and propensity score (hazard ratio [HR], 0.69; 95% CI 0.47–0.99). Conclusions Therapy with beta blockers may have protective effect on survival of patients with heart failure with preserved systolic function.

Background— Elevated serum cholesterol accounts for a considerable proportion of cardiovascular disease worldwide. An understanding of the relationship between country-level economic and health system factors and elevated cholesterol may provide insight for prioritization of cardiovascular prevention programs. Methods and Results— Using hierarchical models, we examined the relationship between elevated total cholesterol (>200 mg/dL) in 53 570 outpatients from 36 countries, and tertiles of several country-level indices: (1) gross national income, (2) total expenditure on health as percentage of gross domestic product, (3) government expenditure on health as percentage of total expenditure on health, (4) out-of-pocket expenditures as percentage of private expenditure on health, and the World Health Organization indices of (5) Health System Achievement and (6) Performance/Efficiency. Overall, 38% of outpatients had total cholesterol >200 mg/dL (>5.18 mmol/L), and 9.3% of the total variability in elevated cholesterol was at the country level; this proportion was higher for patients with (12.1%) versus without (7.4%) history of hyperlipidemia. Among patients with history of hyperlipidemia, countries in the highest tertile of gross national income or World Health Organization Health System Achievement had lower odds of elevated cholesterol than lower tertiles ( P P Conclusions— Global variations in the prevalence of elevated cholesterol among patients with history of hyperlipidemia are associated with country-level economic development and health system indices. These results support the need for strengthening efforts toward effective cardiovascular disease prevention and control and may provide insight for health policy setting at the national level.

We have utilized the computerized data of a nationwide health plan to elucidate several epidemiologic aspects and risk factor of myelodysplastic syndromes (MDS) in Israel. The annual incidence rate (IR) of reported MDS was of 3.32 per 100,000. Among anemic patients aged 40+, the risk of reported MDS was 56.7 per 100,000. Only 44% of the reported MDS cases had an indication of bone marrow examination. In a multivariable model, older age, hemoglobin level9 g/dl, white blood cell count of less than 3500/mm(3), and platelet count of less than 100×10(9)/L were associated with a significantly higher risk of MDS. The mean lag period from the first demonstration of anemia to the final diagnosis of MDS was 3.5 years. Our study results could be helpful for improving the detection of patients with high MDS risk, therapeutic decision-making, and designing interventional trials in the future.

Post-marketing data on weight-loss medications in free living population are a necessary adjunct to data from clinical trials.We conducted a population-based analysis of first-time medication users based on HMO pharmacy purchasing data servingone million adults.During 5 years, usage of orlistat and sibutramine more than doubled and rates were higher during the months May-Aug. As compared to non-users (n = 1,038,828), annual weight-loss drug users (n = 7175) had higher women proportion, body-mass-index (BMI), bariatric surgery history, and usage of diabetes, depression, and cardiovascular medications (p0.001 for all). Among users, men had higher BMI (34.4 kg/m(2) vs. 32.5 kg/m(2)), prevalence of diabetes (25.4% vs. 10.7%) and heart disease (14.2% vs. 3.5%) than women. Mean duration of purchasing weight-loss medications was 2.1 months for orlistat and 2.9 months for sibutramine. Fewer than 2% completed 12 months of weight-loss medication therapy. Among the 25% who continued to purchase at least 4 months, BMI (sub-group analysis) reduced from 33.02 kg/m(2) to 32.04 kg/m(2) (p0.001). In a multivariate model, long-term adherence (≥ 4 months) to weight-loss medications was associated with use of sibutramine vs. orlistat (OR = 2.08; 95%CI: 1.76-2.45), and prevalence of diabetes (OR = 1.20; 95%CI: 1.01-1.25). Age, gender, and baseline BMI were not associated with long-term adherence.Usage of weight-loss drugs is higher among diabetes patients. However, the poor adherence to therapy is substantially below levels reported in clinical trials.

In 1999 Israel began to implement a system for monitoring quality of care in its health plans. That system was based largely on a similar system in the United States that, until recently, was associated with steady improvements in performance. However, in recent years health plan quality in the United States appears to have reached a plateau. In contrast, health plans in Israel have continued to show improvements on many of the same measures. Between 2005 and 2007 they achieved a gain of 6.7 percent in nine measures of primary care quality, while US performance on these measures declined. These gains were achieved, in part, through intense cooperation among health plans and physicians. Israel is a much smaller country and differs greatly from the United States in how it finances health care. Nonetheless, we suggest that the Israeli experience could help the United States accelerate the move toward quality improvement-for example, through increased coordination among US employers, health plans, physicians, and physician groups.

Background The burden of illness of heart failure (HF) may be changing. We performed a study to define temporal trends in hospital admissions and long-term mortality among patients admitted with acute decompensated heart failure. Methods We studied consecutive admissions with HF as a primary diagnosis at seven hospitals from 2000 to 2004. Admissions with a concurrent acute myocardial infarction were excluded from the analysis. Temporal trends in the etiology of HF, associated co-morbid conditions, medications and mortality were identified. Results A total of 21,581 hospitalizations of 12,769 patients with primary diagnosis of HF were studied (average age 75). Monthly admission rate decreased by 10% over the study period, primarily due to a decrease in HF admissions of IHD etiology. Between 2000 and 2004 there was a significant increase in post-discharge purchase of beta-blockers (from 44.0% to 69.0%, p Conclusions The admission of acute HF patients of IHD, but not non-IHD etiology declined throughout the study period. Short term mortality remained stable throughout the study period, while there was a significant improvement in 18month mortality rates. This reduction can be explained by higher utilization of the health services as can be manifested by an increase in statins and beta-blockers use.

Objectives The aim of this study was to assess the direct medical cost of treating major chronic illnesses in Maccabi Healthcare Services, a 1.8 million member health maintenance organization in Israel. Methods Direct medical costs were calculated for each member in 2006. We used multiple linear regression models to evaluate the overall costs of chronic conditions (cardiovascular diseases, diabetes mellitus, hypertension, female infertility treatments, and cancer), pregnancy and treatments for female infertility. Results According to the study model, hypertension was associated with the largest direct medical costs in both sexes. Cardiovascular diseases accounted for 9.5% of the total direct medical costs in men, but only 5.9% in women. Diabetes mellitus accounted for 3.5% of the total medical costs both in men and women and is comparable to the total pregnancy-related costs in women. Conclusions The findings indicate that hypertension, diabetes mellitus and female infertility treatments impose a considerable economic burden on public healthcare services in Israel which is comparable with the costs of cancer and cardiovascular diseases.

Diabet. Med. 27, 779–785 (2010) Abstract Aims To determine the incidence of postpartum diabetes mellitus in the years following a diagnosis of gestational diabetes mellitus (GDM) and to determine whether the severity of GDM, represented by the magnitude of the deviation of diagnostic tests from the normal values or requirement for medications, is associated with the development of diabetes. Methods A retrospective cohort study was performed among 185 416 pregnant women who had glucose challenge test or 3 h oral glucose tolerance test (OGTT) in a large health maintenance organization in Israel. Subsequent diagnosis of diabetes was ascertained by using an automated patient registry. Results A total of 11 270 subjects were diagnosed with GDM, comprising 6.07% of the cohort. During a total follow-up period of 1 049 334 person-years there were 1067 (16.9 per 1000 person-years) and 1125 (1.1 per 1000 person-years) diagnoses of postpartum diabetes among GDM and non-GDM women, respectively. The cumulative risk of incident diabetes in GDM patients with up to 10 years of follow-up was 15.7%, compared with 1% among the non-GDM population. Gestational diabetes mellitus was associated with nearly an eightfold higher risk of postpartum diabetes after adjusting for important confounders, such as socioeconomic status and body mass index. Among women with a history of GDM, the number of abnormal OGTT values and use of insulin were associated with a substantially higher risk for developing diabetes. Conclusions Three or four abnormal OGTT values and GDM requiring insulin or oral hypoglycaemic medications are important predictors of postpartum diabetes risk in women with a history of GDM.

Type 2 diabetes mellitus has been associated with an increased risk of a variety of cancers in observational studies, but few have reported the relationship between diabetes and cancer risk in men and women separately. The main goal of this retrospective cohort study was to evaluate the sex-specific risk of incident overall and site-specific cancer among people with DM compared with those without, who had no reported history of cancer at the start of the follow-up in January 2000. During an average of 8 years of follow-up (SD = 2.5), we documented 1,639 and 7,945 incident cases of cancer among 16,721 people with DM and 83,874 free of DM, respectively. In women, DM was associated with an adjusted hazard ratio of 1.96 (95% CI: 1.53-2.50) and 1.41 (95% CI: 1.20-1.66) for cancers of genital organs and digestive organs, respectively. A significantly reduced HR was observed for skin cancer (0.38; 95% CI: 0.22-0.66). In men with DM, there was no significant increase in overall risk of cancer. DM was related with a 47% reduction in the risk of prostate cancer. These findings suggest that the nature of the association between DM and cancer depends on sex and specific cancer site.

Background In view of the recent reports on a lack of protective effect of statin therapy on clinical outcomes in patients with heart failure, the present study investigated the impact of statin therapy before admission on one-year survival of patients hospitalized due to decompensated heart failure in two groups of patients; with and without ischemic heart disease. Methods We performed a retrospective cohort analysis of 887 consecutive patients older than 18 years hospitalized with decompensated heart failure between 11/December 2001 and 06/June 2005. Two groups of patients were compared: those who received statins within 3 months before the admission (S) and those who did not (NS). The primary outcome was one-year all-cause mortality. To adjust for a potential misbalance between S and NS groups in baseline characteristics, a propensity score for statin therapy was incorporated into the survival model. Results Two hundred eighty-one patients (31.7%) received statins prior to admission. Patients with ischemic heart disease (IHD) (656/887 subjects, 74%) had higher rate of S therapy as compared to the rest 36.3% vs. 18.6%, p Conclusions In our study statins' protective effect on one-year survival in HF patients is restricted to patients with IHD. This stands in disagreement with the results of the randomized trials showing no effect of statin therapy. Statin use may be a marker of better health care and despite an extensive adjustment for baseline characteristics, unaccounted bias inherent to retrospective studies may explain the discrepancy in the results.

PurposeThis article aims to analyze existing and preferred labor divisions between physicians and nurses treating patients with hypertension and diabetes in managed care organizations.Design/methodology/approachA mail survey was conducted in 2002/2003 among a representative sample of 743 physicians employed by Israel's largest managed care health plans (78 percent response rate). A telephone survey among a representative sample of 1,369 hypertensive or diabetic patients (77 percent response rate) was also used.FindingsFindings reveal a conspicuous gap between actual labor division and what physicians perceive to be ideal. Possible reasons for this gap are discussed and strategies for facilitating collaboration, which would improve service quality as well as work life quality for both physicians and nurses.Originality/valueThis study provides empirical data on the extent of nurse involvement in managed care organization chronic patient care, as well as comparing them to physicians' preferences regarding nurse involvement.

Decision-support systems, and specifically rule-based clinical reminders, are becoming common in medical practice. Despite their potential to improve clinical outcomes, physicians do not always use information from these systems. Concepts from the cognitive engineering literature on users’ responses to warning systems may help to define physicians’ responses to reminders. Based on this literature, we suggest an exhaustive set of possible responses to clinical reminders, consisting of four responses named “Compliance”, “Reliance”, “Spillover” and “Reactance”. We suggest statistical measures to estimate these responses and empirically demonstrate them on data from a large-scale clinical reminder system for secondary prevention of cardiovascular diseases. There was evidence for Compliance, probably since the physicians found the reminders informative, but not for Reliance, in line with the notion that Compliance and Reliance are two distinct types of trust in information from decision-support systems. Our research supports the notion that CDSS can promote closing the treatment gap and improve physicians’ adherence to guidelines.

Background Hyperlipidemia remains a major cause of morbidity in Western countries. The objective of this study was to document the percentage of adults who underwent periodical LDL measurement, and the percentage of patients with diabetes and post-angioplasty who were treated to goal. Methods Using a national database, data were obtained on the percentage of adults who had an LDL performed and the percentage of adults with an LDL at pre-specified levels. We also assessed the attainment of target LDL levels in diabetic and post-angioplasty patients. Data were also collected from patients with an acute coronary syndrome (ACS) admitted to seven hospitals within a 5 year period (2000–2004). Results Primary prevention: In 2005, 64.6% of the total population of 754,910 aged 35–44 had at least one record of LDL cholesterol measurement documented. This figure was 79.6% in the 717,617 adults aged 45–54. Secondary prevention: Of 253,233 diabetics in 2005, 220,023 (86.9%) have undergone at least one annual LDL measurement. The percentage of patients on statin therapy 3 and 12 months after an ACS admission increased significantly during the years 2000–2004 and reached 87%. Of the 42,292 patients who underwent PTCA during 2005, 34,346 (81.2%) have purchased at least 3 prescriptions of statins during 2005, 35,261 (83.4%) have performed at least one LDL measurement and 57.8% attained an LDL level of Conclusions We have shown an improvement in primary and secondary preventions of CV disease as documented by LDL measured and attainment of treatment goals, but further efforts are needed.

Introduction: The goal of our study was to characterize patients admitted to the hospital with hypothermia in a desert climate. Methods: This was a retrospective study (1999-2005) in a 1200-bed tertiary care hospital in southern Israel. Patients' data and weather condition (including mean day high and low temperatures, humidity, wind velocity and precipitation) within 48 hours before admission were assessed. Results: One hundred sixty-nine patients with hypothermia were admitted. The mean highest environmental temperature over 48 hours before admission was 15.3°C in the severe hypothermia (9 cases, 5.3%), 21.4°C in the moderate (40 cases, 23.7%), and 29.3°C in the mild group (120 cases, 71.0%). Major medical conditions associated with decreased body temperature were sepsis (65, 38.5%), trauma (34, 20.1%), endocrine disorders (19, 11.2%), and substance abuse (15, 8.9%). The inhospital mortality rate was 47.3%. A risk score based on 5 admission variables (age ≥70 years, mean arterial pressure b90 mm Hg, pH b7.35, creatinine N1.5 mg/dL, and confusion) was generated, predicting inhospital mortality with area under the receiver operating characteristic (ROC) curve of 0.81 (95% confidence interval, 0.75-0.87). Conclusions: Hypothermia should not be overlooked in geographical areas with temperate climates. Using a prognostication system based upon clinical and laboratory variables may identify hypothermia patients with increased risk of death.

Meckel syndrome was diagnosed prenatally by alpha-feto protein and beta-trace protein determinations in amniotic fluid. No central nervous system anomalies were detected in the affected fetus, who presented with large polycystic kidneys and polydactyly. An excessive synthesis of these fetal proteins by the dysplastic kidneys is suggested, allowing for the possibility of prenatal diagnosis of polycystic kidneys in families at risk for this disease. The present family emphasized the importance of amniocentesis in pregnancies at risk for Meckel syndrome, regardless of the presence of a defect in neural tube closure.

Despite continuous efforts, healthcare organizations still find it difficult to influence physicians to follow clinical guidelines. Previous studies have not taken into account the organizational context of the physicians' practice. We conducted a survey of a representative sample of 743 primary care physicians employed in Israel's 2 largest managed care health plans. The findings indicated that "commitment to the health plan" and "perceived monitoring by the health plan" had an independent positive effect on familiarity with guidelines for treating diabetes. We propose that managers of healthcare organizations consider enhancing physicians' commitment to the organization as a means for increasing their adherence with clinical guidelines, thereby improving the quality of care provided to diabetic patients.

Despite the wide distribution of different severity scoring systems for community-acquired pneumonia (CAP) patients, low-risk patients are frequently hospitalized, contrary to current recommendations. The aim of our study was to determine the rate, clinical characteristics, and outcome of low-risk patients with CAP admitted to our institution.During an 18-month period, we prospectively screened all patients admitted to the Division of Internal Medicine with a presumptive diagnosis of CAP. Pneumonia Outcome Research Team (PORT) score and pneumonia severity index (PSI) were calculated for all patients during the first 24 h.A total of 591 patients had a diagnosis of CAP. Some 196 patients (33.1%) were low-risk (PSI class I, II), 98 (16.6%) intermediate (PSI III), and 297 (50.3%) high-risk patients (PSI IV, V). Patients in low-risk classes were younger (45.5+/-15.8 vs. 65.0+/-12.5 and 74.9+/-11.8 years, respectively, p0.001) and had fewer background diseases. They had shorter hospitalizations than intermediate- and high-risk groups (4.4+/-3.2, 5.3+/-3.4, and 6.8+/-6.4 days, respectively, p0.001). There was a significant difference in 30-day mortality between the different risk groups: 0% in the low-risk, 2.0% in the intermediate-risk, and 9.4% in the high-risk group (p0.001).The considerable proportion of low-risk patients hospitalized due to CAP was found to be comparable to the stable 30% rate reported in the literature. We conclude that physicians tend to opt for a wide safety range when considering a CAP patient hospitalization, rather than make a decision based only on severity score calculation.

Diabetes is aggravated by a sedentary lifestyle, obesity and smoking. Based on a theoretical model relating attitudes and behavior, this study examined the association between physicians' self efficacy in counseling diabetic patients on life style behaviors and their counseling practices. Data were gathered from a representative sample of 743 primary care physicians in Israel's two largest health plans. The main findings were that only a small percentage of physicians felt capable of influencing their patients' life-style behaviors. Self-efficacy had an independent effect on the likelihood of counseling diabetic patients on life style behaviors, controlling for other background variables. We conclude that there is a need for enhancing physicians' life-style counseling skills, and that social workers could expand their role by training physicians to counsel effectively. This could both improve the care of diabetic patients, and strengthen the status of the social work profession in the healthcare ...

Objective. To estimate the impact of delays in surgery for hip fracture on short- and long-term outcomes. Design. Analysis of inpatient hospital data integrated with national health plan data and Central Bureau Statistics. Setting. Seven major tertiary hospitals. Patients. All consecutive elderly patients admitted with hip fracture during the years 2001 –2005. Main outcome measures. Time from the hospitalization to operation; one-year mortality. Main results. Study population comprise 4633 patients, older than 65 years. The conservative approach was chosen in 818 patients (17.7%), while 1350 patients (29.1%) waited .2 days from admission to the surgery. There was a substantial variation in median pre-operative stay among the hospitals (range 0 – 4 days). Patients who had surgery within 2 days had lower mortality (in-hospital, 1-month and 1-year) compared to those who waited for surgery .4 days (2.9%, 4.0%, 17.4% vs. 4.6%, 6.1%, 26.2%, respectively). A Cox proportional regression model of 1-year mortality in operated patients adjusted for background morbidity (Charlson index) showed that the length of operation delay has a gradual effect on increasing mortality (,2 days—reference group, 2– 4 days—OR ¼ 1.20, 5 days or longer, OR ¼ 1.50). The 818 (17.7%) non-operated patients suffered the highest 1-year mortality, 36.2%. Conclusions. Delays in surgery for hip fracture are associated with significant increase in short-term and 1-year mortality. Variation among the hospitals was substantial and calls for prompt quality improvement actions.

Objective: Statins have pleiotropic effects that are independent of their lipid-lowering ability. We have previously shown that prior statin therapy is associated with a decreased risk of severe sepsis in patients admitted with acute bacterial infection. The aim of this study was to determine whether statin therapy is associated with a decreased risk of infection-related mortality. Design: A prospective, observational, population-based study. Setting: Tertiary university medical center. Patients: Using a computerized database, 11,490 patients with atherosclerotic diseases were identified and followed for up to 3 yrs. Two groups of patients were compared: those receiving statins in the final month before follow-up termination and those who were not. Interventions: None. Measurements and Main Results: The primary outcome was infection-related mortality. Of the 11,362 patients included in the final analysis, 5,698 (50.1%) belonged to the statin group. Median follow-up was 19.8 months (interquartile range, 14.3-33.3). The risk of infection-related mortality was significantly lower in the statin compared with the no-statin group (0.9% vs. 4.1%), reflecting a relative risk of 0.22 (95% confidence interval, 0.17-0.28). Stepwise Cox proportional hazard survival analysis including a propensity score for receiving statins revealed that the protective effect of statins adjusted for all known potential confounders remained highly significant (hazard ratio, 0.37; 95% confidence interval, 0.27-0.52). Conclusions: Therapy with statins may be associated with a reduced risk of infection-related mortality. This protective effect is independent of all known comorbidities and dissipates when the medication is discontinued. If this finding is supported by prospective controlled trials, statins may play an important role in the primary prevention of infection-related mortality.

Background Developmental dysplasia of the hip (DDH) occurs in 3–5 of 1000 live births and is associated with known risk factors. In most countries, formal practice for early detection of DDH entails the combination of risk factor identification and physical examination of the hip, while the golden standard diagnostic instrument is hip ultrasonography (US). This practice is commonly referred to as selective screening. Infants with positive US findings are treated with a Pavlik harness, a dynamic abduction splint. The objective of our study was to evaluate hip US utilization patterns in Maccabi Healthcare Services (MHS), a large health plan. Methods Study population: All MHS members, born between June 2011 and October 2014, who underwent at least one US before the age of 15 months. Study variables: Practice specialty and number of enrolled infants. Positive US result was defined as referral to an abduction splint. Cost was based on Ministry of Health price list. Chi square and correlation coefficients were employed in the statistical analysis. Results Of the 115,918 infants born during the study period, 67,491 underwent at least one hip US. Of these, 60.6% were female, mean age at performance: 2.2 months. Of those who underwent US, 625 (0.93%) were treated with a Pavlik harness: 0.24% of the male infants and 1.60% of the female infants (p

Stroke is a leading cause of death and disability worldwide. The risk factors for stroke overlap those for cardiovascular disease. Atrial fibrillation (AF) is a particularly strong risk factor and is common, particularly in the elderly. Maccabi Healthcare Services (MHS) has maintained a vascular registry of clinical information for over 100,000 members, among them patients with heart disease and stroke.To determine the prevalence of stroke in MHS, and whether the association of AF and stroke, along with other risk factors, in the Maccabi population is similar to that in published studies.Data on stroke and AF patients aged 45 and older were collected from the database for the year 2010, including age, previous transient ischemic attack (TIA), body mass index (BMI), prior myocardial infarction (MI), diabetes, hypertension, anticoagulation and dyslipidemia. A cross-sectional analysis was used to estimate stroke prevalence by AF status. A case-control analysis was also performed comparing a sample of stroke and non-stroke patients. This permitted estimation of the strength of associations for atrial fibrillation and various other combinations of risk factors with stroke.Stroke prevalence ranged from 3.5 (females, age 45-54 years) to 74.1 (males, age 85+) per thousand in non-AF members, and from 29 (males, age 45-54) to 165 (males, age 85+) per thousand for patients with AF. AF patients had significantly more strokes than non-AF patients in all age groups. Stroke prevalence increased with age and was significantly higher in males. Multivariable analysis revealed that male gender, increasing age, AF, hypertension, diabetes, and history of TIA were highly significant risk factors for stroke. In addition, for males, dyslipidemia and prior Ml were moderately strong risk factors.Analysis of the MHS vascular database yielded useful information on stroke prevalence and association of known risk factors with stroke, which is consistent with the epidemiological literature elsewhere. Further analysis of health fund data could potentially provide useful information in the future.

Background: Hypertension has been associated with lower levels of quality of life (QoL). However, the specific correlates of lower QoL in this patient population have remained largely unclear. Methods: A cross-sectional design of 1,125 primary care patients with hypertension. We evaluated demographics, health status, subjective health and mental health, health behaviors, health beliefs, knowledge of hypertension treatment, satisfaction with medical care, and quality of medical care as potential predictors of QoL and perceived QoL in the hypothetical absence of hypertension. Results: Worse financial status, poorer blood pressure control, worse subjective health, mental distress, lack of hypertension diet, and irregular hypertension care were all associated with worse QoL. Worse financial status, poorer blood pressure control, higher body mass index, mental distress, and following a hypertension diet were associated with better QoL in the hypothetical absence of hypertension. Conclusions: In addition to taking into consideration well known determinants of QoL, such as financial status, health status, and mental health, physicians need to be aware of the potential tradeoff between following medical recommendations that advocate for a strict diet and the impact these have on patients' QoL. Physicians also need to be aware of the effect of imparting information regarding imbalanced blood pressure on perceived QoL.

Objectives: To investigate characteristics, management and outcome of patients with acute myocardial infarction (AMI) and chronic renal insufficiency (CRI). Background: Patients with AMI and CRI are considered to be at high risk of complications and death. Physicians may be reluctant to prescribe life-saving medications to patients with concomitant CRI. Methods: We compared clinical characteristics, management and outcome of 1,683 consecutive AMI patients in three categories of renal function: (1) normal renal function (3.5 mg/dl) (n = 47). Results: CRI patients were older and were more likely to have other co-morbidities such as hypertension, diabetes mellitus, prior AMI, stroke, angina and heart failure. Compared with patients with normal renal function, standard therapy for AMI including thrombolysis, aspirin, angiotensin-converting-enzyme inhibitors, β-blockers and lipid lowering agents was underutilized in CRI patients and these patients were more likely to have in-hospital complications such as heart failure, atrial or ventricular fibrillation, cardiogenic shock, sepsis, worsening of renal function and death within 30 days [odds ratio (OR) = 3.3; 95% confidence interval (CI) = 2.0–4.8]. After adjustment for age and co-morbidities, the association between mild to moderate CRI and 30-days mortality declined, whereas severe CRI remained an independent determinant of mortality (OR = 4.8; 95% CI = 2.0–11.4). Adjustment for aspirin, angiotensin-converting-enzyme inhibitors and β-blocker therapy weakened the association between CRI and death within 30 days after AMI. Conclusions: CRI patients are more likely to experience serious complications and death early after AMI. Underutilization of standard care, particularly β-blocker therapy, contributes to increased mortality risk in these patients.

Acetaminophen is the most common drug employed in deliberate self-poisoning (DSP) in many countries and can lead to acute liver failure. The purpose of the present study was to compare DSP with acetaminophen with DSP with other medications.From January 2001 to December 2002, all patients admitted after DSP to Soroka University Hospital in Beer-Sheva, Israel, were identified. Demographic data and medical history were obtained retrospectively.There were 282 incidences of DSP in the study period. The mean age of 94 patients with an acetaminophen overdose was lower than that of patients who had attempted DSP with other medications (24.8 vs. 34.6 years, p0.001). There was no gender or ethnic difference between the groups. Patients with DSP with acetaminophen were less likely to make recurrent attempts (23.4% vs. 39.9% p=0.006), less likely to have psychiatric disorders (32% vs. 59% p0.001), and had a shorter hospital stay (1.7 vs. 2.1 days, p=0.05). The acetaminophen group had less of an impairment in level of consciousness (84% vs. 52.1% p0.001) and had less need for ICU care (6.4% vs. 14.9%, p=0.04). Serum levels were checked in 68 (72.3%) of the patients in the acetaminophen group and they were found to be high in 6 (8.8%) of them (95% CI 2.1-15.5%).Taking an overdose of acetaminophen is a common method of DSP, with patients tending to have a more benign presentation and shorter hospital stay than those who attempt DSP with other medications. Further research on the optimal care of these patients and multi-disciplinary approaches to DSP prevention are needed.