Israel Journal of Health Policy Research最新文献

Background: In 2017, we published an article addressing drug shortages (DS) in Israel, exploring regulatory perspectives, challenges, and potential solutions. Since then, DS remain a significant concern for patients, healthcare providers, and policymakers globally. In this updated article, we revisit the topic, providing new insights, data, and analysis on the current DS landscape in Israel, efforts to mitigate them, and propose strategies to combat this escalating issue.

Methods: We conducted a comprehensive search of the Israeli Ministry of Health (MOH) DS database, spanning from 2014 to the present. We extracted DS numbers and their reasons. Further searches on the Israeli MOH website, pharmaceutical division archives, and the internet yielded official MOH publications and correspondence regarding regulatory responses to DS from 2017 onwards. Additionally, two specific cases of DS were examined to analyze their handling. Recent activities and publications from the Israeli MOH aimed at reducing DS were also reviewed.

Results: Between 2014 and 2022, DS surged 2.66-fold. Total DS were 3228; 672 due to commercial reasons, and 2556 to operational reasons (20.5% and 79.5% respectively). The average duration of intermittent DS increased 1.56-fold, from 85 to 133 days. Manufacturers informed the MOH 22 days prior to actual shortage on average. Analyzing 2022's DS (640) by ATC groups, prominent categories included nervous system drugs (18%), drugs acting on the alimentary tract and metabolism (14%), and dermatologicals (11%). Operational DS in 2022 (n = 564) were primarily due to stock delivery delays (38%), stock over-utilization (12%), and raw material shortages (9%). Sixteen official MOH publications on DS were identified from 2017 onwards. Moreover, two high-impact DS case studies were examined.

Conclusion: Despite routine monitoring by the Israeli MOH and updating the DS policy throughout this period, DS persist, intensifying annually and posing serious health risks. This trend mirrors international patterns, affecting countries globally. In Israel's uniquely structured healthcare system, with its swift stakeholder cooperation and implementation capabilities, more effective DS management is conceivable. We propose ten universally applicable rules to address DS challenges.

Background: Despite the increase in disclosures of medical errors, transparency remains a challenge. Recognized barriers include shame, fear of litigation, disciplinary actions, and loss of patient trust. In 2018, the Israeli Ministry of Health initiated a series of workshops about disclosure of medical errors. The workshops involved medical center executives, healthcare providers, patients, and family members of patients who had previously been harmed by a medical error. This study presents the lessons learned about perceived challenges in disclosure of errors in 15 such workshops.

Methods: Data collection included participant observations in 15 workshops, full audio recordings of all of the workshops, and documentation of detailed field notes. Analysis was performed under thematic analysis guidelines.

Results: We identified four main themes: "Providers agree on the value of disclosure of a medical error to the patient"; "Emotional challenges of disclosure of medical error to patients"; "The medico-legal discourse challenges transparency"; and "Providers and patients call for a change in the culture regarding disclosure of medical errors". Participant observations indicated that the presence of a patient who had experienced a tragedy in another hospital, and who was willing to share it created an intimate atmosphere that enabled an open conversation between parties.

Conclusion: The study shows the moral, human, and educational values of open discourse in a protective setting after the occurrence of a medical error. We believe that workshops like these may help foster a culture of institutional disclosure following medical errors. We recommend that the Ministry of Health extend such workshops to all healthcare facilities, establish guidelines and mandate training for skills in disclosure for all providers.

Background: The use of opioids has increased dramatically over the past several years in Israel. The aim of this study was to explore the trends of opioid consumption in Israel over a decade (2010-2020) stratified by socioeconomic status (SES), residence in the periphery, and ethnic background.

Methods: This cross-sectional study included all adult Maccabi Healthcare Services (MHS) patients who filled at least one prescription for opioids during the past decade. In order to standardize dosages and compare different opioid medications, we used the Morphine Milligram Equivalent (MME) conversion factor. We performed The Mann-Kendall test with autocorrelation correction to assess each trend. We then checked the differences between the trends with the Mann-Whitney test (for periphery) and the Kruskal Wallis (for SES and ethnic background).

Results: Between the years 2010-2020, 261,270 MHS members met the study's inclusion criteria. The proportions of opioids consumption were 23.9/1000 patients in 2010 and 27.6/1000 patients in 2020, representing a 15% increase. The average daily consumption of opioids was 4.6 and 10.5 MME in 2010 and 2020, respectively, an increase of 227%. The daily MME during 2020 was higher for residents of the periphery compared to non-periphery residents (daily MME of 14.0 compared to 10.1, respectively). Average daily MME increased gradually during the study period for all levels of SES; the values were highest for the low SES group and the lowest for the high SES group (daily MME in 2020 for the lowest, middle, and high SES groups were 15.2 vs. 11.8 vs. 6.7 respectively).

Conclusions: This study highlights that the primary concern in the increase of opioid use is the increasing dosages. The increase in the number of patients using opioids is also significant but to a minor extent. These phenomena disproportionately impact vulnerable populations. Education programs should be offered to physicians regarding the possible harms of long-term use of opioids. These programs should emphasize the risk factors associated with the development of opioid use disorder (OUD) and the caution needed when increasing dosages or switching to higher-potency drugs. Pain clinics and centers for rehabilitation for patients with chronic pain or OUD should be available, not only in central areas but also in the periphery of the country. These clinics and centers should use a holistic approach and a multidisciplinary team that includes specialists in pain and addiction. They should be financially accessible for patients from low SES group and provide solutions in multiple languages.

Background: The COVID-19 pandemic posed numerous challenges to health systems around the world. In addressing many of those challenges, Israel responded quite rapidly. While quick action is not an end in it itself, it can be important in responding to disease outbreaks. Some of Israel's rapid responses to the pandemic contributed significantly to population health and provided important learning opportunities for other countries.

Main body: Some of the most prominent Israeli rapid responses were related to vaccination. Israel led the world in the pace of its initial vaccine rollout, and it was also the first country to approve and administer booster vaccines to broad segments of the population. In addition, Israeli scholars published a series of timely reports analyzing vaccination impact, which informed policy in Israel and other countries. Israel was a rapid responder in additional areas of public health. These include the partial closure of its borders, the adoption of physical distancing measures, the use of digital surveillance technology for contact tracing, the use of wastewater surveillance to monitor viral spread, and the use of vaccine certificates ("green passes") to facilitate a return to routine in the face of the ongoing pandemic. Many factors contributed to Israel's capacity to repeatedly respond rapidly to a broad array of COVID-19 challenges. These include a national health insurance system that promotes public-private coordination, a system of universal electronic health records, a high level of emergency preparedness, a culture of focusing on goal attainment, a culture of innovation, and the presence of a strong scientific community which is highly connected internationally. In addition, some of the rapid responses (e.g., the rapid initial vaccination rollout) facilitated rapid responses in related areas (e.g., the analysis of vaccination impact, the administration of boosters, and the adoption of green passes). While rapid response can contribute to population health and economic resilience, it can also entail costs, risks, and limitations. These include making decisions and acting before all the relevant information is available; deciding without sufficient consideration of the full range of possible effects, costs, and benefits; not providing enough opportunities for the involvement of relevant groups in the decision-making process; and depleting non-renewable resources.

Conclusions: Based on our findings, we encourage leaders in the Israeli government to ensure that its emergency response system will continue to have the capacity to respond rapidly to large-scale challenges, whether of a military or civilian nature. At the same time, the emergency response systems should develop mechanisms to include more stakeholders in the fast-paced decision-making process and should improve communication with the public. In addition, they should put into place mechanisms

Background: According to Israel's National Health Insurance Law (1994), the Ministry of Health is responsible for the provision of health services in the country including physiotherapy services; moreover, the Special Education Law (1988), stipulates that physiotherapy services for children with motor disabilities, as well as other allied health services, are provided by the Ministry of Education in educational settings. Thus, children with motor disabilities are entitled PT services under two different laws by two different ministries.

Method: To describe the physiotherapy services for children with motor disabilities and examine how policymakers view these services, we conducted a qualitative study including in-depth semi-structured interviews with 10 policymakers from the Ministry of Health and the Ministry of Education, and the national directors of physiotherapy services from three of the four health maintenance organizations in Israel.

Results: Study results indicate that there is an array of physiotherapy services and providers. Despite the regulation of these services for children with motor disabilities, uncertainty and lack of knowledge were found about various issues. Therefore, the thematic analysis was structured around four descriptive questions: Where do the children receive physiotherapy? Who is eligible for physiotherapy treatment and who receives treatment? What interventions do children with motor disabilities receive? Who provides therapy for children with motor disabilities?

Conclusions: Policymakers are dubious regarding the provision of these services, questioning whether children with motor disabilities receive physiotherapy services according to their needs. In addition, the abundance of suppliers does not necessarily improve the quality of services provided to children with motor disabilities, which may ultimately harm their developmental potential.

Background: mRNA technology is currently being investigated for a range of oncology indications. We assessed the willingness to pay (WTP) of the general population in Israel for a hypothetical novel mRNA-based treatment for oncology indications.

Methods: We used a contingent valuation methodology to elicit WTP using a web-based questionnaire. A sample of adult participants were presented with a hypothetical scenario in which an mRNA-based intervention increased the likelihood of a cure for various cancer types from 20% to 40% (half of the sample), or 60% (the other half of the sample).

Results: 531 respondents completed the questionnaire. The mean, median and mode WTP for the proposed hypothetical treatment in both scenarios were ILS65,000 (± ILS114,000), ILS20,000 and ILS50,000, respectively (1USD = 3.4ILS). The WTP was skewed towards zero, and 9.6% of the respondents were not willing to pay any amount. WTP higher amounts was significantly associated with higher income (p < 0.01), self-reported good health (p < 0.05), supplementary health insurance (p < 0.05), Jews compared to other populations (p < 0.01), interest in technology (p < 0.001) and a tendency to adopt medical innovations (p < 0.001). No statistical difference between the 40% vs. the 60% potential cure scenarios was found. Logistic and OLS regressions indicated that age, religion, income, and interest in adopting medical innovations were the best predictors of respondents' WTP.

Conclusion: Despite the scientific breakthroughs in oncology treatment over the last few decades, many types of cancer are still incurable. Given the expected development of innovative mRNA-based treatments for cancer, these results should inform policymakers, the pharmaceutical industry and other stakeholders on the future coverage and reimbursement of these technologies incorporating patients' and societal views. To date, WTP considerations have not been given much weight in prioritization of drug reimbursement processes, neither in Israel nor in other countries. As a pioneer in adoption of the mRNA technology, Israel can also lead the incorporation of WTP considerations in this field.

Background: A model of hospital-at-home services called the Home Care Unit ("the unit") has been implemented in the southern region of the Clalit Healthcare Services in Israel. The aim of the present study was to characterize this service model.

Methods: A retrospective cross-over study. included homebound patients 65 years of age and above who were treated for at least one month in the framework of the unit, between 2013 and 2020. We compared the hospitalization rate, the number of hospital days, the number of emergency room visits, and the cost of hospitalization for the six-month period prior to admission to the unit, the period of treatment in the unit, and the six-month period following discharge from the unit.

Results: The study included 623 patients with a mean age of 83.7 ± 9.2 years with a mean Mini-mental State Examination (MMSE) score of 12.0 ± 10.2, a mean Charlson Comorbidity Index (CCI) of 3.7 ± 2.2 and a Barthel Index score of 23.9 ± 25.1. The main indications for admission to the unit were various geriatric syndromes (56.7%), acute functional decline (21.2%), and heart failure (12%). 22.8% died during the treatment period and 63.4% were discharged to ongoing treatment by their family doctor after their condition stabilized. Compared to the six months prior to admission to the unit there was a significant decrease (per patient per month) in the treatment period in the number of days of hospitalization (2.84 ± 4.35 vs. 1.7 ± 3.8 days, p < 0.001) and in the cost of hospitalization (1606 ± 2170 vs. 1066 ± 2082 USD, p < 0.001).

Conclusions: Treatment of homebound adults with a high disease burden in the setting of a hospital-at-home unit can significantly reduce the number of hospital days and the cost of hospitalization. This model of service for homebound patients with multiple medical problems maintained a high level of care while reducing costs. The results support the widespread adoption of this service in the community to enable the healthcare system to respond to the growing population of elderly patients with medical complexity.

Background: For the past two decades, the assessment of the quality of diabetes care has mostly relied on clinical quality indicators. These have not included Patient-Reported Outcome Measures (PROMs) which provide information on outcomes deemed valuable by patients. We aimed to examine the potential utility of PROMs in type 2 diabetes care and to study the association of PROMs with patients' characteristics and clinical quality indicators.

Methods: A cross-sectional survey of recently (≤ 4 years) diagnosed patients with type 2 diabetes (n = 392) in the setting of a large health plan. PROMs were based on two well-validated questionnaires, the Problem Areas in Diabetes (PAID) one-page questionnaire that measures diabetes-related distress, and the ten item PROMIS-10 global health questionnaire that measures general health. Additional items were added following a previous qualitative study among Israeli patients with diabetes. The survey was carried out using phone interviews, and data collected were linked to the electronic medical records. Multivariable regression models were used to assess the associations of socio-demographic variables and clinical quality indicators with the PROMs.

Results: About a fifth of participants (22%) had high diabetes-related distress (PAID score ≥ 40), a third reported that they did not feel confident in self-management of diabetes and about a third reported having sexual dysfunction. Women, younger patients, and those with a low education level (≤ 12 years) reported worse general health, were more likely to experience high diabetes-related distress, and to have low confidence in diabetes self-management. Interestingly, performance of all seven diabetes quality indicators was associated with worse general health and high diabetes-related distress. Of note, levels of glycated hemoglobin, LDL-cholesterol, or blood pressure were not associated with PROMs.

Conclusions: PROMs provide important information on patient self-reported health status and are likely to reflect aspects of the quality of care that are not otherwise available to clinicians. Thus, the use of PROMs has the potential to expand the evaluation of diabetes care and promote patient-centered care. We recommend that policy-makers in the Ministry of Health and health maintenance organizations implement PROMs for assessing and improving the care for patients with type 2 diabetes.

Background: In addition to pressures typical of other medical professions, family physicians face additional challenges such as building long-term relationships with patients, dealing with patients' social problems, and working at a high level of uncertainty. We aimed to assess the rate of burnout and factors associated with it among family medicine residents throughout Israel.

Methods: A cross sectional study based on a self-administered questionnaire.

Results: Ninety family medicine residents throughout Israel completed the questionnaire. The rate of clinically significant burnout, assessed by the composite Shirom-Melamed Burnout Questionnaire score, was 14.4%. In univariate analyses several personal and professional characteristics, as well as all tested psychological characteristics, showed significant associations with burnout. However, in the multivariable logistic regression only psychological work-related characteristics (work engagement, psychological flexibility (reverse scoring), and perceived work-related stress) were significantly associated with burnout at OR (95% CI) = 0.23 (0.06-0.60), 1.31 (1.10-1.71), and 1.16 (1.05-3.749), respectively.

Conclusion: The integration of burnout prevention programs into academic courses during residency could explain the relatively low prevalence of burnout among family medicine residents in this study. Given the strong association of burnout with psychological characteristics, further investment in burnout prevention through targeted structured courses for residents should be encouraged.

Background: While there has been increasing global recognition and impetus for action to transform food systems towards greater food security, sustainability and better health outcomes, Israel has only recently begun to focus on the diverse challenges of its food system and its potential for transformation.

Methods: An expert opinion survey (n = 50) on Israel's food system was conducted as part of a larger study on the systemic features of Israel's food system transition to understand its policy gaps and find strategies towards a healthy and sustainable food system. The survey ranks the relevance and importance of food system challenges and policy preferences. Policy implications are then examined by identifying potential priorities, gaps and dissensus.

Results: The survey finds that there is a majority agreement (76%) that Israel's food policies are lacking or severely lacking. Respondents relate strongly to both concepts of nutritional security (90% think that access to nutritious food is relevant or highly relevant) and national food security (more than 80% perceive food security as part of national security). Respondents overwhelmingly recognize the benefits of Israeli agriculture with 60-90% agreeing or strongly agreeing that it benefits food security, economic value and national identity. Top-ranked problems include overall systemic problems such as the lack of national goals, strategic planning, and integrated policymaking across ministries, and specific ones such as food waste, costly farming inputs, and food affordability. The most preferred policy actions include establishing a national strategy for food and agriculture, making food affordable for vulnerable households, and incentivising sustainable farming methods. The key policy gaps include the lack of resilience in agriculture and the food system, insufficient data and knowledge for policy action, inadequate attention to the regulation of the food industry for better health and inadequate food policy attention for minority groups.

Conclusions: Building on this study's findings, further policy research and implementation areas to be covered include government responsibility for universal food security, strategic systemic policies for food systems, prevention and preparedness for future crises, and promoting resilience. The way forward may best be through an inter-ministerial committee with the responsibility, budgets, mandate and executive authority to plan data-driven policies for a sustainable food system for Israel's future.