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Israel

November 2006

Read about mental health care in the Israeli primary sector here and about the National Primary Care Quality Measurement System here

News from Israel on quality improvement activities in primary care

Dr. Goldfracht Margalit
Quality Improvement Unit
Community Division
Clalit Health Services, Israel

goldfrac@actcom.co.il
margalitgo@clalit.org.il

Organization of the Israeli primary care

The health care in Israel is provided by 4 Sick funds which provide health care according to the directives of Ministry of Health. Each Israeli citizen above age 18 pays 4.5 % of his income to social security institute as Health tax. The funds are given to the sick funds according to certain capitation formula which is dependent on the number of members in each fund and their age. The health bill covers all the health services excluding dentistry (private) and mental health care (direct responsibility of Ministry of Health).The Sick Funds are: Clalit (covers 53% of the population), Maccabi (covers 25%), Meuhedet (covers 11%), Leumit (covers 11%)

The Israeli Association of Family Physicians

By dr. Goldfracht Margalit

The Israeli Association of Family Physicians is promoting quality in primary care since 1993. Israeli representative Dr Tomi Spenser was one of the EQUIP founders and he had established in the Association the committee for quality assurance in 1993.

The activities of quality improvement of the Association focus mainly on the following;

CME activities on subjects inherent to primary care generally with leading opinion leaders of family medicine and experts
Long term CME activities on subjects as diabetes, obesity
Guidelines on subjects from primary care perspective
Knowledge dissemination such as:

The quality improvement committee of the Association presents quality improvement workshops in various association's conferences.
Since 2000 the Association devotes at least one session in each scientific conference to presentations and research outcomes in quality improvement

5. Quality improvement in residency in family medicine

Since 1997 in the final board examinations in family medicine specialty, each resident has to present an implementation project in quality improvement performed in his practice, including outcomes. We expect of each resident in family medicine to understand the rudiments of quality improvement

Israeli Ministry of Health

By: Dr. Michael Dor

Director of General Medical Division, Deputy Director, Medical Administration

Since 2005 the Israeli Ministry of Health, started a systematical evaluation and control of the primary care services. The process was carried out by the General Medicine Division, headed by a family physician. The primary care in Israel is given by four HMO’s, dispersed in twenty-four districts, 4-8 per HMO.. Twelve out of twenty-four have already been inspected. Twenty detailed check lists were prepared and published in the Ministry Website. The care providers were asked to be prepared to present their services to the examination team, according to those parameters. On previously appointed dates, a team of controllers from the Ministry met with the district authorities. The examining staff consisted of physicians, nursed, pharmacists, physiotherapists, social workers anesthesiologists, or nurses and other health care professionals. Following a brief presentation from the district services, each professional met with his counterpart in the district office and examined it. At the end of the day, all participants met and there was a brief presentation, giving the results of the examination.

In a fourteen day period following the inspection, the controllers prepared a detailed report and submitted it to the Head of the General Medicine Division for review and editing. It was then presented to the district authorities’ attention for follow-up and correctional activities. Copies of the reports were routinely sent to the heads of the Ministry and the HMOs’ managements. At this stage the results were not published to the media, and the team did not attempt to grade the services or to compare each of the HMO’s.

The preliminary evaluation of the process demonstrated a very serious approach of the HMO’s. It started by active participation in the preparation of the check lists, and was followed by the meticulous preparation of every visit. Since the process is still on going, it is too early to assess the influence upon primary medical care. However, the improvements noticed by the team, following each visit have been impressive.

After the completion of the first round, it will be necessary to make a thorough evaluation of the process and to decide how to continue next year.

Activities in quality improvement of health care - Clalit Health Services

By dr. Goldfracht Margalit

Quality Improvement Unit

Community Division

Clalit Health Services (CHS) is the major and foremost health care organization in Israel. It insures 3,800,000 members, some 53% of the population nationwide. 80% of the primary care is delivered by 1300 public clinics with primary care staff that includes 3500 physicians, general practitioners and family physicians (pediatricians not included), 2050 nurses, administrators and pharmacists (almost all the employees have lifetime tenure). 20% is delivered by primary care physicians who work as independent contractors of the Clalit.

The main intervention of Clalit are

Guidelines: 32 different guidelines
Indicators of clinical care from the level of the whole organization to the level of individual physician (54 indicators)
Planned long term interventions: diabetes, hypertension, primary prevention of cardiovascular diseases, asthma, elderly citizens' case management, depression and anxiety, heart failure
Teaching principles of quality improvement to the leading teams of primary care clinics
Yearly competition on quality improvement projects with final conference attended by 2000 employees
Research

The main projects

Diabetes in the community
Cardiovascular prevention in primary care

Diabetes in the Community - Ten years of chronic disease management program

M. Goldfracht 1,2, D. Levin1, O. Peled1, I. Poraz1, E. Stern3, D. Weiss1, N.Lieberman1

1 Community Division, Clalit Health Services, Tel Aviv, Israel; 2Department of Family Health Care, Bruce Rappaport Faculty of Medicine, The Technion, Haifa Israel; 3Diabetes Department, Tel Aviv ¨C Jaffo District, Clalit Health Services, Israel;

Background: Diabetes is a chronic disease on rise and it continues to be a challenge for all health care providers. Clalit Health Services, Israeli largest HMO, which insures 53% of Israeli population and 70% of all registered diabetic patients in Israel, has started a program for improving the care of diabetes patients in the community since 1996. The program included all the elements of chronic disease management model like community resources and policies, health care organization, self management support, delivery system design, decision support, clinical information systems.

Methods: All the primary care providers; 2000 physicians and 2200 nurses participate in long term, nation wide, quality improvement program starting in 1996 till today. Multi facets interventions included guidelines, organizational changes, multi-disciplinary steering teams, mandatory continuing medical education sessions, diabetes register, care maps, clinical pathways, follow‑up and feedback. The patients were provided with educational tools and educational/motivation workshops. The program was implemented during the years 1996-2006 in 1030 clinics. Outcome indicators included the number of diabetic patients reporting to the central register, and indicators of diabetic care (e.g., HbA1c, microalbuminuria, LDL cholesterol). The outcomes were measured by number of diabetes patients in the central register of chronic diseases, by manual reviews of medical records during the years 1996-1999. Since 2001 we measure the outcomes (performance of follow up and diabetes control) by central computerized software, which includes data of all the diabetes patients in central diabetes register.

Results: The number of diabetics who reported to the central register rose from 20.2/1000 (1995) to 53.4/1000 (2005). There was improvement from 1.5‑ to 4‑fold for all care indicators. The rate of annual testing for HbA1c rose from 22.3% to 83.2% and low‑density lipoprotein cholesterol from 22.7% to 83 %. The percentage of patients with HbA1c<7 rose from 30.4% to 43.4%. Percentage of patients with HbA1c>9 descended from 40.2% to 17.0%.

Conclusions: Clalit intervention program in primary care has national implications for Israel, due to percentage of diabetes patients insured by Clalit. We attribute the interventional program¡¯s success to tailoring interventions to existing working conditions, using multidisciplinary steering teams, multidisciplinary educational interventions and involving patients in their care.

Does management of chronic diseases saves money?
The "diabetes in the community" program in Clalit Health services

Margalit Goldfracht 1,2, Ronit Adler1, Nickey Lieberman1, Sigal Regev1

1 Community Medicine Section, Clalit Health Services, Tel Aviv, Israel; 2Department of Family Health Care, Bruce Rappaport Faculty of Medicine, The Technion, Haifa Israel

Background: Diabetes mellitus is one of the major health problems in the community with serious effects on morbidity and mortality. Although diabetes patients are 2%-4% of the population, the diabetes care consumes about 14% of health care budget in developed countries. Clalit Health Services, Israeli largest HMO, which insures 53% of Israeli population and 70% of all registered diabetic patients in Israel, has started a program for improving the care of diabetes patients in the community since 1996. During the last ten years there was fourfold improvement in the quality of follow up of diabetes patients, according to accepted indicators of care and two fold improvement in the control of diabetes. This study investigated the cost of diabetes patients in 2004 and focused on the connection between control of diabetes according to HbA1c blood levels and costs.

Methods: We have included in the study all the diabetes patients registered in Clalit diabetes register during the years 2004 (191,000). All the data were taken from the Clalit central computerized data system. In the cost containment analysis diabetes patients with severe diseases (definition according to Ministry of Health) and oncologic patients were excluded. The following costs were included; hospitalization, drugs, secondary care, private suppliers.

Results: The customary diabetes patient's cost is higher 1.56 fold comparing to standardized Clalit member. We have found a significant connection between diabetes control and costs; the patients with well controlled diabetes had lower costs by 20% comparing to the patients with worst control. The major difference was in the hospitalization costs. Patients who received benefits from social security system had costs higher in 34% comparing to diabetes patients without social benefits. Patients with damage in end organs (IHD, CVA) had significantly higher costs. The accompanying diseases which had influence on costs were hypertension, smoking, depression. We may conclude that according to our results improvement in the management of chronic disease is cost effective and besides benefiting the patients it achieves cost containment.

Improving diabetes care for minorities in Israel

Goldfracht Margalit1,2, Diane Levin1, Ofra Peled1, Irit Poraz1, Erwin Stern3, Dorit Weiss1, Nickey Lieberman1

1 Community Medicine Section, Clalit Health Services, Tel Aviv, Israel; 2Department of Family Health Care, Bruce Rappaport Faculty of Medicine, The Technion, Haifa Israel 3Diabetes Department, Tel Aviv ¨C Jaffo District, Clalit Health Services, Israel;

Background: The discrepancies of health outcomes among different ethnic groups are well documented. The Arabic population in Israel is not an exception. During the last 8 years, Israeli largest HMO, Clalit Health Services (CHS), which insures 70% of all diabetes patients in Israel, has conducted a diabetes intervention program in all primary care clinics. Seventy-seven (77%) of Arab diabetes patients performed a HbA1c test at least once a year versus 70% among clinics that served mainly Jewish population. Nevertheless the diabetes control was worse within the Arab population; 42% (S.D 0.32 %) of the diabetes patients that have recorded HbA1c test in 2001 had HbA1c higher than 9% versus 26% (S.D 0.12%) among Jewish population. The prevalence of well-controlled diabetes, defined as HbA1c ¡Ü7% in the last HbA1c test in 2001, was 37% (S.D 0.13%) of diabetes patients treated in clinics with mainly Jewish population versus 26% (S.D 0.29%) among the Arab population. This data are based on computerized report of all diabetes patients of CHS.

To improve the diabetes control we had chosen to focus on cultural competence of the Arab population by organizing a community health fairs

The aim of our intervention was to precipitate changes in participant lifestyle, to provide information about diabetes, and to improve the prestige of local primary care team among the patients as providers of diabetes care. Consequently we intended to improve diabetes control of the participants.

Research design and methods: The study design was a longitudinal cohort study.
In every primary care clinic, which serves primary an Arab population with more than 3000 people, a health fair was conducted. The fair included stations on the topics of diet, physical activity, and foot care for diabetics, smoking cessation and identification of metabolic syndrome (BMI calculation, glucose tests, blood pressure measurement.) The stations distributed educational material in Arabic, exhibits (e.g food exhibits with their caloric content listed in Arabic)( fig 1) and conducted demonstrations (e.g. a special doll which demonstrated the influence of one cigarette on the lungs). The clinic staff (90% Arabic speaking) operated the stations.

The central activity at each event was a lecture in Arabic by a clinic physician on care of diabetes,(fig 2) and a personal testimonial by an Arab patient with diabetes, also delivered in Arabic.

There were 92 health fairs nationwide in 2001-2000, in which 6674 people participated, 15% of all the diabetes patients from Arabic population

From among Arab enrollees with diabetes who attending the fairs, we selected a random sample of 300 patients and performed a telephone survey in Arabic. The survey was performed from 2 to 4 weeks after the fair. 292 people from the random sample participated in the survey, response rate of 97.3%.

Hemoglobin A1c results were collected for each patient from CHS central laboratory databases for 6 months prior to and 6 months after the health fair which the respondent attended. The data were analyzed using Wilcoxon test.

Results: Diabetes control improved significantly among the participants; 62% improved their diabetes control in average of 1.38 (SD 1.44) HbA1c%. The maximal improvement was 6.80 HbA1c%. (Sig.=0.007 Z=-2.687). 1

The percentage of diabetics with uncontrolled diabetes (HbA1c¡Ý9) decreased from 44.6% to 36.6%, and the percentage of well-controlled diabetics (HbA1c¡Ü7) increased from 27.7% to 33%. (Fig 3)

In comparison with all Arab diabetics (n=26320) registered in central CHS register there was a substantial improvement (p<0.0001) within the intervention group. (Table 1)

At the time of the telephone survey 95% of participants responding to the survey recalled the 6 main components of the fair. Reported change changed some aspect of lifestyle (diet, physical activity) after the health event occurred in of 24 % to 40% of the participants. (Table 2, 3)

Conclusions: This study has shown that an intervention among ethnic minorities can be successful if it takes into account the population¡¯s health beliefs, norms, and language and is performed by health professionals from the ethnic minority.

Publications

M. Goldfracht, A. Porat, M. Wiener, ¡°Making St. Vincent Work - Implementation of the St. Vincent Declaration in the Community¡±, Diabetes Nutrition & Metabolism Clinical and Experimental, Vol. 10, Suppl. 1, Lisbon, Portugal, February 1997, p. 60.
M. Goldfracht , A. Porat, ¡°The quality of care of diabetic patients in Israel¡± Diab. Nutr Metab 12: 221,1999, St, Vincent Declaration ten years on, Istanbul, Turkey, October 1999
M. Goldfracht, A. Porath, ¡°Nationwide program for improving the care of diabetic patients in Israeli primary care centers¡± Diab Care 23: 495-499,2000
Goldfracht M. Porath A. Lieberman N. "Diabetes in the community" a nationwide diabetes improvement programme in primary care in Israel. Quality in primary care 2005, 13:105-11
Ben Bassat C, Stern E, Goldfracht M. "Impact of a two-arm educational program for improving diabetes care in primary care centers" Int j Clin Pract 2005; 59:1126-1130
Vinker S, Y Fogelman, Elhayany A, Nakar S, Kahan E. Using electronic databases for the detection of unrecognized diabetic patients. Cardiovasc Diabetol. 2:13 2003 Nov 14

Cardiovascular prevention in primary care

Computerized Community Cardiovascular Control (4C).

By Dr. Gilutz Harel

Aim: To improve primary and secondary prevention guideline adherence: screening, monitoring and pharmacotherapy.

Methods: We established a computerized global risk factor management, integrating primary-care teams with cardiovascular specialists, using available computerized databases. Cross-referencing laboratory values and drug dispensing automatically corrected over-diagnoses and misdiagnoses. High-risk patients are identified using and an automatic risk-profile processor. Guidelines for diabetes, hypertension and dyslipidemia were used to formulate computerized patient-specific recommendations.

The first project ¨Secondary prevention of patients with atherosclerosis and Dyslipidemia, is running since January 20014C targeting patients with atherosclerosis and Dyslipidemia recommending high cholesterol and triglycerides management. One-year follow-up was available for 2798 patients out of 11500 enrolled patients. Enhanced screening of 8% (p<0.001) a significant improvement of lipid-lowering medication (p=0.0017) and a significant reduction of all cardiac events, (29.9% vs. 36.9%, p=0.019 was achieved.

The second project ¨Primary prevention of patients of high cardiovascular risk patients: All patients, without known cardiovascular disease from the primary health care clinics in Israeli's southern were included.

Results: Out of 82,106 studied patients, 13,383 (15%) were found to be at high risk for CVD events. Under monitoring was documented in 30% and under treatment in 35% of these patients. High-risk patient's management status is automatic calculated and global risk recommendations are sent to the GP's every 6 months.

Importance: These projects improve monitoring and treatment of modifiable risk factors in the primary care setting. These projects serve as a basis for an HMO-wide intervention program using computerized information system of reminders and performance measures.

Publications

H Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh , Zvi Liss, Roni Peleg, Max Mayslus, Ilia Reuven, Avi Porath, Computerized Community Cholesterol Control (4C). Annual meeting of the Israel Heart Society, April 2001.
H. Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh , Zvi Liss, Roni Peleg, Max Mayslus, Ilia Reuven, Avi Porath, Computerized Community Cholesterol Control (4C). Annual meeting of the Israeli Atherosclerosis and Prevention Society, May 2001.
H. Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh , Zvi Liss, Roni Peleg, Max Mayslus, Ilia Reuven, Avi Porath, Computerized Community Cholesterol Control (4C). Annual meeting of the Israeli Atherosclerosis and Prevention Society, May 2001.
H. Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh , Zvi Liss, Roni Peleg, Max Mayslus, Ilia Reuven, Avi Porath, Computerized Community Cholesterol Control (4C). Politics and health, December 2001, Jerusalem.
Harel Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh, Zvi Liss, Roni Peleg, Max Mayslus, Reuben Ilia, Avi Porath; A Computerized Community Cholesterol Control (4C) 51th Annual Scientific Sessions, American College of Cardiology, Atlanta, GA, March 2002. Supplement to Journal of the American College of Cardiology, March 6, 2002, Vol. 39, Issue 5, Suppl.
Harel Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh, Zvi Liss, Roni Peleg, Max Mayslus, Reuben Ilia, Avi Porath; A Computerized Community Cholesterol Control (4C) XIVth World Congress of Cardiology, 5-9 May 2002; Supplement to Journal of the American College of Cardiology.
H. Gilutz, J. Zelingher, Y. Henkin, D.Y. Bonneh , Z. Liss, R. Peleg, M. Mayslus, R. Ilia, A. Porath. Computerized Community Cholesterol Control (4C). Annual meeting of the Israel Heart Society, April 2002.
Avi Porath, Harel Gilutz, Ilan Zelinger. Secondary Prevention of Dyslipidemia in the Community Using a Computerized Expert-Based Reminder System. 19th International Conference of the International Society for Quality in Health Care¡. Paris 2002.
Harel Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh, Zvi Liss, Roni Peleg, Max Mayslus, Reuben Ilia, Dan Vardy, Avi Porath. Computerized Community Cholesterol Control (4C). An effective massive secondary prevention intervention. The annual meeting of Family Medicine on the Name of Dr. Shabtay Ben-Meir. Tel Aviv 2003.
H. Gilutz, J. Zelingher, Y. Henkin, D.Y. Bonneh, Z. Liss, R. Peleg, M. Mayslus, R. Ilia, D. Vardy, A. Porath, Computerized Community Cholesterol Control (4C). An effective massive secondary prevention intervention. Israel Heart Meeting Tel Aviv May 2003.
H. Gilutz, J. Zelingher, Y. Henkin, D.Y. Bonneh, Z. Liss, R. Peleg, M. Mayslus, R. Ilia, D. Vardy, A. Porath, Computerized Community Cholesterol Control (4C). An effective massive secondary prevention intervention.3rd World Congress on Heart Disease - New Trends in Research, Diagnosis and Treatment of the International Academy of Cardiology, Washington DC, July 2003.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath,. Computerized Community Cholesterol Control (4C): Meeting Secondary Prevention Challenge. European Cardiac Society, Vienna September 2003.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath,. Is There a Ceiling for Lipid Lowering Compliance? Computerized Community Cholesterol Control (4C). Tel Aviv Israel Heart Meeting April 2004.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath, Computerized Community Cholesterol Control (4C): Meeting secondary prevention challenge. Israel Heart Meeting Tel Aviv April 2004.
Harel Gilutz, Ilana Harman-Boehm, Ester Paran, Roni Peleg, Avi Porath. Computerized Community Cardiovascular Control (4C-HR): Primary Prevention, The Tip of The Iceberg. Israel Heart Meeting. Tel Aviv April 2004.
Harel Gilutz, Ilana Harman-Boehm, Ester Paran, Roni Peleg, Avi Porath. Computerized Community Cardiovascular Control (4C-HR): Identifying High Risk Patients For Cardiovascular Primary Prevention. Israel Heart Meeting. Tel Aviv April 2004.
Harel Gilutz, Ilana Harman-Boehm, Ester Paran, Roni Peleg, Avi Porath. Computerized Community Cardiovascular Control (4C-HR): The Treatment Gap in the Primary Prevention Setting is a Canyon. Israel Heart Meeting. Tel Aviv, April 2004.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath,. Is There a Ceiling for Lipid Lowering Compliance? Computerized Community Cholesterol Control (4C). 2nd Scientific Conference on Compliance in Healthcare and Research, Washington DC; May 2004.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath,. Computerized Community Cholesterol Control (4C): Meeting Secondary Prevention Challenge. 2nd Scientific Conference on Compliance in Healthcare and Research, Washington DC; May 2004.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath,. Computerized Community Cardiovascular Control (4C-HR). Identifying High Risk Patients For Cardiovascular Primary Prevention. 5th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Washington DC; May 2004.

Maccabi Sick Fund

Quality Promotion in Maccabi Healthcare Services

By dr. Racheli Wilf - Miron

Background

In recent years, Maccabi has focused its attention and efforts on promoting the quality of health care.. This stretches beyond the everyday activities of every employee and independent physicians in order to ensure that Maccabi patients receive the best possible service.

A Balanced Set of Quality Indicators

During the year 2004, a set of balanced indicators was launched ¨C the Health Value Added (HVA) Model, integrating indicators from a number of major fields - clinical, perceived quality (patient satisfaction) and financial.

These Indicators are measured on three levels: the organization as a whole, the region, and the branch (the smallest administrative unit). This quality information is transparent within the organization.

The clinical indicators assist in focusing attention on several areas: Screening mammography, comprehensive diabetic care, primary and secondary prevention of cardiovascular disease, treatment for depression, influenza and pneumovax immunization.

Professionalism in Quality Improvement (QI)

Clinical QI is relatively a new science, with unique terminology and methodology. To help promote a culture of quality, a central body was assigned to adopt and adapt the most effective tools and methods from healthcare and other industries that can improve work processes. This involved; regional quality teams responsible for identifying, analyzing and finding solutions to local quality gaps, followed by the dissemination of acquired local knowledge to contribute to organizational learning.

A unique training program has been formulated, based on the program of Intermountain Health Care adapted to the community-based care environment of Maccabi,. Quality teams and middle-level medical managers were trained, forming the nucleus of "Quality Champions" or change agents.

At the beginning of 2006, a web-based frame for knowledge management ("Quality Promotion Site") will serve as an additional tool to promote organizational learning.

Performance Measurement Accelerates Improvement

We believe that the establishment of measurement across the entire organization was an essential initial stage in the creation of organizational commitment towards provision of the best possible care. The following examples of focused attention may support this assumption:

Screening mammography ¨C starting with unsatisfactory performance on a national and organizational level (only 50% of eligible women), Maccabi invested in analyzing and suggesting solutions for nests of sub-optimal performance. This was particularly evident within selected population groups such as Arab women. IT infrastructure was developed to help identify non-compliance and produced decision aids for the staff. Within 18 months, performance increased by 20%. Rates among some Arab towns increased two-fold.

Influenza Immunization ¨C The entire nursing profession was recruited to the "influenza campaign", with personal letters sent to the target population, outreach of nurses to patients confined to bed and the use of decision aids to help physicians identify patients who have not yet been immunized. In 2004, 65% of Maccabi members aged 65 and older were vaccinated.

Care of diabetic patients ¨C reorganization of the system of care for diabetic patients included multi-disciplinary teamwork, support groups to help patients towards independence and training of nurses dedicated to the care of diabetics, all helped to achieve considerable improvement: The number of poorly controlled diabetics decreased by 19% in 12 months. Concomitantly, the number of patients with good control of Hba1C (below 7%) increased from 50.5% to 56.6%.

Leumit Sick Fund

By Prof. Eliezer Kitai

(For Leumit Quality Committee: Dr¡¯s E. Matz, E. Yaari, JL. Brami, A. Fruman)

16/11/05

Leumit HMO supplies primary health care services to 670,000 people around all the country, by about 300 PHC's (Primary Health Clinics). There are about 800 primary physicians , full or part time position. The rate of family medicine specialists among these doctors is low, but is in increase due to initiation of residency program in Leumit. There is teamwork in the PHC"s including also nurses, dieticians, pharmacists, physiotherapies and administrative staff. There is a free access to secondary care consultants without gate keeping. Leumit use central electronic medical files, in which there is an integration of all the medical data about the patient.

Quality assurance activities - Leumit HMO C 2004/5

1. Clinical Guidelines:

Creation- Antibiotics prescription, Diabetes, Hypertension, Dyspepsia, Acute LBP
Education- CME activity to all family physicians and community pediatricians, guidelines oriented, 15 meetings per year, by video conference long distance learning

2. Quality Assessment:

Participation in the national Hmo's quality tracers measurements: Diabetes care, Asthma care, Influenza vaccinations, Breast Cancer Screening, Mammographys

3. Central interventions:

Creation of central electronic medical file, based on Equip guidelines for Medical files
Use of decision online support systems : Diabetes follow-up, Antibiotic selection in tonsillitis and pneumonia, drugs monitoring
Creation of data warehouse system that will support tracers measurements and evaluation

4. Local interventions:

Improvement of asthma control (central district)
Reduction of polypharmacy use (central district)
Hospitalizations reduction chronic complex patients (south area)

Background information on the Israeli primary sector

July 2006

The Sick Funds are: Clalit (covers 53% of the population), Maccabi (covers 25%), Meuhedet (covers 11%), Leumit (covers 11%)

The Israeli Association of Family Physicians
By dr. Goldfracht Margalit

The Israeli Association of Family Physicians is promoting quality in primary care since 1993. Israeli representative Dr Tomi Spenser was one of the EQUIP founders and he had established in the Association the committee for quality assurance in 1993.

The activities of quality improvement of the Association focus mainly on the following;

CME activities on subjects inherent to primary care generally with leading opinion leaders of family medicine and experts
Long term CME activities on subjects as diabetes, obesity
Guidelines on subjects from primary care perspective
Knowledge dissemination such as:
5. Quality improvement in residency in family medicine

Activities in quality improvement of health care - Clalit Health Services
By dr. Goldfracht Margalit

Quality Improvement Unit

Community Division

The main intervention of Clalit are

Guidelines: 32 different guidelines
Indicators of clinical care from the level of the whole organization to the level of individual physician (54 indicators)
Planned long term interventions: diabetes, hypertension, primary prevention of cardiovascular diseases, asthma, elderly citizens' case management, depression and anxiety, heart failure
Teaching principles of quality improvement to the leading teams of primary care clinics
Yearly competition on quality improvement projects with final conference attended by 2000 employees
Research

The main projects

Diabetes in the community
Cardiovascular prevention in primary care

Diabetes in the Community - Ten years of chronic disease management program
M. Goldfracht 1,2, D. Levin1, O. Peled1, I. Poraz1, E. Stern3, D. Weiss1, N.Lieberman1

Background: Diabetes is a chronic disease on rise and it continues to be a challenge for all health care providers. Clalit Health Services, Israeli largest HMO, which insures 53% of Israeli population and 70% of all registered diabetic patients in Israel, has started a program for improving the care of diabetes patients in the community since 1996. The program included all the elements of chronic disease management model like community resources and policies, health care organization, self management support, delivery system design, decision support, clinical information systems.

Methods: All the primary care providers; 2000 physicians and 2200 nurses participate in long term, nation wide, quality improvement program starting in 1996 till today. Multi facets interventions included guidelines, organizational changes, multi-disciplinary steering teams, mandatory continuing medical education sessions, diabetes register, care maps, clinical pathways, follow‑up and feedback. The patients were provided with educational tools and educational/motivation workshops. The program was implemented during the years 1996-2006 in 1030 clinics. Outcome indicators included the number of diabetic patients reporting to the central register, and indicators of diabetic care (e.g., HbA1c, microalbuminuria, LDL cholesterol). The outcomes were measured by number of diabetes patients in the central register of chronic diseases, by manual reviews of medical records during the years 1996-1999. Since 2001 we measure the outcomes (performance of follow up and diabetes control) by central computerized software, which includes data of all the diabetes patients in central diabetes register.

Results: The number of diabetics who reported to the central register rose from 20.2/1000 (1995) to 53.4/1000 (2005). There was improvement from 1.5‑ to 4‑fold for all care indicators. The rate of annual testing for HbA1c rose from 22.3% to 83.2% and low‑density lipoprotein cholesterol from 22.7% to 83 %. The percentage of patients with HbA1c<7 rose from 30.4% to 43.4%. Percentage of patients with HbA1c>9 descended from 40.2% to 17.0%.

Conclusions: Clalit intervention program in primary care has national implications for Israel, due to percentage of diabetes patients insured by Clalit. We attribute the interventional program¡¯s success to tailoring interventions to existing working conditions, using multidisciplinary steering teams, multidisciplinary educational interventions and involving patients in their care.

Does management of chronic diseases saves money? The "diabetes in the community" program in Clalit Health services
Margalit Goldfracht 1,2, Ronit Adler1, Nickey Lieberman1, Sigal Regev1

1 Community Medicine Section, Clalit Health Services, Tel Aviv, Israel; 2Department of Family Health Care, Bruce Rappaport Faculty of Medicine, The Technion, Haifa Israel

Background: Diabetes mellitus is one of the major health problems in the community with serious effects on morbidity and mortality. Although diabetes patients are 2%-4% of the population, the diabetes care consumes about 14% of health care budget in developed countries. Clalit Health Services, Israeli largest HMO, which insures 53% of Israeli population and 70% of all registered diabetic patients in Israel, has started a program for improving the care of diabetes patients in the community since 1996. During the last ten years there was fourfold improvement in the quality of follow up of diabetes patients, according to accepted indicators of care and two fold improvement in the control of diabetes. This study investigated the cost of diabetes patients in 2004 and focused on the connection between control of diabetes according to HbA1c blood levels and costs.

Methods: We have included in the study all the diabetes patients registered in Clalit diabetes register during the years 2004 (191,000). All the data were taken from the Clalit central computerized data system. In the cost containment analysis diabetes patients with severe diseases (definition according to Ministry of Health) and oncologic patients were excluded. The following costs were included; hospitalization, drugs, secondary care, private suppliers.

Results: The customary diabetes patient's cost is higher 1.56 fold comparing to standardized Clalit member. We have found a significant connection between diabetes control and costs; the patients with well controlled diabetes had lower costs by 20% comparing to the patients with worst control. The major difference was in the hospitalization costs. Patients who received benefits from social security system had costs higher in 34% comparing to diabetes patients without social benefits. Patients with damage in end organs (IHD, CVA) had significantly higher costs. The accompanying diseases which had influence on costs were hypertension, smoking, depression. We may conclude that according to our results improvement in the management of chronic disease is cost effective and besides benefiting the patients it achieves cost containment.

Improving diabetes care for minorities in Israel
Goldfracht Margalit1,2, Diane Levin1, Ofra Peled1, Irit Poraz1, Erwin Stern3, Dorit Weiss1, Nickey Lieberman1

Background: The discrepancies of health outcomes among different ethnic groups are well documented. The Arabic population in Israel is not an exception. During the last 8 years, Israeli largest HMO, Clalit Health Services (CHS), which insures 70% of all diabetes patients in Israel, has conducted a diabetes intervention program in all primary care clinics. Seventy-seven (77%) of Arab diabetes patients performed a HbA1c test at least once a year versus 70% among clinics that served mainly Jewish population. Nevertheless the diabetes control was worse within the Arab population; 42% (S.D 0.32 %) of the diabetes patients that have recorded HbA1c test in 2001 had HbA1c higher than 9% versus 26% (S.D 0.12%) among Jewish population. The prevalence of well-controlled diabetes, defined as HbA1c ¡Ü7% in the last HbA1c test in 2001, was 37% (S.D 0.13%) of diabetes patients treated in clinics with mainly Jewish population versus 26% (S.D 0.29%) among the Arab population. This data are based on computerized report of all diabetes patients of CHS.

To improve the diabetes control we had chosen to focus on cultural competence of the Arab population by organizing a community health fairs

The aim of our intervention was to precipitate changes in participant lifestyle, to provide information about diabetes, and to improve the prestige of local primary care team among the patients as providers of diabetes care. Consequently we intended to improve diabetes control of the participants.

Research design and methods: The study design was a longitudinal cohort study.
In every primary care clinic, which serves primary an Arab population with more than 3000 people, a health fair was conducted. The fair included stations on the topics of diet, physical activity, and foot care for diabetics, smoking cessation and identification of metabolic syndrome (BMI calculation, glucose tests, blood pressure measurement.) The stations distributed educational material in Arabic, exhibits (e.g food exhibits with their caloric content listed in Arabic)( fig 1) and conducted demonstrations (e.g. a special doll which demonstrated the influence of one cigarette on the lungs). The clinic staff (90% Arabic speaking) operated the stations.

The central activity at each event was a lecture in Arabic by a clinic physician on care of diabetes,(fig 2) and a personal testimonial by an Arab patient with diabetes, also delivered in Arabic.

There were 92 health fairs nationwide in 2001-2000, in which 6674 people participated, 15% of all the diabetes patients from Arabic population

Results: Diabetes control improved significantly among the participants; 62% improved their diabetes control in average of 1.38 (SD 1.44) HbA1c%. The maximal improvement was 6.80 HbA1c%. (Sig.=0.007 Z=-2.687). 1

The percentage of diabetics with uncontrolled diabetes (HbA1c¡Ý9) decreased from 44.6% to 36.6%, and the percentage of well-controlled diabetics (HbA1c¡Ü7) increased from 27.7% to 33%. (Fig 3)

In comparison with all Arab diabetics (n=26320) registered in central CHS register there was a substantial improvement (p<0.0001) within the intervention group. (Table 1)

Conclusions: This study has shown that an intervention among ethnic minorities can be successful if it takes into account the population¡¯s health beliefs, norms, and language and is performed by health professionals from the ethnic minority.

Publications

M. Goldfracht, A. Porat, M. Wiener, ¡°Making St. Vincent Work - Implementation of the St. Vincent Declaration in the Community¡±, Diabetes Nutrition & Metabolism Clinical and Experimental, Vol. 10, Suppl. 1, Lisbon, Portugal, February 1997, p. 60.
M. Goldfracht , A. Porat, ¡°The quality of care of diabetic patients in Israel¡± Diab. Nutr Metab 12: 221,1999, St, Vincent Declaration ten years on, Istanbul, Turkey, October 1999
M. Goldfracht, A. Porath, ¡°Nationwide program for improving the care of diabetic patients in Israeli primary care centers¡± Diab Care 23: 495-499,2000
Goldfracht M. Porath A. Lieberman N. "Diabetes in the community" a nationwide diabetes improvement programme in primary care in Israel. Quality in primary care 2005, 13:105-11
Ben Bassat C, Stern E, Goldfracht M. "Impact of a two-arm educational program for improving diabetes care in primary care centers" Int j Clin Pract 2005; 59:1126-1130

Cardiovascular prevention in primary care

Computerized Community Cardiovascular Control (4C).
By Dr. Gilutz Harel

Aim: To improve primary and secondary prevention guideline adherence: screening, monitoring and pharmacotherapy.

Methods: We established a computerized global risk factor management, integrating primary-care teams with cardiovascular specialists, using available computerized databases. Cross-referencing laboratory values and drug dispensing automatically corrected over-diagnoses and misdiagnoses. High-risk patients are identified using and an automatic risk-profile processor. Guidelines for diabetes, hypertension and dyslipidemia were used to formulate computerized patient-specific recommendations.

The first project ¨Csecondary prevention of patients with atherosclerosis and Dyslipidemia, is running since January 20014C targeting patients with atherosclerosis and Dyslipidemia recommending high cholesterol and triglycerides management. One-year follow-up was available for 2798 patients out of 11500 enrolled patients. Enhanced screening of 8% (p<0.001) a significant improvement of lipid-lowering medication (p=0.0017) and a significant reduction of all cardiac events, (29.9% vs. 36.9%, p=0.019 was achieved.

The second project ¨Cprimary prevention of patients of high cardiovascular risk patients: All patients, without known cardiovascular disease from the primary health care clinics in Israel¡¯s southern were included.

Results: Out of 82,106 studied patients, 13,383 (15%) were found to be at high risk for CVD events. Under monitoring was documented in 30% and under treatment in 35% of these patients. High-risk patient¡¯s management status is automatic calculated and global risk recommendations are sent to the GP¡¯s every 6 months.

Publications

H Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh , Zvi Liss, Roni Peleg, Max Mayslus, Ilia Reuven, Avi Porath, Computerized Community Cholesterol Control (4C). Annual meeting of the Israel Heart Society, April 2001.
H. Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh , Zvi Liss, Roni Peleg, Max Mayslus, Ilia Reuven, Avi Porath, Computerized Community Cholesterol Control (4C). Annual meeting of the Israeli Atherosclerosis and Prevention Society, May 2001.
H. Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh , Zvi Liss, Roni Peleg, Max Mayslus, Ilia Reuven, Avi Porath, Computerized Community Cholesterol Control (4C). Annual meeting of the Israeli Atherosclerosis and Prevention Society, May 2001.
H. Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh , Zvi Liss, Roni Peleg, Max Mayslus, Ilia Reuven, Avi Porath, Computerized Community Cholesterol Control (4C). Politics and health, December 2001, Jerusalem.
Harel Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh, Zvi Liss, Roni Peleg, Max Mayslus, Reuben Ilia, Avi Porath; A Computerized Community Cholesterol Control (4C) 51th Annual Scientific Sessions, American College of Cardiology, Atlanta, GA, March 2002. Supplement to Journal of the American College of Cardiology, March 6, 2002, Vol. 39, Issue 5, Suppl.
Harel Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh, Zvi Liss, Roni Peleg, Max Mayslus, Reuben Ilia, Avi Porath; A Computerized Community Cholesterol Control (4C) XIVth World Congress of Cardiology, 5-9 May 2002; Supplement to Journal of the American College of Cardiology.
H. Gilutz, J. Zelingher, Y. Henkin, D.Y. Bonneh , Z. Liss, R. Peleg, M. Mayslus, R. Ilia, A. Porath. Computerized Community Cholesterol Control (4C). Annual meeting of the Israel Heart Society, April 2002.
Avi Porath, Harel Gilutz, Ilan Zelinger. Secondary Prevention of Dyslipidemia in the Community Using a Computerized Expert-Based Reminder System. 19th International Conference of the International Society for Quality in Health Care¡. Paris 2002.
Harel Gilutz, Julian Zelingher, Yaakov Henkin, Dan Y. Bonneh, Zvi Liss, Roni Peleg, Max Mayslus, Reuben Ilia, Dan Vardy, Avi Porath. Computerized Community Cholesterol Control (4C). An effective massive secondary prevention intervention. The annual meeting of Family Medicine on the Name of Dr. Shabtay Ben-Meir. Tel Aviv 2003.
H. Gilutz, J. Zelingher, Y. Henkin, D.Y. Bonneh, Z. Liss, R. Peleg, M. Mayslus, R. Ilia, D. Vardy, A. Porath, Computerized Community Cholesterol Control (4C). An effective massive secondary prevention intervention. Israel Heart Meeting Tel Aviv May 2003.
H. Gilutz, J. Zelingher, Y. Henkin, D.Y. Bonneh, Z. Liss, R. Peleg, M. Mayslus, R. Ilia, D. Vardy, A. Porath, Computerized Community Cholesterol Control (4C). An effective massive secondary prevention intervention.3rd World Congress on Heart Disease - New Trends in Research, Diagnosis and Treatment of the International Academy of Cardiology, Washington DC, July 2003.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath,. Computerized Community Cholesterol Control (4C): Meeting Secondary Prevention Challenge. European Cardiac Society, Vienna September 2003.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath,. Is There a Ceiling for Lipid Lowering Compliance? Computerized Community Cholesterol Control (4C). Tel Aviv Israel Heart Meeting April 2004.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath, Computerized Community Cholesterol Control (4C): Meeting secondary prevention challenge. Israel Heart Meeting Tel Aviv April 2004.
Harel Gilutz, Ilana Harman-Boehm, Ester Paran, Roni Peleg, Avi Porath. Computerized Community Cardiovascular Control (4C-HR): Primary Prevention, The Tip of The Iceberg. Israel Heart Meeting. Tel Aviv April 2004.
Harel Gilutz, Ilana Harman-Boehm, Ester Paran, Roni Peleg, Avi Porath. Computerized Community Cardiovascular Control (4C-HR): Identifying High Risk Patients For Cardiovascular Primary Prevention. Israel Heart Meeting. Tel Aviv April 2004.
Harel Gilutz, Ilana Harman-Boehm, Ester Paran, Roni Peleg, Avi Porath. Computerized Community Cardiovascular Control (4C-HR): The Treatment Gap in the Primary Prevention Setting is a Canyon. Israel Heart Meeting. Tel Aviv, April 2004.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath,. Is There a Ceiling for Lipid Lowering Compliance? Computerized Community Cholesterol Control (4C). 2nd Scientific Conference on Compliance in Healthcare and Research, Washington DC; May 2004.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath,. Computerized Community Cholesterol Control (4C): Meeting Secondary Prevention Challenge. 2nd Scientific Conference on Compliance in Healthcare and Research, Washington DC; May 2004.
Harel Gilutz, Julian Zelingher, Dan Bonneh, Zvi Liss, Yaakov Henkin, Roni Peleg, Max Mayslus, Avi Porath,. Computerized Community Cardiovascular Control (4C-HR). Identifying High Risk Patients For Cardiovascular Primary Prevention. 5th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Washington DC; May 2004.

Maccabi Sick Fund

Quality Promotion in Maccabi Healthcare Services
By dr. Racheli Wilf - Miron

Background
In recent years, Maccabi has focused its attention and efforts on promoting the quality of health care.. This stretches beyond the everyday activities of every employee and independent physicians in order to ensure that Maccabi patients receive the best possible service.

A Balanced Set of Quality Indicators
During the year 2004, a set of balanced indicators was launched ¨C the Health Value Added (HVA) Model, integrating indicators from a number of major fields - clinical, perceived quality (patient satisfaction) and financial.

Professionalism in Quality Improvement (QI)
Clinical QI is relatively a new science, with unique terminology and methodology. To help promote a culture of quality, a central body was assigned to adopt and adapt the most effective tools and methods from healthcare and other industries that can improve work processes. This involved; regional quality teams responsible for identifying, analyzing and finding solutions to local quality gaps, followed by the dissemination of acquired local knowledge to contribute to organizational learning.

At the beginning of 2006, a web-based frame for knowledge management ("Quality Promotion Site") will serve as an additional tool to promote organizational learning.

Performance Measurement Accelerates Improvement
We believe that the establishment of measurement across the entire organization was an essential initial stage in the creation of organizational commitment towards provision of the best possible care. The following examples of focused attention may support this assumption:

Leumit Sick Fund
By Prof. Eliezer Kitai
(For Leumit Quality Committee: Dr¡¯s E. Matz, E. Yaari, JL. Brami, A. Fruman)
16/11/05

Leumit HMO supplies primary health care services to 670,000 people around all the country, by about 300 PHC¡¯s (Primary Health Clinics). There are about 800 primary physicians , full or part time position. The rate of family medicine specialists among these doctors is low, but is in increase due to initiation of residency program in Leumit. There is teamwork in the PHC¡¯s including also nurses, dieticians, pharmacists, physiotherapies and administrative staff. There is a free access to secondary care consultants without gatekeeping. Leumit use central electronic medical files, in which there is an integration of all the medical data about the patient.

Quality assurance activities - Leumit HMO C 2004/5

1. Clinical Guidelines:

Creation- Antibiotics prescription, Diabetes, Hypertension, Dyspepsia, Acute LBP
Education- CME activity to all family physicians and community pedriaticians, guidelines oriented, 15 meetings per year, by video conference long distance learning

2. Quality Assessment:

Participation in the national Hmo¡¯s quality tracers measurements: Diabetes care, Asthma care, Influenza vaccinations, Breast Cancer Screening, Mammographys

3. Central interventions:

Creation of central electronic medical file, based on Equip guidelines for Medical files
Use of decision online support systems : Diabetes follow-up, Antibiotic selection in tonsillitis and pneumonia, drugs monitoring
Creation of data warehouse system that will support tracers measurements and evaluation

4. Local interventions:

Improvement of asthma control (central district)
Reduction of polypharmacy use (central district)
Hospitalizations reduction chronic complex patients (south area)

- on Israeli health statistics

Israel

News from Israel on quality improvement activities in primary care

Organization of the Israeli primary care

The Israeli Association of Family Physicians

Israeli Ministry of Health

Activities in quality improvement of health care - Clalit Health Services

Diabetes in the Community - Ten years of chronic disease management program

Does management of chronic diseases saves money? The "diabetes in the community" program in Clalit Health services

Improving diabetes care for minorities in Israel

Publications

Cardiovascular prevention in primary care

Publications

Maccabi Sick Fund

A Balanced Set of Quality Indicators

Professionalism in Quality Improvement (QI)

Performance Measurement Accelerates Improvement

Quality assurance activities - Leumit HMO C 2004/5

Background information on the Israeli primary sector

Links

Does management of chronic diseases saves money?
The "diabetes in the community" program in Clalit Health services