Publications by authors named "Alex Lustman"

12 Publications

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Associations of Chronic Medication Adherence with Emergency Room Visits and Hospitalizations.

J Gen Intern Med 2021 May 6. Epub 2021 May 6.

Department of Quality Measurements and Research, Clalit Health Services, Tel Aviv, Israel.

Introduction: Good medication adherence is associated with decreased healthcare expenditure; however, adherence is usually assessed for single medication. We aim to explore the associations of adherence levels to 23 chronic medications with emergency room (ER) visits and hospitalizations. The primary endpoints are ER visits and hospitalizations in internal medicine and surgical wards.

Methods: Individuals aged 50-74 years, with a diagnosis of diabetes mellitus or hypertension, treated with at least one antihypertensive or antidiabetic medication during 2017 were included. We determined personal adherence rates by calculating the mean adherence rates of the medications prescribed to each individual. Adherence rates were stratified into categories. We retrieved information about all the ER visits, and hospitalizations in internal medicine and surgical wards during 2016-2018.

Results: Of 268,792 persons included in the study, 50.6% were men. The mean age was 63.7 years. Hypertension was recorded for 217,953 (81.1%), diabetes for 160,082 (59.5%), and both diabetes and hypertension for 109,225 (40.6%). The mean number of antihypertensive and antidiabetic medications used was 2.2 ± 1.1. In total, 51,301 (19.1%) of the cohort visited the ER at least once during 2017, 21,740 (8.1%) were hospitalized in internal medicine wards, and 10,167 (3.8%) in surgical wards during 2017. Comparing the highest adherence category to the lowest, adjusted odds ratios were 0.64 (0.61, 0.67) for ER visits, 0.56 (0.52, 0.60) for hospitalization in internal wards, and 0.63 (0.57, 0.70) for hospitalization in surgical wards. Odds ratios were similar for the three consecutive years 2016-2018.

Conclusion: Better medication adherence was associated with fewer ER visits and hospitalizations among persons with diabetes and hypertension. Investing in improving medication adherence may reduce health costs and improve patients' health.
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http://dx.doi.org/10.1007/s11606-021-06864-9DOI Listing
May 2021

Should patients treated with oral anti-coagulants be operated on within 48 h of hip fracture?

J Thromb Thrombolysis 2021 May;51(4):1132-1137

Department of Family Medicine Central District, Clalit Health Service, Rehovot, Israel.

To investigate if patients treated with oral anticoagulants (OAC) have delayed surgical intervention (more than 48 h) compared to patients without OAC therapy, and if there is an impact to surgery timing on hospitalization length and mortality. A retrospective cohort study of all patients aged over 65 registered with a new diagnosis of hip fracture who underwent surgery in one of the general hospitals run by Clalit, Israel between 01/01/2014 and 31/12/2017. Data was retrieved for patient demographics, OAC treatment, and Charlson comorbidity index. 5828 patients were operated for hip fractures, mean age was 82.8 years (65-108), 4013 (68.8%) were female. 415 were treated with direct oral anticoagulants (DOACs) (7.1%) and 311 with warfarin (5.3%) prior to their hospitalization. Patients taking OAC were less likely to be operated within 48 h from arrival to the hospital compared to patients not receiving OAC. The 30 day mortality was 4.2% among patients not receiving OAC, 6.0% among patients taking DOACs and 10.0% among patients receiving warfarin (p < 0.001). Adjusted odds ratio for mortality at 30 day among patients taking DOACs was similar to patients who didn't take OAC. (OR 1.0, CI 0.7, 1.6). The 30 day mortality rate of patients who were receiving OAC (either DOACs or warfarin) was not significantly different whether patients were operated within 48 h or not. Mortality rate was highest among patients taking warfarin. For patients who received DOACs, operation within 48 h wasn't associated with lower mortality rate. In these patients it seemed reasonable to adjust surgery time according to patients' characteristics and needs.
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http://dx.doi.org/10.1007/s11239-020-02261-xDOI Listing
May 2021

Adherence to oral antihypertensive medications, are all medications equal?

J Clin Hypertens (Greenwich) 2019 02 7;21(2):243-248. Epub 2019 Feb 7.

Department of Family Medicine Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Good medication adherence is a key factor in chronic disease management. Poor adherence is associated with adverse outcomes and high costs. We aimed to explore adherence rates among oral antihypertensive medications. The study included members of the Central District of Clalit Health Services in Israel aged between 40 and 75 years, who were diagnosed with hypertension before 2012 and who filled at least one prescription per year during 2012-2014, for the following medications: hydrochlorothiazide, nifedipine, amlodipine, lercanidipine hydrochloride, atenolol, bisoprolol, angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor antagonists (ARBs), and statins. Purchase of at least nine monthly prescriptions during 2013 was considered as "good medication adherence." We compared systolic blood pressure and LDL levels, according to medication adherence, for each medication and cross-adherence rates between medications. The study included 31 530 subjects. The rates of good medication adherence varied widely among the medications investigated, ranging from 53% for statins and hydrochlorothiazide to 71% for amlodipine. Mean systolic BP and LDL levels were statistically significantly lower among persons with good, compared to lower adherence, for each of the medications investigated. Both advanced age and more chronic medications were associated with higher adherence rates for all medications tested. Poor adherence to any single medication was found to be associated with lower adherence to other medications. Different antihypertensive medications have different adherence rates. Since adherence to one medication is related to adherence to other medications, investing in medication adherence may be highly beneficial.
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http://dx.doi.org/10.1111/jch.13475DOI Listing
February 2019

Diabetes medication persistence, different medications have different persistence rates.

Prim Care Diabetes 2017 08 15;11(4):360-364. Epub 2017 Apr 15.

Department of Family Medicine Sackler Faculty of Medicine, Tel Aviv University, Israel.

Aim: To assess the persistence of diabetic patients to oral medications.

Methods: The study included all type 2 diabetic patients over 40 years, members of one District of Clalit Health Services Israel, who were diagnosed with diabetes mellitus before 2008 and who filled at least one prescription per year during 2008-2010, for the following medications: metformin, glibenclamide, acarbose, statins, angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor antagonists (ARBs). Purchase of at least 9 monthly prescriptions during 2009 was considered "good medication persistence". We compared HbA1c and LDL levels, according to medication persistence, for each medication; and cross persistence rates between medications.

Results: 21,357 patients were included. Average age was 67.0±11.0years, 48.9% were men, and 35.8% were from low SES. Good medication persistence rates for ARBs were 78.8%, ACEI 69.0%, statins 66.6%, acarbose 67.8%, metformin 58.6%, and glibenclamide 55.3%. Good persistence to any of the medications tested was associated with a higher rate of good persistence to other medications. Patients who took more medications had better persistence rates.

Conclusions: Different oral medications used by diabetic patients have different persistence rates. Good persistence for any one medication is an indicator of good persistence to other medications. Investment in enhancing medication persistence in persons with diabetes may improve persistence to other medications, as well as improve glycemic control.
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http://dx.doi.org/10.1016/j.pcd.2017.03.006DOI Listing
August 2017

Interpersonal continuity of care and type two diabetes.

Prim Care Diabetes 2016 06 1;10(3):165-70. Epub 2015 Nov 1.

Clalit Health Services, Tel Aviv, Israel; Department of Family Medicine, Tel Aviv University, Tel Aviv, Israel.

Introduction: Continuity of care is one of the core principles of primary care. The importance of interpersonal continuity in treating diabetic patients is unclear.

Aim: To examine the association of interpersonal continuity of care, by the primary care physician, on the process of diabetic care and on health end points including diabetes control, hospital admissions and mortality.

Methods: We conducted a population based cohort study, 23,294 eligible participants were identified in Clalit Health Services Central Region at January 1, 2011 and followed through to December 31, 2012. Multivariate logistic regression models were applied to the data to study simultaneously the independent relationship between low interpersonal continuity, adjusted for background characteristics, and outcomes of care, including hospitalization and mortality.

Results: Achieving clinical targets was more likely in the high interpersonal continuity group HBA1 C OR 1.11 (CI 1.04-1.19), blood pressure OR 1.12 (1.04-1.20), LDL OR 1.14 (1.06-1.22). Patients with high interpersonal continuity had lower odds for mortality OR 0.59 (0.50-0.70). Admissions to hospital were lower in the high interpersonal continuity group, OR 0.82 (0.75-0.90), however when adjusting for background characteristics the difference in OR for hospital admissions became non-significant 0.92 (0.84-1.01).

Conclusion: High interpersonal continuity was associated with improved outcomes of process, and both primary and secondary clinical targets amongst adult patients with diabetes. This study is the first to find an association between interpersonal continuity and mortality amongst adults with diabetes.
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http://dx.doi.org/10.1016/j.pcd.2015.10.001DOI Listing
June 2016

Structured nursing follow-up: does it help in diabetes care?

Isr J Health Policy Res 2014 29;3:27. Epub 2014 Aug 29.

Department of Family Medicine Central District, Clalit Health Service, Rehovot, Israel ; Department of Family Medicine Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: In 1995 Clalit Health Services introduced a structured follow-up schedule, by primary care nurses, of diabetic patients. This was supplementary care, given in addition to the family physician's follow-up care. This article aims to describe the performance of diabetes follow-up and diabetes control in patients with additional structured nursing follow-up care, compared to those patients followed only by their family physician.

Methods: We randomly selected 2,024 type 2 diabetic subjects aged 40-76 years. For each calendar year, from 2005-2007, patients who were "under physician follow-up only" were compared to those who received additional structured nursing follow-up care.

Main Outcomes: Complete diabetes follow-up parameters including: HbA1c, LDL cholesterol, microalbumin, blood pressure measurements and fundus examination.

Results: The average age of study participants was 60.7 years, 52% were females and 38% were from low socioeconomic status (SES). In 2005, 39.5% of the diabetic patients received structured nursing follow-up, and the comparable figures for 2006 and 2007 were 42.1% 49.6%, respectively. The intervention subjects tended to be older, from lower SES, suffered from more chronic diseases and visited their family physician more frequently than the control patients. Patients in the study group were more likely to perform a complete diabetes follow-up plan: 52.8% vs. 21.5% (2005; p < 0.001) 55.5% vs. 30.3% (2006; p < 0.001), 52.3% vs. 35.7% (2007; p < 0.001). LDL cholesterol levels were lower in the study group only in 2005: 103.7 vs. 110.0 p < 0.001.

Conclusion: Subjects with supplementary structured nursing follow-up care were more likely to perform complete diabetes follow-up protocol. Our results reinforce the importance of teamwork in diabetic care. Further study is required to identify strategies for channeling the use of the limited resources to the patients who stand to benefit the most.
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http://dx.doi.org/10.1186/2045-4015-3-27DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4150555PMC
September 2014

Patient characteristics correlated with quality indicator outcomes in diabetes care.

Br J Gen Pract 2010 Sep;60(578):655-9

Department of Family Medicine, Clalit Health Service, Israel.

Background: Quality indicators were adopted to compare quality of care across health systems.

Aim: To evaluate whether patient characteristics influence primary care physicians' diabetes quality indicators.

Design Of Study: Retrospective cohort study.

Setting: Primary care setting.

Method: The study was conducted in the Central District of Clalit Health Service in Israel. The five measures of diabetes follow-up were: the percentage of patients with diabetes for whom glycosylated haemoglobin (HbA(1c)), microalbumin, low-density lipoprotein (LDL)-cholesterol, and blood pressure were measured at least once, and the percentage of patients who were seen by an ophthalmologist, during 2005. Three outcome measures were chosen: the percentage of patients with diabetes and HbA(1c) <7 mg%, the percentage of patients with diabetes and blood pressure <130/80 mmHg, and the percentage of patients with diabetes and LDL-cholesterol <100 mg/dl in 2005. Sociodemographic information was retrieved about all the physicians' patients with diabetes.

Results: One-hundred and seventy primary care physicians took care of 18 316 patients with diabetes. The average number of patients with diabetes per physician was 107 (range 10-203). A lower quality indicator score for HbA(1c) <7 mg% was correlated with a higher percentage of patients of low socioeconomic status (P<0.001) and new immigrants (P = 0.002), and correlated with borderline significance with higher mean patients' body mass index (P = 0.024); lower quality indicator score for blood pressure <130/80 mmHg was related to higher patients' age (P = 0.006). None of the diabetes follow-up measures were related to patients' characteristics.

Conclusion: Achieving good glycaemic control is dependent on patient characteristics. New immigrants, patients of low socioeconomic status, and older patients need special attention to avoid disparities.
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http://dx.doi.org/10.3399/bjgp10X515368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2930219PMC
September 2010

Statin administration and risk of cholecystectomy: a population-based case-control study.

Expert Opin Drug Saf 2010 Jul;9(4):539-43

Department of Family Medicine Leumit HMO, Israel.

Background: Gallstone disease is common in Western countries. Statins reduce biliary cholesterol secretion and have anti-inflammatory effects, suggesting that they may play a role in reducing the incidence of surgically treated gallstone disease.

Aim: To examine a potential association between statin administration and risk of cholecystectomy.

Methods: We conducted a population-based case-control study of surgically treated gallstone disease using the database of Clalit Health Services (CHS). The study population consisted of all individuals age 40 - 85 enrolled with the central region of CHS during the period 1 January 2000 to 31 December 2006. We identified patients who underwent cholecystectomy between 1 January 2003 and 31 December 2006 (n = 1465). Controls (n = 5860) were individually matched on year of birth and sex in a 4:1 ratio. Multivariable conditional logistic regression models to compute the odds ratio of cholecystectomy associated with statin therapy were constructed to control for patients' clinical and socio-demographic characteristics.

Results: Statin use with at least 80% adherence to treatment was associated with about 30% reduction in the risk of cholecystectomy (adjusted odds ratio 0.69; 95% CI 0.57 - 0.84).

Conclusion: The results of our large population-based study suggest that the use of statins reduces the risk of surgery for gallstone disease.
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http://dx.doi.org/10.1517/14740338.2010.485190DOI Listing
July 2010

Measurement of quality improvement in family practice over two-year period using electronic database quality indicators: retrospective cohort study from Israel.

Croat Med J 2009 Aug;50(4):387-93

Department of Family Medicine, Tel Aviv University, Ashdod, Israel.

Aim: To investigate the associations between family physicians' characteristics and the change in quality of health care indicators (QI) over a two-year period.

Methods: The retrospective cohort study included 161 (60.5%) of 266 family physicians who worked for the Clalit health fund in Israel in the period from January 2003 until December 2005. Family physicians' background characteristics included seniority, location of the clinic (urban or rural), workload, sex, managerial responsibilities, and board certification. The performance in 11 QIs, including indicators of diabetes follow-up (n=4) and control (n=2), hospitalization for chronic obstructive pulmonary disease and congestive heart failure (n=2), and preventive medicine measures (influenza immunization for high risk patients and mammography) was evaluated at the end of 2003 and 2005.

Results: There was an improvement in all the QIs except mammography. The improvement was significant for 8/10 QIs, the greatest being in achieving low-density lipoprotein cholesterol (+18.2%) and HbA1c (+5.9%) targets in diabetic patients. Multivariate regression model showed that the most significant factor associated with better QIs in December 2003 was board certification, while 2 years later it was female sex and having a managerial position. Being a board-certified physician remained positively associated with high QIs for diabetes control.

Conclusion: There was an improvement in most QIs in the period of 2 years. Initially, board certification was significantly associated with high QIs, but clinic managers and female physicians showed the ability to improve their scores. Research should continue to find ways to make all physicians responsive to their QIs.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728389PMC
http://dx.doi.org/10.3325/cmj.2009.50.387DOI Listing
August 2009

Quality of diabetes care in the community: a cross-sectional study in central Israel.

Isr Med Assoc J 2005 Oct;7(10):643-7

Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.

Background: Good care of the diabetic patient reduces the incidence of long-term complications. Treatment should be interdisciplinary; in the last decade a debate has raged over how to optimize treatment and how to use the various services efficiently.

Objectives: To evaluate the quality of care of diabetic patients in primary care and diabetes clinics in the community in central Israel.

Methods: We conducted a retrospective cross-sectional study of a random sample of 209 diabetic patients in a district of the largest health management organization in Israel. Patients were divided into two groups - those treated only by their family physician and those who had attended diabetes clinics. Data included social demographics, medications, risk factors, quality of follow-up, laboratory tests, quality of diabetes and blood pressure control, and complications of diabetes.

Results: Of the 209 patients 38% were followed by a diabetes clinic and 62% by a family physician. Patients attending the specialist clinic tended to be younger (P= 0.01) and more educated (P= 0.017). The duration of their diabetes was longer (P < 0.01) and they had more diabetic microvascular complications (P= 0.001). The percentage of patients treated with insulin was higher among the diabetes clinic patients (75% vs. 14%, P= 0.0001). More patients with nephropathy received angiotensin-converting enzyme inhibitors in the diabetes clinic (94% vs. 68%, P= 0.02). Follow-up in the specialist clinic as compared to by the family physician was better in the areas of foot examination (P< 0.01), fundus examination (P= 0.0001), and hemoglobin A1c testing (P= 0.01). On a regression model only fundus examination, foot examination and documentation of smoking status were significantly better in the diabetes clinic (P< 0.05).

Conclusion: There is still a large gap between clinical guidelines and clinical practice. Joint treatment of diabetic patients between the family physician and the diabetes specialist may be a proposed model to improve follow-up and diabetes control. This model of treatment should be checked in a prospective study.
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October 2005

[Family practitioners' knowledge and attitudes towards various fields of non-conventional medicine].

Harefuah 2002 Oct;141(10):883-7, 930

Department of Family Medicine, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel.

Background: The common feature of the different varieties of non-conventional medicine (NCM) is the lack of recognition, complete or partial, given to them by the institutions of conventional medicine. Treating all varieties in the same way can cause confusion.

Aim: To investigate the knowledge and attitudes of family practitioners (FP) in the methods of NCM that are most commonly practiced in Israel.

Methods: Anonymous questionnaires were used that tested knowledge and probed attitudes about FP about acupuncture, homeopathy, shiatsu and reflexology.

Results: 130 FP participated in the study (response rate 91%). In-depth training of any one of the NCM methods was rare (3-7%). Overall, a very minimal level of knowledge of all four methods was found--58% did not manage to answer even one knowledge question correctly, and the best result was five correct answers out of eight. Most of the doctors recognized NCM as legitimate, and thought that conventional and non-conventional medicine should co-exist side by side. Over 30% saw the possibility of integrating all four NCM methods within the institutions of conventional medicine. No significant difference was found in the doctors' attitudes towards the different methods. Better knowledge was associated with more positive attitudes towards NCM (p < 0.05), and a greater likelihood of referring patients (p < 0.1).

Conclusion: Since attitudes towards NCM seem to be shaped by knowledge to a certain extent, educators should consider teaching more about these treatments both in medical schools and as part of CME.
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October 2002

Erectile dysfunction--the effect of sending a questionnaire to patients on consultations with their family doctor.

Fam Pract 2002 Jun;19(3):247-50

Department of Family Medicine University of Tel Aviv, Israel.

Background: Erectile dysfunction (ED) is a common problem among male adults that generally has been ignored by family practitioners.

Objective: Our aim was to assess the effect of a mailed questionnaire about ED on the readiness of patients to raise the subject with their family doctor.

Methods: The study population included all men aged 40 years and over on the patient list of a family practitioner. A control group made up of males of similar ages was chosen in another family practice. The patient files were reviewed for ED. Anonymous questionnaires including questions about sexual dysfunction and satisfaction with sex life, as well as demographic and medical details, were sent to the study population. Patients who suffered from ED were invited to visit their family doctor. In the following 2 months, the study and control group populations' visits to the family practitioner were monitored for complaints of sexual dysfunction.

Results: In the 2 years prior to the study, 14/205 (6.8%) of the study population had complained to their family practitioner of ED in comparison with 6/205 (2.9%) in the control group (P = NS). In the 2 months following the sending of the questionnaire, 23 patients consulted their family practitioner with ED, 19 of whom had not discussed their problem with the family practitioner previously; only a further two patients went to discuss ED in the same period in the control group (P < 0.001). A total of 85/205 (41.5%) patients returned the questionnaire and 35/85 (42.5%) said they suffered from ED. Of 35 patients who reported ED, 15 had been for a consultation; only six of them consulted their family doctor.

Conclusion: ED is reported infrequently to family doctors. Sending an anonymous questionnaire on the subject increases awareness of the problem and in turn increases the number of cases that can be treated.
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http://dx.doi.org/10.1093/fampra/19.3.247DOI Listing
June 2002